Common use of Organizational Set up and Functions Clause in Contracts

Organizational Set up and Functions. a. In addition to the support staff for other duties, the Insurer shall recruit or employ experienced and qualified personnel exclusively for the purpose of implementation of the AB-PMJAY and for the performance of its obligations and discharge of its liabilities under the Insurance Contract.Detailed list of staff to be provided by Insurer is provided under Schedule 16: b. In addition to the personnel mentioned in Schedule 16, the Insurer shall recruit or employ experienced and qualified personnel for each of the following roles within its organisation exclusively for the purpose of the implementation of the Scheme: (i) To undertake Information Technology related functions which will include, among other things, collating and sharing claims related data with the SHA and running of the website at the State level and updating data at regular intervals on the website. The website shall have information on AB-PMJAY in the local language and English with functionality for claims settlement and account information access for the AB- PMJAY Beneficiaries and the EHCP. (ii) To implement the grievance redressal mechanism and to participate in the grievance redressal proceedings provided that such persons shall not carry out any other functions simultaneously if such functioning will affect their independence as members of the grievance redressal committees at different levels. (iii) To coordinate the Insurer’s State level obligations with the State level administration of the SHA. c. In addition to the personnel mentioned above, the Insurer shall recruit or employ experienced and qualified personnel for each of the following roles within its organisation at the State/district level, exclusively for the purpose of the implementation of the AB- PMJAY: (i) To undertake the Management Information System (MIS) functions, which include creating the MIS dashboard and collecting, collating and reporting data. (ii) To generate reports in formats prescribed by the SHA from time to time or as specified in the Scheme Guidelines, at monthly intervals. (iii) Processing and approval of beneficiary identity verification requests, received from Xxxxxxxx Xxxxxx at the hospitals, as per the process defined in the scheme. Scrutiny and approval of beneficiary identity verification requests if all the conditions are fulfilled, within 30 minutes of receiving the requests from Xxxxxxxx Xxxxxx at the network hospital. (iv) To undertake the Pre-authorisation functions under AB-PMJAY. (v) To undertake paperless claims settlement for the Empanelled Health Care Providers with electronic clearing facility, including the provision of necessary Medical Practitioners to undertake investigation of claims made. (vi) To undertake audit and fraud control functions. (vii) To undertake feedback functions which include designing feedback formats, collecting data based on those formats from different stakeholders like AB-PMJAY beneficiaries, the EHCPs etc., analysing the feedback data and recommending appropriate actions. (viii) To coordinate the Insurer’s district level obligations with the district level administration of the SHA. d. The Insurer shall not be required to appoint the concerned personnel if it has outsourced any of the roles and functions listed in the above sections to third parties in accordance with Clause 24. e. Provided, however, that the Insurer shall not outsource any roles or functions that are its core functions as a health insurer or that relate to its assumption of risk under AB-PMJAY Cover or that the Insurer is prohibited from outsourcing under the Insurance Laws, including but not limited to: implementation of the grievance redressal mechanism, managing its District Offices, undertaking pre-authorisation (other than in accordance with the Health Insurance Regulations), undertaking Claims Payments (other than in accordance with the Health Insurance Regulations). f. The Insurer shall provide a list of all such appointments and replacement of such personnel to the SHA within 30 days of all such appointments and replacements. The Insurer shall ensure that its employees coordinate and consult with the SHA’s corresponding personnel for the successful implementation of AB-PMJAY and the due performance of the Insurer's obligations and discharge of the Insurer's liabilities under the Insurance Contract and the Policies issued hereunder. g. The Insurer shall complete the recruitment of such employees within 45 days of the signing of the Insurance Contract and in any event, prior to commencement of the Policy Cover Period. h. The Insurer shall raise timely invoices for the due premium amount as per the terms of this Insurance Contract. i. The Insurer shall promptly refund the due premium amount in pursuance of Clause 10.2 of this Insurance Contract.

