Common use of EXTENT OF COVERAGE Clause in Contracts

EXTENT OF COVERAGE. i. The Provider Hospital shall extend only inpatient hospitalization for General and / OR Specialized Purpose viz. OR As per list enclosed OR as notified/amended by Ministry of Health & Family Welfare Department of Health & Family Welfare under CGHS, (City) for that Hospital (remove whichever is not applicable) to the members under this Agreement and claims will be settled directly by the Food Corporation of India under ‘Direct Payment System’. For the ‘out-patient treatment’, the Corporation employee shall take such treatment on the agreed rates on cash basis and Food Corporation shall not be responsible for any such medical expenditure on this account under ‘Direct Payment System’. ii. The Provider will charge agreed rates. The provider shall charge the negotiated rates for IPD and OPD treatment including diagnostics as contained in Clause 0.9. iii. The Hospital will extend the services of their lab for diagnostic tests to all members on cash down basis on advice of Registered Medical Practitioner for OPD treatment/ purpose. iv. As per existing policy, in the absence of FCI Medical Officer in the respective District Office/ Regional Office/Zonal Office/ Headquarters (as the case may be), the First Admission Report/ Pre-Authorization duly signed/issued online by the Competent Authority of the concerned empanelled hospital is acceptable subject to the fulfillment of other terms and conditions. FCI Authority competent to issue Authorization letter (online or offline as the case may be) in various offices of FCI are given at Annexure-I. Changes if any shall be intimated from time to time. Sample copies of First Admission Report/ Pre-Authorization Letter and Authorization letter are also given at ▇▇▇▇▇▇▇▇-▇▇ and III respectively. v. The claim bill along with copies of investigation reports, first admission report/ pre- authorization letter, copy of authorization letter, original cash memos and discharge summary report be submitted by the Hospital to the AGM(Bills) of concerned FCI office i.e. HQ/ZO/RO (strike off or remove whichever is not applicable) within the stipulated period as per agreed terms and conditions. The bills submitted should contain the CGHS Code/Hospital Code applicable against each procedure charged to facilitate processing of the bill at the earliest. These documents are also to be uploaded including system generated Discharge Summary in Hospital Administration System (HAS). List of Administrative offices of FCI are provided at Annexure-IV. The same are also given on FCI Website link ▇▇▇▇://▇▇▇.▇▇▇.▇▇/articles/view/331. The bills are to be raised by hospital through BTS (Bill Tracking System). vi. As per existing Post Retirement Medical Scheme of the Corporation the members and their dependents (as the notified by FCI from time to time) are members of the Scheme, are entitled for IPD and OPD treatment subject to prescribed ceiling as amended from time to time. vii. To facilitate hospitals & the member to know the credit limit available to the member for taking treatment under Direct Payment system on FCI account, the balance credit limit during the Financial year shall be reflected in the authorization letter of FCI for retired employees, their dependent as per rules. In case the medical expenditure exceeds the balance credit limit, the patient may be given treatment on CGHS / agreed empanelled rates (as agreed at Clause 0.9 of this agreement) for which the balance amount will be deposited by the beneficiary (retired employees / spouse / Disabled children as the case may be). For the ‘out patient treatment’, the beneficiaries shall take such treatment on the agreed rates on cash basis and Food Corporation shall not be responsible for any such medical expenditure on this account under “Direct Payment System’. viii. Authentication of the beneficiary members must be verified from the online Medical I- Card available on hospital login for serving/regular employees / Medical I Card issued by FCI for other beneficiaries as per agreement and in case of non-compliance of the same hospital will be held responsible. ix. The Provider Hospital shall ensure that each time a member/ dependent avails service envisaged in this Agreement, the expenses are regulated strictly with reference to the eligibility and monetary limits fixed with reference to the entitlement status. x. The Hospital shall ensure that the benefits are made available to the member strictly as per terms of this Agreement and no benefit outside the terms of this Agreement shall be allowed without prior approval unless the same is essential for the recovery of members. xi. FCI shall not be liable to make any payment on account of claims which are in the opinion of FCI fraudulent or are as a result of fabricated claims. Corporation would have the right to blacklist the hospital if the Hospital is found to have facilitated the lodging of false claims, without prejudice to any other rights that the Corporation may have under the law.

