30.8.17 ECHS - Revised Procedure for Procession of Waiver and Sanctions: Online Claims


Central Organisation ECHS
Adjutant General Branch
Integrated HQ of MoD (Army)
Maude Line
Delhi Cantt-110010
BI49778/AG/ECHS/Claim/Policy 
30 Aug 17

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(All Regional Centres ECHS)

REVISED PROCEDURE FOR PROCESSING OF WAIVER AND SANCTIONS : ONLlNE CLAIMS

1. Refs:-
(a) Our letter No Bl49779/OutsourcingIAG/ECHS dt 11 Jun 14.
(b) Our letter No BI49770/AGIECHS dt 09 Jun 15.
(c) Our letter No B/49779-Outsourcing/AG/ECHS dt 24 Jul 17.
(d) Our letter No B/49779-Outsourcing/AG/ECHS dt 22 Aug 17.

2. The ‘Online Bill Processing' was initiated pan India was 01 Apr 15, for efficient and timely settlement of claims while maintaining transparency between the ECHS beneficiaries, empanelled hospitals, EPA and Central Org ECHS.

3. The existing timeline for processing of online claims is as under:-

Ser No
Details
Timeline
Empanelled Hospital Claims
(a)Admission IntimationWithin 24 Hrs-from time ADMISSION
(b)Online Submission of ClaimWithin 04 Days from Date of Discharge
(c)Submission of Hard Copies of ClaimWithin 30 Days from Date of Discharge
(d)Query & Need more Info Reply Within 30 Days of Query/NMI Date
Individual Reimbursement Claims
(e)Admission Intimation (EIR)Within 48 hrs from time of admission
Submission of Hard CopyWithin 30 Days from Date of Discharge

4. However of late, it has been observed that empanelled hospitals/ECHS beneficiaries are not adhering to the stipulated timelines and also not responding to the NMI queries raised by BPA within stipulated time frame, thereby, delaying the final settlement of online claims.

5. Based on numerous requests from the environment and to streamline online bill processing, the revised procedure for processing of waivers and sanctions of online   claims has been formulated and attached along as per Appx attached to this letter. The time limits for various activities have been revised as per requests from AFVs /Empanelled Hospitals / Regional Centres and are exclusive of date of discharge in respective claims. However, it is pertinent to mention that all the stakeholders to strive for speedy processing of claims and early settlement by avoiding delays, besides ensuring integrity of financial claims.

6. Following amdts are incorporated in Para 6 of this HO letter mentioned at Para 1(d), regarding one time waiver for all NMI:-

(a)  For.   One time delay condonation for late submission of physical bills and associated documents is also given whenever online bills have been uploaded.             

 (b) Read. One time waiver is hereby accorded for all NMI cases i.e, delay in intimation  of  admission,  delay  in  online  claim (IP&OP)  submission,  delay  in submission of hard copy & delay in reply of NMI.

7. You are requested to disseminate the revised procedure for waivers and sanctions along with timelines to the environment for strict compliance.   The above policy will be implemented with effect from 01 Oct 17,

8, This has the approval of the MD ECHS.

Sd/-
(Niranjan Kumar)
Brig Dy MD
For MD ECHS

APPX
(Refer to Central Org ECHS letter No
B/49778/AG/ECHS/Claim/Policy dt 30 Aug 17)

