on

Operational Guidelines
on

Ayushman Bharat
National Health
Protection Mission
(AB-NHPM)
 TABLE OF CONTENTS
I. Foreword

II. Introduction and Salient Features of AB-NHPM

1. Guidelines on Constitution of State Health Agency (SHA) 01

2. Guidelines on Process of Beneficiary Identification 07

3. Guidelines on Process for Empanelment of Hospitals 19

4. Guidelines on Process for Hospital Transaction 40

5. Guidelines on Claim Settlement Process 48

6. Guidelines on Grievance Redressal 51

7. Guidelines on Release of Premium/ Grant-in-Aid 60

8. Guidelines on Use of Claim Amount Earned by Public Hospitals Under 71

AB-NHPM

9. Guidelines on Portability of Benefits 73

10. Structure and Tasks of State Health Agency for Implementation of 77

AB-NHPM in Assurance Mode
I. Introduction and Salient Features of the
AB-NHPM
Salient features of the Ayushman Bharat - National Health Protection Mission for families belonging
to poor, vulnerable and disadvantage sections of populations are as below:

1. Cashless and paperless access to services for the beneficiary at the point of service in any (both
public and private) empanelled hospitals across India.

2. The benefit coverage of AB-NHPM will be Rs. 5,00,000/- covering over 10 Crore beneficiary
families (identified through SECC database).

3. No restriction on family size, ensuring all members of designated families specifically girl child
and senior citizens get coverage. It is suggested that a female member of the household is
made the head of the family to preferably make women as the head of family.

4. This scheme is on entitlement basis. Every family figuring in defined Socio Economic Caste
Census 2011 database will be entitled to claim benefit under the scheme. The beneficiaries will
be encouraged to bring Aadhaar for the purpose of identification. However, no person will be
denied benefits under the scheme in the absence of Aadhaar.

5. Implementation Arrangement – States would have the option to use an existing Trust/ Society/
Not for Profit Company or set up a new Trust/ Society/ Not for Profit Company [State Health
Agency] to implement the scheme. With respect to implementation, the States will be free to
choose the modalities for implementation. They can implement the scheme through insurance
company or directly through the Trust/ Society or mixed model.

6. A well-defined Complaint and Public Grievance Redressal Mechanism actively utilising

electronic, mobile platform, internet as well as social media, will be put in place through which
complaints/ grievances will be registered, acknowledged, escalated for relevant action, resolved
and monitored.

7. While ensuring user convenience, AB-NHPM would create robust safeguards to prevent misuse/
fraud/ abuse by providers and users. Pre-Authorisation will be made mandatory for all tertiary
care and selected secondary care packages.
 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

1. Guidelines on Constitution of State Health

Agency (SHA)
In order to facilitate the effective implementation of the scheme, the State Government shall set up
the State Health Agency (SHA) or designate this function under any existing agency/ trust/ society
designated for this purpose, such as the state nodal agency for RSBY or a trust/ society set up for a
state insurance program. SHA can either implement the scheme directly (Trust/ Society mode) or it
can use an insurance company to implement the scheme. The SHA shall be responsible for delivery
of the services under AB-NHPM at the State level.

Similar to the National Health Agency (NHA) at the central level, the day-to-day operations of the
SHA will be administered by a Chief Executive Officer (CEO) appointed by the State Government.
The CEO will look after all the operational aspects of the implementation of the scheme in the
State and shall be supported by a team of specialists (dealing with specific functions). The CEO/
operations team will be counselled and overseen by a governing council set up at the State level.

1.1. Roles and Responsibilities of SHA

All key functions relating to delivery of services under AB-NHPM shall be performed by
the SHA viz. data sharing, verification/validation of families and members, awareness
generation, monitoring etc. The SHA shall perform following activities through staff of SHA/
Implementation Support Agency (ISA):

- Policy related issues of State Health Protection/ Insurance scheme and its linkage to
AB-NHPM
- Convergence of State scheme with AB-NHPM
- Selection of Insurance Company through tendering process (if implementing AB-NHPM
through Insurance Companies)
- Selection of Implementation Support Agencies (in Trust/ society mode) if needed
- Awareness generation and Demand creation
- Aadhaar seeding and issuing print out of E-card to validated AB-NHPM beneficiaries
- Empanelment of network hospitals which meet the criteria
- Monitoring of services provided by health care providers
- Fraud and abuse Control
- Punitive actions against the providers
- Monitoring of pre-authorizations which are already approved by Insurer/ ISA
- Administration of hospital claims which are already approved by Insurer/ ISA
- Package price revisions or adaptation of AB-NHPM list
- Adapting AB-NHPM treatment protocols for listed therapies to state needs, as needed

