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 TPA shall recruit or employ experienced and qualified personnel exclusively for the purpose of implementation of the MEDISEP scheme for the performance of its obligations and discharge of its liabilities under the SLA. Detailed list of staff to be provided by TPA : 1 State Head for OIC 1 2 State Head at Project office 1 3 District coordinator 14 4 MIS - OIC 1 5 MIS -Project office 1 7 Grievance officer 3 8 MBBS Doctors 10 9 Expert Doctors(Full time & Part time) 5 10 Project office 1 11 District may ask to set up an office 12 Medical Auditor - MBBS 4 14 Miscellaneous 5 15 Executive having IT Background 2 16 Call Center – 3 executive for day time and 2 night time. One of the executive should be group leader. 5 Total 57 b. In addition to the personnel mentioned above, the TPA 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 OICL and running of the website at the State level and updating data at regular intervals on the website. The website shall have information on MEDISEP in the local language and English with functionality for claims settlement and account information access for the MEDISEP 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 TPA’s State level obligations with the State level administration of the SNC. c. In addition to the personnel mentioned above, the TPA 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 scheme (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 OICL from time to time or as specified in the Scheme Guidelines, at monthly intervals. (iii) To undertake the Pre-authorisation functions. (iv) To undertake claims settlement for the Empanelled Health Care Providers including the provision of necessary Medical Practitioners to undertake investigation of claims made. (v) To undertake audit and fraud control functions. (vi) To undertake feedback functions which include designing feedback formats, collecting data based on those formats from different stakeholders analysing the feedback data and recommending appropriate actions. (vii) To coordinate the TPA’s district level obligations with the district level administration of the SNC. d. The TPA 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 e. The TPA shall provide a list of all such appointments and replacement of such personnel to the OICL within 20 days of all such appointments and replacements. The TPA shall ensure that its employees coordinate and consult with the OICL’s corresponding personnel for the successful implementation of MEDISEP scheme and the due performance of the TPA's obligations and discharge of the TPA's liabilities under the SLA. f. The TPA shall complete the recruitment of such employees within 10 days of the signing of the SLA and in any event, prior to commencement of the Policy Cover Period. g. TPA may be required to depute personnel at EHCP as and when advised by SNC/ OICL.

Organizational Set up and Functions. a. In addition to the support staff for other duties, the TPA Insurer shall recruit or employ experienced and qualified personnel exclusively for the purpose of implementation of the MEDISEP scheme AB-PMJAY and for the performance of its obligations and discharge of its liabilities under the SLA. Insurance Contract.Detailed list of staff to be provided by TPA : 1 State Head for OIC 1 2 State Head at Project office 1 3 District coordinator 14 4 MIS - OIC 1 5 MIS -Project office 1 7 Grievance officer 3 8 MBBS Doctors 10 9 Expert Doctors(Full time & Part time) 5 10 Project office 1 11 District may ask to set up an office 12 Medical Auditor - MBBS 4 14 Miscellaneous 5 15 Executive having IT Background 2 16 Call Center – 3 executive for day time and 2 night time. One of the executive should be group leader. 5 Total 57Insurer is provided under Schedule 16: b. In addition to the personnel mentioned abovein Schedule 16, the TPA 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 OICL 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 MEDISEP AB-PMJAY in the local language and English with functionality for claims settlement and account information access for the MEDISEP 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 TPAInsurer’s State level obligations with the State level administration of the SNCSHA. c. In addition to the personnel mentioned above, the TPA 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 schemeAB- 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 OICL SHA from time to time or as specified in the Scheme Guidelines, at monthly intervals. (iii) To undertake Processing and approval of beneficiary identity verification requests, received from Xxxxxxxx Xxxxxx at the Pre-authorisation functionshospitals, 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. (vvi) To undertake audit and fraud control functions. (vivii) 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. (viiviii) To coordinate the TPAInsurer’s district level obligations with the district level administration of the SNCSHA. d. The TPA 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 partiesparties 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 TPA Insurer shall provide a list of all such appointments and replacement of such personnel to the OICL SHA within 20 30 days of all such appointments and replacements. The TPA Insurer shall ensure that its employees coordinate and consult with the OICLSHA’s corresponding personnel for the successful implementation of MEDISEP scheme AB-PMJAY and the due performance of the TPAInsurer's obligations and discharge of the TPAInsurer's liabilities under the SLAInsurance Contract and the Policies issued hereunder. f. g. The TPA Insurer shall complete the recruitment of such employees within 10 45 days of the signing of the SLA Insurance Contract and in any event, prior to commencement of the Policy Cover Period. g. TPA may be required to depute personnel at EHCP h. The Insurer shall raise timely invoices for the due premium amount as and when advised by SNC/ OICLper 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 TPA Insurer shall recruit or employ experienced and qualified personnel exclusively for the purpose of implementation of the MEDISEP scheme AB-PMJAY and for the performance of its obligations and discharge of its liabilities under the SLA. Insurance Contract.Detailed list of staff to be provided by TPA : 1 State Head for OIC 1 2 State Head at Project office 1 3 District coordinator 14 4 MIS - OIC 1 5 MIS -Project office 1 7 Grievance officer 3 8 MBBS Doctors 10 9 Expert Doctors(Full time & Part time) 5 10 Project office 1 11 District may ask to set up an office 12 Medical Auditor - MBBS 4 14 Miscellaneous 5 15 Executive having IT Background 2 16 Call Center – 3 executive for day time and 2 night time. One of the executive should be group leader. 