Organizational Set up and Functions. a. In addition to the support staff for other duties, the Insurer shall recruit or employ experienced and qualified personnel exclusively for the purpose of implementation of the AB-PMJAY and for the performance of its obligations and discharge of its liabilities under the Insurance Contract.Detailed list of staff to be provided by Insurer is provided under Schedule 16: b. In addition to the personnel mentioned in Schedule 16, the Insurer shall recruit or employ experienced and qualified personnel for each of the following roles within its organisation exclusively for the purpose of the implementation of the Scheme: (i) To undertake Information Technology related functions which will include, among other things, collating and sharing claims related data with the SHA and running of the website at the State level and updating data at regular intervals on the website. The website shall have information on AB-PMJAY in the local language and English with functionality for claims settlement and account information access for the AB- PMJAY Beneficiaries and the EHCP. (ii) To implement the grievance redressal mechanism and to participate in the grievance redressal proceedings provided that such persons shall not carry out any other functions simultaneously if such functioning will affect their independence as members of the grievance redressal committees at different levels. (iii) To coordinate the Insurer’s State level obligations with the State level administration of the SHA. c. In addition to the personnel mentioned above, the Insurer shall recruit or employ experienced and qualified personnel for each of the following roles within its organisation at the State/district level, exclusively for the purpose of the implementation of the AB- PMJAY: (i) To undertake the Management Information System (MIS) functions, which include creating the MIS dashboard and collecting, collating and reporting data. (ii) To generate reports in formats prescribed by the SHA from time to time or as specified in the Scheme Guidelines, at monthly intervals. (iii) Processing and approval of beneficiary identity verification requests, received from Xxxxxxxx Xxxxxx at the hospitals, as per the process defined in the scheme. Scrutiny and approval of beneficiary identity verification requests if all the conditions are fulfilled, within 30 minutes of receiving the requests from Xxxxxxxx Xxxxxx at the network hospital. (iv) To undertake the Pre-authorisation functions under AB-PMJAY. (v) To undertake paperless claims settlement for the Empanelled Health Care Providers with electronic clearing facility, including the provision of necessary Medical Practitioners to undertake investigation of claims made. (vi) To undertake audit and fraud control functions. (vii) To undertake feedback functions which include designing feedback formats, collecting data based on those formats from different stakeholders like AB-PMJAY beneficiaries, the EHCPs etc., analysing the feedback data and recommending appropriate actions. (viii) To coordinate the Insurer’s district level obligations with the district level administration of the SHA. d. The Insurer shall not be required to appoint the concerned personnel if it has outsourced any of the roles and functions listed in the above sections to third parties in accordance with Clause 24. e. Provided, however, that the Insurer shall not outsource any roles or functions that are its core functions as a health insurer or that relate to its assumption of risk under AB-PMJAY Cover or that the Insurer is prohibited from outsourcing under the Insurance Laws, including but not limited to: implementation of the grievance redressal mechanism, managing its District Offices, undertaking pre-authorisation (other than in accordance with the Health Insurance Regulations), undertaking Claims Payments (other than in accordance with the Health Insurance Regulations). f. The Insurer shall provide a list of all such appointments and replacement of such personnel to the SHA within 30 days of all such appointments and replacements. The Insurer shall ensure that its employees coordinate and consult with the SHA’s corresponding personnel for the successful implementation of AB-PMJAY and the due performance of the Insurer's obligations and discharge of the Insurer's liabilities under the Insurance Contract and the Policies issued hereunder. g. The Insurer shall complete the recruitment of such employees within 45 days of the signing of the Insurance Contract and in any event, 7 days prior to commencement of the Policy Cover Period. h. The Insurer shall raise timely invoices for the due premium amount as per the terms of this Insurance Contract. i. The Insurer shall promptly refund the due premium amount in pursuance of Clause 10.2 of this Insurance Contract.

