Common use of Monitoring and Control Clause in Contracts

Monitoring and Control. Scope of Monitoring Monitoring under AB-PMJAY shall include supervision and monitoring of all the activities under the AB-PMJAY undertaken by the Insurer and ensuring that the Insurer complies with all the provisions of the Insurance Contract signed with the State Health Agency (SHA) and all contracts and sub-contracts/ agreements issued by the Insurer pursuant to the Insurance Contract with the SHA for implementation of the Scheme. Monitoring shall include but not be limited to: Overall performance and conduct of the Insurer. Claims management process. Grievance redressal process. Fraud control process Any other aspect/ activity of the Insurer related to the implementation of the Scheme. Monitoring Activities to be undertaken by the Insurer General Monitoring Obligations Under the AB-PMJAY, the Insurer shall monitor the entire process of implementation of the Scheme on an ongoing basis to ensure that it meets its obligations under its Insurance Contract with the SHA. Towards this obligation the Insurer shall undertake, but not be limited to, the following tasks: Ensure compliance to all the terms, conditions and provisions of the Scheme. Ensure monitoring of processes for seamless access to cashless health care services by the AB-PMJAY beneficiaries under the provisions of the Scheme. Ensure monitoring of processes for timely processing, management and payment of all claims of the EHCPs. Ensure monitoring of processes/transactions/entities for fraud control Ensure fulfilment of minimum threshold levels as per the agreed Key Performance Indicators (KPIs) laid down in Schedule 12. Ensure compliance from all its sub-contractors, vendors and intermediaries hired/ contracted by the Insurer under the Scheme for the fulfilment of its obligations. Monitoring Activities to be undertaken by the State Health Agency Audits by the State Health Agency Audit of the audits undertaken by the Insurer: The SHA shall have the right to undertake sampled audits of all audits (Medical Audit and Hospital Audit) undertaken by the Insurer. Direct audits: In addition to the audit of the audits undertaken by the Insurer referred in Clause 23.3.1.a, the SHA shall have the right to undertake direct audits on a regular basis conducted either directly by it or through its authorized representatives/ agencies including appointed third parties. Direct audits shall include: Claims audit: For the purpose of claims audit, the SHA shall constitute a Claims Review Committee (CRC) that shall look into 100 percent of the claims rejected or partially settled by the Insurer to assure itself of the legitimacy of the Insurer’s decisions. Claims settlement decisions of the Insurer that are disputed by the concerned EHCP shall be examined in depth by the CRC after such grievance of the EHCP is forwarded by the concerned Grievance Redressal Committee (GRC) to the CRC. CRC shall examine the merits of the case within 30 working days and recommend its decision to the concerned GRC. The GRC shall then communicate the decision to the aggrieved party (the EHCP) as per the provisions specified in the Clause of Grievance Redressal Mechanism. During the claims audit the SHA shall look into the following aspects (indicative, not exhaustive): Evidence of rigorous review of claims adjudication. Comprehensiveness of claims submissions (documentation) by the EHCPs. Number of type of queries raised by the Insurer during review of claims – appropriateness of queries. Accuracy of claims settlement.

Monitoring and Control. Scope of Monitoring Monitoring under AB-PMJAY shall include supervision and monitoring of all the activities under the AB-PMJAY undertaken by the Insurer ISA and ensuring that the Insurer ISA complies with all the provisions of the Insurance Implementation Support Contract signed with the State Health Agency (SHA) and all contracts and sub-contracts/ agreements issued by the Insurer ISA pursuant to the Insurance Implementation Support Contract with the SHA for implementation of the Scheme. Monitoring shall include but not be limited to: Overall performance and conduct of the InsurerISA. Claims management process. Grievance redressal process. Fraud control process Any other aspect/ activity of the Insurer ISA related to the implementation of the Scheme. Monitoring Activities to be undertaken by the Insurer ISA General Monitoring Obligations Under the AB-PMJAY, the Insurer ISA shall monitor the entire process of implementation of the Scheme on an ongoing basis to ensure that it meets its obligations under its Insurance Implementation Support Contract with the SHA. Towards this obligation the Insurer ISA shall undertake, but not be limited to, the following tasks: Ensure compliance to all the terms, conditions and provisions of the Scheme. Ensure monitoring of processes for seamless access to cashless health care services by the AB-PMJAY beneficiaries under the provisions of the Scheme. Ensure monitoring of processes for timely processing, claim processing and management and payment of all claims of the EHCPs. Ensure monitoring of processes/transactions/entities for fraud control Ensure fulfilment of minimum threshold levels as per the agreed Key Performance Indicators (KPIs) laid down in Schedule 12. Ensure compliance from all its sub-contractors, vendors and intermediaries hired/ contracted by the Insurer ISA under the Scheme for the fulfilment of its obligations. Monitoring Activities to be undertaken by the State Health Agency Audits by the State Health Agency Audit of the audits undertaken by the InsurerISA: The SHA shall have the right to undertake sampled audits of all audits (Medical Audit and Hospital Audit) undertaken by the InsurerISA. Direct audits: In addition to the audit of the audits undertaken by the Insurer ISA referred in Clause 23.3.1.a, the SHA shall have the right to undertake direct audits on a regular basis conducted either directly by it or through its authorized representatives/ agencies including appointed third parties. Direct audits shall include: Claims audit: For the purpose of claims audit, the SHA shall constitute a Claims Review Committee (CRC) that shall look into 100 percent of the claims rejected recommended for rejection or partially processed by the ISA or partially settled by the Insurer ▇▇▇ to assure itself of the legitimacy of the InsurerISA’s decisions. Claims settlement decisions of the Insurer ISA that are disputed by the concerned EHCP shall be examined in depth by the CRC after such grievance of the EHCP is forwarded by the concerned Grievance Redressal Committee (GRC) to the CRC. CRC shall examine the merits of the case within 30 working days and recommend its decision to the concerned GRC. The GRC shall then communicate the decision to the aggrieved party (the EHCP) as per the provisions specified in the Clause of Grievance Redressal Mechanism. During the claims audit the SHA shall look into the following aspects (indicative, not exhaustive): Evidence of rigorous review of claims adjudication. Comprehensiveness of claims submissions (documentation) by the EHCPs. Number of type of queries raised by the Insurer ISA during review of claims – appropriateness of queries. Accuracy of claims settlement.