Common use of Preauthorization and claims Clause in Contracts

Preauthorization and claims. (i) The Provider agrees to follow and adhere to the online pre-authorization and claims workflow of the Scheme in providing services to its Beneficiaries. (ii) The Provider shall submit the pre-authorization request on the web portal, after admitting the patient as inpatient. The documents will include signed copy of consent, digital photograph, all relevant test reports, X ray, CT Scan, MRI films, biopsy/cytology reports along with those taken in the hospital should be scanned/ digitized and uploaded, with the proposed treatment along with doctor notes etc. The ISA shall approve the preauthorization within 6 hours of submission of documents by the Hospital any queries by ISA shall be answered without delay. (iii) The pre-authorization is applicable only for a period of 14 (fourteen) days, including the date of issue. The pre-authorization is only provided to a specific provider and is not transferable. However may be extended for additional 7 (seven) days, if a written request is made by the provider/ hospital. Beyond 21 (twenty one) days, the pre-authorization will stand cancelled. In such cases the provider should obtain fresh approval for the cancelled pre-authorizations by mentioning valid reasons. (iv) In case of extended stay, additional procedure or any readmission arising out of complication authorization is required, a fresh query will be raised by the Provider. (v) In cases of emergency, the Provider will obtain emergency telephonic approval. The ISA in coordination with State Health Agency reserves the right to cancel the emergency telephonic approval, if the Provider fails to update the details of the Beneficiary, online within 6 (six) hours of emergency telephonic approval. The Provider also agrees to update the Surgery / Therapy details online for telephonic approvals, mentioning the date and time along with specific remarks and photographic evidences, starting from the telephonic intimation. (vi) The Provider, will update the Surgery/ procedure details on the portal, online after performing the surgery including surgical notes and other clinical documents, within 7 (seven) days of the date of the surgery or prior to the last day of validity of the pre-authorization, whichever is earlier. This information is required to confirm, if the surgery/ procedure has been undertaken, as per the available approvals. (vii) The Provider, after 10 (ten) days of discharge of the Beneficiary, will uploads the original xxxx, discharge summary and other relevant documents including the Feedback / Complaint Form for claims processing. The uploaded xxxx should clearly indicate the claim amount payable to the Provider. The Provider also agrees to consider those Beneficiaries who were admitted as non-Scheme/non- Beneficiary patient due to over-sight but subsequently identified as Beneficiary during the course of stay in the Provider’s hospital. In such cases any payment received from the Beneficiary shall be refunded immediately after getting pre- authorization approval and before discharge of the Beneficiary from the Provider’s hospital duly obtaining a receipt thereof. (viii) The State Health Agency reserves the right to deny/deduct the claim if the Surgery/Therapy is performed before any approval from the ISA or intimation to emergency telephonic approval and pre-authorization is obtained at a later date while keeping the ISA/State Health Agency uninformed about the Surgery / Therapy. (ix) The package rates are the maximum rate indicated for each procedure. However, the settlement of the claims shall be made on the basis of actual bills submitted by the Provider and the validation of the same as per protocol by ISA; (x) The settlement of claims in death cases, LAMA/DAMA shall be as per the Adjudication Guidelines issued by SHA from time to time; (xi) In case of any dispute related to preauthorization or Claims or any other grievance, the decision of State Health Agency shall be deemed to be final and binding; (xii) The Provider shall comply with Guidelines on Processes for Hospital Transaction and Guidelines on Process of Claims Settlement and SOP, letters, orders, circulars passed by SHA from time to time.