Organizational Set up and Functions. a. In addition to the support staff for other duties, the Insurer shall recruit or employ experienced and qualified personnel exclusively for the purpose of implementation of the AB-PMJAY PMJAY, MA and MAV and for the performance of its obligations and discharge of its liabilities under the Insurance Contract.. Detailed list of staff to be provided by Insurer is provided under Schedule 16: b. In addition to the personnel mentioned in Schedule 16, the Insurer shall recruit or employ experienced and qualified personnel for each of the following roles within its organisation exclusively for the purpose of the implementation of the Scheme: (i) To undertake Information Technology related functions which will include, among other things, collating and sharing claims related data with the SHA and running of the website at the State level and updating data at regular intervals on the website. The website shall have information on AB-PMJAY PMJAY, MA and MAV in the local language and English with functionality for claims settlement and account information access for the AB- PMJAY AB-PMJAY, MA and MAV Beneficiaries and the EHCP. (ii) To implement the grievance redressal mechanism and to participate in the grievance redressal proceedings provided that such persons shall not carry out any other functions simultaneously if such functioning will affect their independence as members of the grievance redressal committees at different levels. (iii) To coordinate the Insurer’s State level obligations with the State level administration of the SHA. c. In addition to the personnel mentioned above, the Insurer shall recruit or employ experienced and qualified personnel for each of the following roles within its organisation at the State/district level, exclusively for the purpose of the implementation of the AB- PMJAY, MA and MAV: (i) To undertake the Management Information System (MIS) functions, which include creating the MIS dashboard and collecting, collating and reporting data. (ii) To generate reports in formats prescribed by the SHA from time to time or as specified in the Scheme Guidelines, at monthly intervals. (iii) Processing and approval of beneficiary identity verification requests, received from Xxxxxxxx Xxxxxx at the hospitals, as per the process defined in the scheme. Scrutiny and approval of beneficiary identity verification requests if all the conditions are fulfilled, within 30 minutes of receiving the requests from Xxxxxxxx Xxxxxx at the network hospital. (iv) To undertake the Pre-authorisation functions under AB-PMJAY, MA and MAV. (v) To undertake paperless claims settlement for the Empanelled Health Care Providers with electronic clearing facility, including the provision of necessary Medical Practitioners to undertake investigation of claims made. (vi) To undertake audit and fraud control functions. (vii) To undertake feedback functions which include designing feedback formats, collecting data based on those formats from different stakeholders like AB-PMJAY AB- PMJAY, MA and MAV beneficiaries, the EHCPs etc., analysing the feedback data and recommending appropriate actions. (viii) To coordinate the Insurer’s district level obligations with the district level administration of the SHA. d. The Insurer shall not be required to appoint the concerned personnel if it has outsourced any of the roles and functions listed in the above sections to third parties in accordance with Clause 24. e. Provided, however, that the Insurer shall not outsource any roles or functions that are its core functions as a health insurer or that relate to its assumption of risk under AB-PMJAY PMJAY, MA and MAV Cover or that the Insurer is prohibited from outsourcing under the Insurance Laws, including but not limited to: implementation of the grievance redressal mechanism, managing its District Offices, undertaking pre-authorisation (other than in accordance with the Health Insurance Regulations), undertaking Claims Payments (other than in accordance with the Health Insurance Regulations). f. The Insurer shall provide a list of all such appointments and replacement of such personnel to the SHA within 30 days of all such appointments and replacements. The Insurer shall ensure that its employees coordinate and consult with the SHA’s corresponding personnel for the successful implementation of AB-PMJAY PMJAY, MA and MAV and the due performance of the Insurer's obligations and discharge of the Insurer's liabilities under the Insurance Contract and the Policies issued hereunder. g. The Insurer shall complete the recruitment of such employees within 45 days of the signing of the Insurance Contract and in any event, prior to commencement of the Policy Cover Period. h. The Insurer shall raise timely invoices for the due premium amount as per the terms of this Insurance Contract. i. The Insurer shall promptly refund the due premium amount in pursuance of Clause 10.2 of this Insurance Contract.