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

- Adapting operational guidelines in consultation with NHA, where necessary

- Forming grievance redressal committees and overseeing the grievance redressal
function
- Capacity development planning and undertaking capacity development initiatives
- Development of proposals for policy changes – e.g. incentive systems for public
providers and implementation thereof
- Management of funds through the Escrow account set up for purposes of premium
release to Insurance Company under AB-NHPM
- Data management
- Evaluation through independent agencies
- Convergence of AB-NHPM with State funded health insurance/ protection scheme (s)
- Alliance of State scheme with AB-NHPM
- Setting up district level offices and hiring of staff for district
- Overseeing district level offices
- Preparation of periodic reports based on scheme data and implementation status
- Implementing incentive systems for ASHA workers & public providers in line with
national guidance

1.2. Constitution of SHA/Governing Council

The suggested composition of SHA is as follows:

S. No. Name / Designation Position

1 Chief Secretary Chairperson, ex-officio
2 Principal Secretary to Government, Health & Vice-Chairperson, ex officio
Family Welfare Department
3 Secretary, Finance Department Member, ex officio
4 Secretary, Department of Rural Development Member, ex officio
5 Secretary, Department of Housing and Urban Member, ex officio
Affairs
6 Secretary, Department of IT Member, ex officio
7 Secretary, Department of Labour Member, ex officio
8 MD, NHM or Commissioner, Health Department Member, ex officio
9 Director of Medical Education or his/her nominee Member, ex officio
10 Director of Health Services or his/her nominee Member, ex officio
11 CEO (SHA) Member Secretary, ex officio
12 Representative of NHA Special Invitee
13 1 Subject matter expert as nominated by the Special Invitee
State Government

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

1.3. Operational Core Team of SHA

The Chief Executive Officer (CEO) will look after all the operational aspects of the
implementation of the scheme and shall be supported by a team of specialists (dealing with
specific functions). The SHA should hire the following team to support the Chief Executive
Officer in discharge of different functions:

No. in Category No. in Category

Position Responsibility
A State B State
Operations Manager (s) • Pre-authorization 2 3
process
• Claims management
• Finalization of
Packages & Pricing
Monitoring & Evaluation • Monitoring & evaluation 2 4
Manager of functioning of key
vendors including
any insurers, ISA,
hospitals, field
personnel, monitoring
achievement of goals
of the scheme
Policy • Designing policy for 1 2
State Schemes and
convergence thereof
with AB-NHPM
IT Support cum Data • Data availability, 2 3
Manager integrity and security
• MIS coordination
• Management of IT
hardware & software
Beneficiary Verification • Co-ordination for 1 2
smooth beneficiary
verification process
• Manage issues
related to beneficiary
verification
Grievance Redressal • Oversee Grievance 1 2
Manager redressal mechanisms
• Undertake beneficiary
communication.
• Local grievance
redressal

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

Medical Management & • Designing standard 2 4

Quality Manager packages and hospitals
empanelment criterion
for additionalities
like State schemes
such that they are
complimentary to AB-
NHPM
• Empanelment of
Hospital
• Quality & Patient safety
• Punitive action against
hospitals
IEC Manager • Strategic 1 2
communication
planning and execution
Capacity Development • Training & capacity 1 2
Manager building planning and
organization
Finance Manager • Fund management 2 3
• Managing initial corpus
& funding of trust
• Managing finance &
admin processes
• Claim settlement
• Payments
• Budgeting & accounting
• Internal and external
audit
Accounts Assistant • Assisting Accounts 1 1
manager in finance &
admin processes
Administrative Officer • General administration 1 1
of the programme

*States have been categorized based on AB-NHPM target population size as below, in two
groups, where group B may need more than one official for the same role.

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

Category State Names

A Arunachal Pradesh, Goa, Himachal Pradesh, Jammu and
Kashmir, Manipur, Meghalaya, Mizoram, Nagaland, NCT Delhi,
Sikkim, Tripura, Uttarakhand and 6 Union Territories (Andaman
and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli,
Daman and Diu, Lakshadweep and Puducherry)
B Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana,
Jharkhand, Karnataka, Kerala, Madhya Pradesh, Maharashtra,
Odisha, Punjab, Rajasthan, Tamil Nadu, Telangana, Uttar
Pradesh, West Bengal

1.4. Structure at District Level

In addition to the State level posts, a District Implementation Unit (DIU) will also be required
to support the implementation in every district included under the scheme. This team will be
in addition to the team deployed by Insurance Company/ ISA. A DIU shall be created which
would be chaired by the Deputy Commissioner/ District Magistrate/ Collector/ of the district.
This Unit is to coordinate with the Implementing Agency (ISA/ Insurer) and the Network
Hospitals to ensure effective implementation and also send review reports periodically. DIU
will also work closely and coordinate with District Chief Medical officer and his/ her team.

Proposed staffing pattern of the DIU as follows:

Post Qualification Status No.

