Common use of Claims Management Clause in Contracts

Claims Management. All EHCPs shall be obliged to submit their claims within 24 hours of discharge in the format prescribed. However, in case of Public EHCPs this time may be relaxed as defined by SHA. The SHA (recommended by ISA) / Insurer shall be responsible for settling all claims within 15 days after receiving all the required information/ documents. Member may bring the following to the AB PM-▇▇▇ helpdesk: Letter from MoHFW/NHA RSBY Card Any other defined document as prescribed by the State Government Arogya Mitra/Operator will check if AB PM-▇▇▇ e-Card/ AB PM-▇▇▇ ID/ Aadhaar Number is available with the beneficiary In case Internet connectivity is available at hospital Operator/Arogya Mitra identifies the beneficiary’s eligibility and verification status from AB PM-▇▇▇ Central Server If beneficiary is eligible and verified under AB PM-▇▇▇, server will show the details of the members of the family with photo of each verified member If found OK then beneficiary can be registered for getting the cashless treatment. If patient is eligible but not verified then patient will be asked to produce Aadhaar Card/Number/ Ration Card for verification (in absence of Aadhaar) Beneficiary mobile number will be captured. If Aadhaar Card/Number is available and authenticated online then patient will be verified under scheme (as prescribed by the software) and will be issued a AB PM-▇▇▇ e-Card for getting the cashless treatment. Beneficiary gender and year of birth will be captured with Aadhaar eKYC or Ration Card If Aadhaar Card/Number is not available then beneficiary will advised to get the Aadhaar Card/number within stipulated time. In case Internet connectivity is not available at hospital Arogya Mitra at AB PM-▇▇▇ Registration Desk at Hospital will call Central Helpline and using IVRS enters AB PM-▇▇▇ ID or Aadhaar number of the patient. IVRS will speak out the details of all beneficiaries in the family and hospital will choose the beneficiary who has come for treatment. It will also inform the verification status of the beneficiary If eligible and verified then beneficiary will be registered for getting treatment by sending an OTP on the mobile number of the beneficiary In case beneficiary is eligible but not verified then she/he can be verified using Aadhaar OTP authentication and can get registered for getting cashless treatment In case of emergency or in case person does not show AB PM-▇▇▇ e-Card/ID or Aadhaar Card/Number and claims to be AB PM-▇▇▇ beneficiary and show some photo ID proof issued by Government, then beneficiary may get the treatment after getting TPIN (Telephonic Patient Identification Number) from the call centre and same will be recorded. Government Photo ID proof need not be insisted in case of emergency. In all such cases, relevant AB PM-▇▇▇ beneficiary proof will be supplied within specified time before discharge otherwise beneficiary will pay for the treatment to the Hospital. If eligibility, verification and authentication are successful, beneficiary should be allowed for treatment These details captured will be available at SHA/ Insurance Company/ ISA level for their approval. Once approved, the beneficiary will be considered as successfully identified and verified under AB PM-▇▇▇.