Organizational Set up and Functions. a. In addition to the support mandatory staff for other the duties, the Insurer ISA shall recruit or employ experienced and qualified personnel exclusively for the purpose of implementation of the AB-PMJAY scheme and for the performance of its obligations and discharge of its liabilities under the Insurance insurance Contract.Detailed list . List of staff to be provided by Insurer is provided under Schedule 1615 are minimum manpower to start the project, but ISA must have sufficient manpower to perform the various functions of the scheme implementation: b. In addition to the personnel mentioned in Schedule 162, the Insurer ISA shall recruit or employ experienced and qualified personnel for each of the including but not limited to following roles within its organisation exclusively for the purpose of the implementation of the Scheme: (i) To undertake Information Technology related functions which will include, among other things, collating and sharing claims related data with the SHA and running of the website at the State level NHA and updating data at regular intervals on the website. The website shall have information on AB-PMJAY in the local language and English with functionality for claims settlement and account information access for the AB- PMJAY Beneficiaries and the EHCP. (ii) Coordination including linkage with national call center as defined by NHA (iii) To implement the grievance redressal mechanism and to participate in the grievance redressal proceedings provided that such persons shall not carry out any other functions simultaneously if such functioning will affect their independence as members of the grievance redressal committees at different levels. (iii) To coordinate the Insurer’s State level obligations with the State level administration of the SHA. c. In addition to the personnel mentioned above, the Insurer shall recruit or employ experienced and qualified personnel for each of the following roles within its organisation at the State/district level, exclusively for the purpose of the implementation of the AB- PMJAY: (iiv) To undertake the Management Information System (MIS) functions, which include creating the MIS dashboard and collecting, collating and reporting data. (iiv) To generate reports in formats prescribed by the SHA NHA from time to time or as specified in the Scheme Guidelines, at monthly intervals. (iiivi) Processing and approval of beneficiary identity verification requests, received from Xxxxxxxx Xxxxxx at the hospitals, as per the process defined in the scheme. Scrutiny and approval of beneficiary identity verification requests if all the conditions are fulfilled, within 30 minutes of receiving the requests from Xxxxxxxx Xxxxxx Pradhan Mantri Arogya Mitras at the network hospital. (ivvii) To undertake the Pre-authorisation functions under AB-PMJAYthe scheme. (vviii) To undertake paperless claims settlement for the Empanelled Health Care Providers with electronic clearing facility, including the provision of necessary Medical Practitioners to undertake investigation of claims made. (viix) To undertake audit and fraud control functionsclaims settlement for the beneficiaries in case of reimbursement mode with electronic clearing facility, including the provision of necessary Medical Practitioners to undertake investigation of claims made. (viix) To undertake internal monitoring and control functions including fraud detection along with providing a team with adequate manpower to analyse data for analyzing patterns, frauds and taking actions against the hospitals. (xi) To undertake feedback functions which include designing feedback formats, collecting data based on those formats from different stakeholders like AB-PMJAY beneficiaries, the EHCPs HCPs etc., analysing the feedback data and recommending appropriate actions. (viii) . To coordinate with SHA on the InsurerISA’s district level obligations with obligations. ISA shall provide laptops, mobiles, any IT related hardware, internet connectivity etc. as per the district level administration requirement of the SHAscheme implementation. ISA shall not ask for any expenses from NHA on such requirements. d. The Insurer shall not be required to appoint the concerned personnel if it has outsourced any of the roles and functions listed in the above sections to third parties in accordance with Clause 24. e. c. Provided, however, that the Insurer ISA shall not outsource any roles or functions that are its core functions as a health insurer or that relate to its assumption of risk under AB-PMJAY Cover ISA or that the Insurer ISA is prohibited from outsourcing under the Insurance Laws, including but not limited to: implementation of the grievance redressal mechanism, managing its District Offices, undertaking pre-authorisation (other than in accordance with the Health Insurance Regulations), undertaking Claims Payments (other than in accordance with the Health Insurance Regulations). f. d. The Insurer ISA shall provide a list of all such appointments and replacement of such personnel to the SHA NHA within 30 7 days of all such appointments and replacements. The Insurer ISA shall ensure that its employees coordinate and consult with the SHANHA’s corresponding personnel for the successful implementation of AB-PMJAY scheme and the due performance of the InsurerISA's obligations and discharge of the InsurerISA's liabilities under the Insurance Contract Empanelment Agreement and the Policies issued hereunder. g. e. The Insurer ISA shall complete the recruitment recruitment/deploy of such employees within 45 15 days of the signing of the Insurance Contract Empanelment Agreement and in any event, prior to commencement of the Policy Cover Periodwork. h. f. The Insurer shall raise timely invoices ISA agrees to provide support to national toll-free telephone services for the due premium amount guidance and benefit of the beneficiaries whereby the covered Persons shall receive guidance about various issues by dialing a National Call Centre as per the terms guidelines of this Insurance Contract. i. The Insurer shall promptly refund the due premium amount in pursuance Government of Clause 10.2 of this Insurance Contract.India