5 Total 57Insurer is provided under Schedule 16: b. In addition to the personnel mentioned abovein Schedule 16, the TPA 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 OICL 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 MEDISEP AB-PMJAY in the local language and English with functionality for claims settlement and account information access for the MEDISEP 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 TPAInsurer’s State level obligations with the State level administration of the SNCSHA. c. In addition to the personnel mentioned above, the TPA 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 schemeAB- 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 OICL SHA from time to time or as specified in the Scheme Guidelines, at monthly intervals. (iii) To undertake Processing and approval of beneficiary identity verification requests, received from Xxxxxxxx Xxxxxx at the Pre-authorisation functionshospitals, 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. (vvi) To undertake audit and fraud control functions. (vivii) 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. (viiviii) To coordinate the TPAInsurer’s district level obligations with the district level administration of the SNCSHA. d. The TPA 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 partiesparties 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 TPA Insurer shall provide a list of all such appointments and replacement of such personnel to the OICL SHA within 20 30 days of all such appointments and replacements. The TPA Insurer shall ensure that its employees coordinate and consult with the OICLSHA’s corresponding personnel for the successful implementation of MEDISEP scheme AB-PMJAY and the due performance of the TPAInsurer's obligations and discharge of the TPAInsurer's liabilities under the SLAInsurance Contract and the Policies issued hereunder. f. g. The TPA Insurer shall complete the recruitment of such employees within 10 45 days of the signing of the SLA Insurance Contract and in any event, 7 days prior to commencement of the Policy Cover Period. g. TPA may be required to depute personnel at EHCP h. The Insurer shall raise timely invoices for the due premium amount as and when advised by SNC/ OICLper 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 TPA Insurer shall recruit or employ experienced and qualified personnel exclusively for the purpose of implementation of the MEDISEP scheme AB-PMJAY, MA and MAV and for the performance of its obligations and discharge of its liabilities under the SLAInsurance Contract. Detailed list of staff to be provided by TPA : 1 State Head for OIC 1 2 State Head at Project office 1 3 District coordinator 14 4 MIS - OIC 1 5 MIS -Project office 1 7 Grievance officer 3 8 MBBS Doctors 10 9 Expert Doctors(Full time & Part time) 5 10 Project office 1 11 District may ask to set up an office 12 Medical Auditor - MBBS 4 14 Miscellaneous 5 15 Executive having IT Background 2 16 Call Center – 3 executive for day time and 2 night time. One of the executive should be group leader. 5 Total 57Insurer is provided under Schedule 16: b. In addition to the personnel mentioned abovein Schedule 16, the TPA 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 OICL 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 MEDISEP AB-PMJAY, MA and MAV in the local language and English with functionality for claims settlement and account information access for the MEDISEP 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 TPAInsurer’s State level obligations with the State level administration of the SNCSHA. c. In addition to the personnel mentioned above, the TPA 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 schemeAB- 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 OICL SHA from time to time or as specified in the Scheme Guidelines, at monthly intervals. (iii) To undertake Processing and approval of beneficiary identity verification requests, received from Xxxxxxxx Xxxxxx at the Pre-authorisation functionshospitals, 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. (vvi) To undertake audit and fraud control functions. (vivii) To undertake feedback functions which include designing feedback formats, collecting data based on those formats from different stakeholders like AB- PMJAY, MA and MAV beneficiaries, the EHCPs etc., analysing the feedback data and recommending appropriate actions. (viiviii) To coordinate the TPAInsurer’s district level obligations with the district level administration of the SNCSHA. d. The TPA 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 partiesparties 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, 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 TPA Insurer shall provide a list of all such appointments and replacement of such personnel to the OICL SHA within 20 30 days of all such appointments and replacements. The TPA Insurer shall ensure that its employees coordinate and consult with the OICLSHA’s corresponding personnel for the successful implementation of MEDISEP scheme AB-PMJAY, MA and MAV and the due performance of the TPAInsurer's obligations and discharge of the TPAInsurer's liabilities under the SLAInsurance Contract and the Policies issued hereunder. f. g. The TPA Insurer shall complete the recruitment of such employees within 10 45 days of the signing of the SLA Insurance Contract and in any event, prior to commencement of the Policy Cover Period. g. TPA may be required to depute personnel at EHCP h. The Insurer shall raise timely invoices for the due premium amount as and when advised by SNC/ OICLper 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.