Preauthorization and claims. (i) The Provider agrees to follow and adhere to the online pre-authorization and claims workflow of the Scheme in providing services to its Beneficiaries.; (ii) The Provider shall submit the pre-authorization request on the web portal, after admitting the patient as inpatient. The documents will include signed copy of consent, digital photograph, all relevant test reports, X ray, CT Scan, MRI films, biopsy/cytology reports along with those taken in the hospital should be scanned/ digitized and uploaded, with the proposed treatment along with doctor notes etc. The ISA shall approve the preauthorization within 6 hours of submission of documents by the Hospital any queries by ISA shall be answered without delay.delay ; (iii) The pre-authorization is applicable only for a period of 14 (fourteen) days, including the date of issue. The pre-authorization is only provided to a specific provider and is not transferable. However may be extended for additional 7 (seven) days, if a written request is made by the provider/ hospital. Beyond 21 (twenty one) days, the pre-authorization will stand cancelled. In such cases the provider should obtain fresh approval for the cancelled pre-authorizations by mentioning valid reasons.; (iv) In case of extended stay, additional procedure or any readmission arising out of complication authorization is required, a fresh query will be raised by the Provider.; (v) In cases of emergency, the Provider will obtain emergency telephonic approval. The ISA in coordination with State Health Agency reserves the right to cancel the emergency telephonic approval, if the Provider fails to update the details of the Beneficiary, online within 6 (six) hours of emergency telephonic approval. The Provider also agrees to update the Surgery / Therapy details online for telephonic approvals, mentioning the date and time along with specific remarks and photographic evidences, starting from the telephonic intimation.; (vi) The Provider, will update the Surgery/ procedure details on the portal, online after performing the surgery including surgical notes and other clinical documents, within 7 (seven) days of the date of the surgery or prior to the last day of validity of the pre-authorization, whichever is earlier. This information is required to confirm, if the surgery/ procedure has been undertaken, as per the available approvals.; (vii) The Provider, after 10 (ten) days of discharge of the Beneficiary, will uploads the original xxxx, discharge summary and other relevant documents including the Feedback / Complaint Form for claims processingprocessing . The uploaded xxxx should clearly indicate the claim amount payable to the Provider. The Provider also agrees to consider those Beneficiaries who were admitted as non-Scheme/non- non-Beneficiary patient due to over-sight but subsequently identified as Beneficiary during the course of stay in the Provider’s hospital. In such cases any payment received from the Beneficiary shall be refunded immediately after getting pre- authorization approval and before discharge of the Beneficiary from the Provider’s hospital duly obtaining a receipt thereof.; (viii) The State Health Agency reserves the right to deny/deduct the claim if the Surgery/Therapy is performed before any approval from the ISA or intimation to emergency telephonic approval and pre-pre- authorization is obtained at a later date while keeping the ISA/State Health Agency uninformed about the Surgery / Therapy.; (ix) The package rates are the maximum rate indicated for each procedure. However, the settlement of the claims shall be made on the basis of actual bills submitted by the Provider and the validation of the same as per protocol by ISA; (x) The settlement of claims in death cases, LAMA/DAMA shall be as per the Adjudication Guidelines adjudication guidelines issued by SHA from time to time; (xi) In case of any dispute related to preauthorization or Claims or any other grievance, the decision of State Health Agency shall be deemed to be final and binding; (xii) The Provider However provision of one appeal to the Principal Secretary shall comply with Guidelines on Processes for Hospital Transaction and Guidelines on Process be allowed in case of Claims Settlement and SOP, letters, orders, circulars passed by SHA from time disputes related to time.claim

Preauthorization and claims. (i) The Provider agrees to follow and adhere to the online pre-authorization and claims workflow of the Scheme in providing services to its Beneficiaries.; (ii) The Provider shall submit the pre-authorization request on the web portal, after admitting the patient as inpatient. The documents will include signed copy of consent, digital photograph, all relevant test reports, X ray, CT Scan, MRI films, biopsy/cytology reports along with those taken in the hospital should be scanned/ digitized and uploaded, with the proposed treatment along with doctor notes etc. The ISA shall approve the preauthorization within 6 hours of submission of documents by the Hospital any queries by ISA shall be answered without delay.delay ; (iii) The pre-authorization is applicable only for a period of 14 (fourteen) days, including the date of issue. The pre-authorization is only provided to a specific provider and is not transferable. However may be extended for additional 7 (seven) days, if a written request is made by the provider/ hospital. Beyond 21 (twenty one) days, the pre-authorization will stand cancelled. In such cases the provider should obtain fresh approval for the cancelled pre-authorizations by mentioning valid reasons.; (iv) In case of extended stay, additional procedure or any readmission arising out of complication authorization is required, a fresh query will be raised by the Provider.; (v) In cases of emergency, the Provider will obtain emergency telephonic approval. The ISA in coordination with State Health Agency reserves the right to cancel the emergency telephonic approval, if the Provider fails to update the details of the Beneficiary, online within 6 (six) hours of emergency telephonic approval. The Provider also agrees to update the Surgery / Therapy details online for telephonic approvals, mentioning the date and time along with specific remarks and photographic evidences, starting from the telephonic intimation.; (vi) The Provider, will update the Surgery/ procedure details on the portal, online after performing the surgery including surgical notes and other clinical documents, within 7 (seven) days of the date of the surgery or prior to the last day of validity of the pre-authorization, whichever is earlier. This information is required to confirm, if the surgery/ procedure has been undertaken, as per the available approvals.; (vii) The Provider, after 10 (ten) days of discharge of the Beneficiary, will uploads the original xxxxbill, discharge summary and other relevant documents including the Feedback / Complaint Form for claims processing. The uploaded xxxx bill should clearly indicate the claim amount payable to the Provider. The Provider also agrees to consider those Beneficiaries who were admitted as non-Scheme/non- non-Beneficiary patient due to over-sight but subsequently identified as Beneficiary during the course of stay in the Provider’s Provider‟s hospital. In such cases any payment received from the Beneficiary shall be refunded immediately after getting pre- authorization approval and before discharge of the Beneficiary from the Provider’s Provider‟s hospital duly obtaining a receipt thereof.; (viii) The State Health Agency reserves the right to deny/deduct the claim if the Surgery/Therapy is performed before any approval from the ISA or intimation to emergency telephonic approval and pre-authorization is obtained at a later date while keeping the ISA/State Health Agency uninformed about the Surgery / Therapy.; (ix) The package rates are the maximum rate indicated for each procedure. However, the settlement of the claims shall be made on the basis of actual bills submitted by the Provider and the validation of the same as per protocol by ISA; (x) The settlement of claims in death cases, LAMA/DAMA shall be as per the Adjudication Guidelines issued by SHA from time to time; (xi) In case of any dispute related to preauthorization or Claims or any other grievance, the decision of State Health Agency shall be deemed to be final and binding; (xii) The Provider shall comply with Guidelines on Processes for Hospital Transaction and Guidelines on Process of Claims Settlement and SOP, letters, orders, circulars passed by SHA from time to time.