REVISED PROCEDURE FOR PROCESSING OF WAIVERS AND SANCTION : ONLINE CLAIMS

Ser NoType of ActivityProcedure in Vogue (Timeline)Revised Procedure wef 01 Oct 17Remarks (Including Disposal of old cases)
EMPANELLED HOSPITAL CLAIMS
1intimation of Admission to  BPAWithin 24 Hrs-from time of admissionWithin 48 Hrs from time of admission (Revised Timeline)One time waiver is accorded for all old cases till 30 Sep 17
Upto 30 days - Waiver by Dir RC on justification
Beyond 30 days - No (NO) waiver will be accorded
2Emergency Referral (ER) in Emergency CasesWithin 24 Hrs from time of admissionWithin 48 Hrs from time of admission (Revised Timeline)One time waiver is accorded for all old cases till 30 Sep 17
Waiver by OIC Polyclinic upto 07 days from the date of hospitalization I date of discharge whichever earlier (valid justification needed)
Upto 30 days - Waiver by Dir RC on justification
Beyond 30 days - No (NO) waiver will be accorded
3Online Claim (IPIOP) Submission in BPA portalWithin 04 working days from date of dischargeWithin 07 working days from date of discharge (Revised Timeline)One time waiver is
Upto 60 days - Waiver by Dir RC on justificationaccorded for all old
Beyond 60 days - No (NO) waiver will be accordedcases till 30 Sep 17
4Submission of Hard Copy of Claim (IP/OP) to Regional CentreWithin 30 days from    date of dischargeWithin 60 days from date of discharge (Revised Timeline)One time waiver is accorded for all old cases till 30 Sep 17
Wef 61- 90 days - Waiver by Dir RC on justification
Beyond 90 days  No NO waiver will be accorded
5Need More Information (NW)Within 30 days from date of NMIThe prevailing procedure of granting waiver at various intervals shall be discontinued wef 01 Oct 17 vide letter No B/49779-Outsourcing/AG/ECHS dt 24 Jul 17 as amended vide our letter No B/49779-Outsourcing/AG/ECHS dt 22 Aug 17 and also a comprehensive guidelines for disposal of NMI cases within stipulated time frame has been issuedAfter 180 days, claim to be settled based on available documents with deductions (if needed) or rejected depending upon the status of the claim
INDIVIDUAL REIMBURSEMENT CLAIMS (NON EMPANELLED HOSPITALS)
6Intimation of Admission/ Emergency Information Report (EIR) to Polyclinic by ECHS beneficiary/ NOK in case of Emergency admission in Non Empanelled HospitalsWithin 48 Hrs from time of admissionWithin 48 Hrs from time of admissionOIC Polyclinic and Dir RC to ensure that no reimbursement claim remains pending in the system for NMI disposal beyond 180 days
Waiver by Dir RC, if intimation recd within hospitalization  period
If delayed beyond hospitalization period upto 90 days from date of discharge, application to be processed by Dir RC with justification to Central Org ECHS, as per format fwd vide our letter No 13/49770/AG/ECHS dt 21 Nov 16
7Submission of Hard Copy of claim to PolyclinicWithin 30 days from date of dischargeWithin 90 days from date of discharge (Revised Timeline)
Wef 91-180 days from date of discharge, waiver to be given by Dir RC
Beyond 180 days from date of discharge, waiver to be given by Central Org ECHS
8Need More information (NMI)Within 30 days from date of NMIThere is no stage wise time restriction imposed on the individual reimbursement claims and a comprehensive guidelines for processing of Individual Reimbursement Claims has been issued vide letter No B/49779-Outsourcing/AG/ECHS dt 24 Jul 17 GOVT HOSPITALS
9Treatment in Govt HospitalsECHS beneficiary may avail treatment without obtaining referral from polyclinics. However, referral will only be required for the specified treatment such as Organ Treatment Surgery, Knee and Hip Joint Replacement, Cancer Treatment, Neurosurgery and Cardiac Surgery vide Gel, MoD letter No 22D(09)/2013/US(WE)/ D(Res) dt 26 Jul 16Intimation of Admission within 48 Hrs by ECHS beneficiary / NOK to parent / nearest Polyclinic
Within 90 days from date of discharge - Hard copy of claim by ECHS beneficiary / dependent should be submitted at Polyclinic
Upto 180 days - Waiver by Dir RC on justification for delay in admission intimation and referral both
Beyond 180 days from date of discharge, waiver to be given by Central Org ECHS for delay in admission intimation and referral both
MISC CONCURRENCE CASES
10Misc concurrence required by BPA to process the claims, as follows (a) Discrepancy in overlapping of admission and discharge dates (b) Repeated admission for same ailment within short duration (c) On table procedure/additional procedure doneNo policy existsWaiver to be given  by Central Org  ECHS. Cases to be examined in detail by RC and fwd with due justification and recommendation of Dir RC as per format fwd v de our letter No 13/497713/AG/ECHS/ Claim/Policy dt 03 Nov 16
SANCTIONS
11Approval on Appx 'A' of Cardiologist of Comd 1 Zonal Hospital for:- (a) Unlisted procedures. (b) Cardiac implants (listed 1 unlisted). (c) More than 02 DES and 01 Base Metal Stent (PTCA)Approval given by Cardiologist after physical checking of all relevant DocumentsStatus  quo  to  be  maintained.  However, PC/RC may consider feasibility to obtain online approval to save time and subsequently hard copy to be sent by postIn case of emergency, no approval need to be taken
12Organ Transplant (Liver & Lungs)Approval given by MD ECHSStatus quo to be maintained
13Approval on Appx 'A' for Unlisted Procedure/Test/Implants at ECHS Empanelled HospitalApproval given by SEMO on revised Appx 'A' as per our letter No B1497781 AG/ECHS/PA/Ruling dt 03 Feb 17Status quo to be maintained
14Extended Hospital Admission on Appx 'A'13-30 days by OIC PolyclinicStatus quo to be maintained
15Extended Hospital Admission on Appx 'B'31-60 days by Dir RCStatus quo to be maintained
16Extended Hospital Admission on Appx 'C'61-120 days by MD ECHSStatus quo to be maintained

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