EXTENT OF COVERAGE. i. The Provider Hospital shall extend only inpatient hospitalization for General and / OR Specialized Purpose and/or Specialised Purposes viz. OR As per list enclosed OR as notified/amended by Ministry of Health & Family Welfare Department of Health & Family Welfare under CGHS, (City) for that Hospital (remove whichever is not applicable) to the members under this Agreement and claims will be settled directly by the Food Corporation of India under ‘Direct Payment System’. For the ‘out-patient treatment’, the Corporation employee shall take such treatment on the agreed rates on cash basis and Food Corporation shall not be responsible for any such medical expenditure on this account under ‘Direct Payment System’. ii. The Provider will charge agreed rates. The provider shall charge the negotiated rates for IPD and OPD treatment including diagnostics as contained in Clause 0.9. iii. The Hospital will extend the services of their lab for diagnostic tests to all members on cash down basis on advice of Registered Medical Practitioner for OPD treatment/ purpose. iv. As per existing policy, in the absence of FCI Medical Officer in the respective District Office/ Regional Office/Zonal Office/ Headquarters (as the case may be), the First Admission Report/ Pre-Authorization duly signed/issued online signed by the Competent Authority of the concerned empanelled hospital is acceptable subject to the fulfillment of other terms and conditions. FCI Authority competent to issue Authorization letter (online or offline as the case may be) in various offices of FCI are given at Annexure-I. Changes if any shall be intimated from time to time. Sample copies of First Admission Report/ Pre-Authorization Letter and Authorization letter are also given at ▇▇▇▇▇▇▇▇-▇▇ and III respectively. v. The claim bill along with alongwith copies of investigation reports, first admission report/ pre- authorization letter, copy of authorization letter, original cash memos and discharge summary report be submitted by the Hospital to the AGM(Bills) of concerned FCI office i.e. HQ/ZO/RO (strike off or remove whichever is not applicable) within the stipulated period as per agreed terms and conditions. The bills submitted should contain the CGHS Code/Hospital Code applicable against each procedure charged to facilitate processing of the bill at the earliest. These documents are also to be uploaded including system generated Discharge Summary in Hospital Administration System (HAS). List of Administrative offices of FCI are provided at Annexure-IV. The same are also given on FCI Website link ▇▇▇▇://▇▇▇.▇▇▇.▇▇/articles/view/331. The bills are to be raised by hospital through BTS (Bill Tracking System). vi. As per existing Post Retirement Medical Scheme of the Corporation the members and their dependents (as the notified by FCI from time to time) are members of the Scheme, are entitled for IPD and OPD treatment subject to prescribed ceiling as amended from time to time. vii. To facilitate hospitals & the member to know the credit limit available to the member for taking treatment under Direct Payment system on FCI account, the balance credit limit during the Financial year shall be reflected in the authorization letter of FCI for retired employees, their dependent as per rules. In case the medical expenditure exceeds the balance credit limit, the patient may be given treatment on CGHS / agreed empanelled rates (as agreed at Clause 0.9 of this agreement) for which the balance amount will be deposited by the beneficiary (retired employees / spouse / Disabled children as the case may be). For the ‘out patient treatment’, the beneficiaries shall take such treatment on the agreed rates on cash basis and Food Corporation shall not be responsible for any such medical expenditure on this account under “Direct Payment System’. viii. Authentication of the beneficiary members must be verified from the online Medical I- Card available on hospital login for serving/regular employees / Medical I Card issued by FCI for other beneficiaries as per agreement and in case of non-compliance of the same hospital will be held responsible. ix. The Provider Hospital shall ensure that each time a member/ dependent avails service envisaged in this Agreement, the expenses are regulated strictly with reference to the eligibility and monetary limits fixed with reference to the entitlement status. x. The Hospital shall ensure that the benefits are made available to the member strictly as per terms of this Agreement and no benefit outside the terms of this Agreement shall be allowed without prior approval unless the same is essential for the recovery of members. xi. FCI shall not be liable to make any payment on account of claims which are in the opinion of FCI fraudulent or are as a result of fabricated claims. Corporation would have the right to blacklist the hospital if the Hospital is found to have facilitated the lodging of false claims, without prejudice to any other rights that the Corporation may have under the law.concerned