Preauthorization and claims. (i) The Provider agrees to follow and adhere to the online pre-authorization and claims workflow of the Scheme in providing services to its Beneficiaries.; (ii) The Provider shall submit the pre-authorization request on the web portal, after admitting the patient as inpatient. The documents will include signed copy of consent, digital photograph, all relevant test reports, X ray, CT Scan, MRI films, biopsy/cytology reports along with those taken in the hospital should be scanned/ digitized and uploaded, with the proposed treatment along with doctor notes etc. The ISA shall approve the preauthorization within 6 hours of submission of documents by the Hospital any queries by ISA shall be answered without delay.delay ; (iii) The pre-authorization is applicable only for a period of 14 (fourteen) days, including the date of issue. The pre-authorization is only provided to a specific provider and is not transferable. However may be extended for additional 7 (seven) days, if a written request is made by the provider/ hospital. Beyond 21 (twenty one) days, the pre-authorization will stand cancelled. In such cases the provider should obtain fresh approval for the cancelled pre-authorizations by mentioning valid reasons.; (iv) In case of extended stay, additional procedure or any readmission arising out of complication authorization is required, a fresh query will be raised by the Provider.; (v) In cases of emergency, the Provider will obtain emergency telephonic approval. The ISA in coordination with State Health Agency reserves the right to cancel the emergency telephonic approval, if the Provider fails to update the details of the Beneficiary, online within 6 (six) hours of emergency telephonic approval. The Provider also agrees to update the Surgery / Therapy details online for telephonic approvals, mentioning the date and time along with specific remarks and photographic evidences, starting from the telephonic intimation.; (vi) The Provider, will update the Surgery/ procedure details on the portal, online after performing the surgery including surgical notes and other clinical documents, within 7 (seven) days of the date of the surgery or prior to the last day of validity of the pre-authorization, whichever is earlier. This information is required to confirm, if the surgery/ procedure has been undertaken, as per the available approvals.; (vii) The Provider, after 10 (ten) days of discharge of the Beneficiary, will uploads the original xxxx, discharge summary and other relevant documents including the Feedback / Complaint Form for claims processing. The uploaded xxxx should clearly indicate the claim amount payable to the Provider. The Provider also agrees to consider those Beneficiaries who were admitted as non-Scheme/non- non-Beneficiary patient due to over-sight but subsequently identified as Beneficiary during the course of stay in the Provider’s Provider‟s hospital. In such cases any payment received from the Beneficiary shall be refunded immediately after getting pre- authorization approval and before discharge of the Beneficiary from the Provider’s Provider‟s hospital duly obtaining a receipt thereof.; (viii) The State Health Agency reserves the right to deny/deduct the claim if the Surgery/Therapy is performed before any approval from the ISA or intimation to emergency telephonic approval and pre-authorization is obtained at a later date while keeping the ISA/State Health Agency uninformed about the Surgery / Therapy.; (ix) The package rates are the maximum rate indicated for each procedure. However, the settlement of the claims shall be made on the basis of actual bills submitted by the Provider and the validation of the same as per protocol by ISA; (x) The settlement of claims in death cases, LAMA/DAMA shall be as per the Adjudication Guidelines issued by SHA from time to time; (xi) In case of any dispute related to preauthorization or Claims or any other grievance, the decision of State Health Agency shall be deemed to be final and binding; (xii) The Provider shall comply with Guidelines on Processes for Hospital Transaction and Guidelines on Process of Claims Settlement and SOP, letters, orders, circulars passed by SHA from time to time.