District Nodal Program Officer designated by Regular state 1 per district
Officer (AB- the State. Regular state official official, may be
NHPM) and responsible for the AB- part-time role
NHPM implementation in the
district.
District Program Staff hired with experience Contractual, full 1 per district
Coordinator in medical management/ time
health insurance industry
overseeing grievance redressal,
Aadhaar seeding, validation
of beneficiaries, awareness,
monitoring, spot checks, and
capacity building.

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

District Staff hired with experience Contractual, full 1 per district

Information in IT hardware and hospital time
Systems software functionality helping
Manager hospitals and implementing
agencies (insurer/ISA) with
use of the information system,
troubleshooting, report-
generation and ensuring uptime
of system functionality across
the National Health Network.
District Staff hired with experience Contractual, full 1 per district
Grievance in grievance management time
Manager for managing complaint and
grievances at the district level.
Also responsible for organising
meetings of District Grievance
Committees.

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

2. Guidelines on Process of Beneficiary

Identification

2.1. Brief Process Flow

The core principle for finalising the operational guidelines for proposed AB-NHPM is to
construct a broad framework as guiding posts for simplifying the implementation of the
Mission under the ambit of the policy and the technology while providing requisite flexibility
to the States to optimally chalk out the activities related to implementation in light of the
peculiarities of their own State/UT, as ownership of implementation of scheme lies with
them.

A. AB-NHPM will target about 10.74 crore poor, deprived rural families and identified
occupational category of urban workers’ families as per the latest Socio-Economic Caste
Census (SECC) data, both rural and urban. Additionally, all such enrolled families under
RSBY that do not feature in the targeted groups as per SECC data will be included as
well.

B. States covering a much larger population than the AB-NHPM beneficiary list will need
to

i) Provide a declaration that their eligibility criteria covers AB-NHPM beneficiaries

ii) Setup a process to ensure any family in AB-NHPM list who may be missed under
the State’s criteria is covered when they seek care
iii) Beneficiaries obtaining treatment should be tagged if they are AB-NHPM
beneficiaries. Reports to MoHFW/ NHA will need to be provided for these
beneficiaries
iv) Link all AB-NHPM beneficiaries with the State’s Scheme ID and Aadhaar in a
defined time period

C. State/UT will be responsible for carrying out Information, Education and Communication
(IEC) activities amongst targeted families such that they are aware of their entitlement,
benefit cover, empanelled hospitals and process to avail the services under AB-
NHPM. This will include leveraging village health and nutrition days, making available
beneficiary family list at Panchayat office, visit of ASHA workers to each target family
and educating them about the scheme, Mass media, etc among other activities. The
following 2 IEC activities are designed to aid in Beneficiary Identification:

i) AB-NHPM Additional Data Collection drive at Gram Sabha’s across India took
place on 30th April. MoHFW in collaboration with Ministry of Rural Development
(MoRD). In the drive details related to beneficiary identification such as Ration

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

Card, Mobile Number, etc. were collected for each AB-NHPM household. Similar
exercise was carried out for urban beneficiaries in May 2018.
ii) Government of India will send a personalised letter via mass mail to each targeted
family through postal department in states launching AB-NHPM. This letter will
include details about the scheme, toll free helpline number and family details and
their ID under AB-NHPM
iii) States which are primarily covering AB-NHPM beneficiaries are encouraged to
create multiple service locations where beneficiaries can check if they are covered.
These include
→ Contact points or kiosks set up at CSCs, PHCs, Gram Panchayat, etc
→ Empanelled Hospital
→ Self-check via mobile or web
→ Or any other contact point as deemed fit by States

D. Beneficiary identification will include the following broad steps:

i) The operator searches through the AB-NHPM list to determine if the person
is covered.
ii) Search can be performed by Name and Location, Ration Card No or Mobile
number (collected during data drive) or ID printed on the letter sent to family
or RSBY URN.
iii) If the beneficiary’s name is found in the AB-NHPM list, Aadhaar (or an
alternative government ID) and Ration Card (or an alternative family ID) is
collected against the Name / Family.
iv) The system determines a confidence score for the link based on how close
the name / location / family members between the AB-NHPM record and
documents is provided.
v) The operator sends the linked record for approval to the Insurance company
/ Trust.
vi) If the confidence score is high (as specified by software) the operator can
immediately issue the e-Card and admit the patient for treatment. Otherwise,
the patient must be advised to wait for approval from the insurance company/
trust
vii) The insurance company / Trust will setup a Beneficiary approval team
that works on fixed service level agreements on turnaround time. The AB-
NHPM details and the information from the ID is presented to the verifier.
The insurance company / Trust can either approve or recommend a case for
rejection with reason.

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

viii) All cases recommended for rejection will be scrutinised by a State team that
works on fixed service level agreements on turnaround time. The state team
will either accept rejection or approve with reason.
ix) The e-card will be printed with the unique ID under AB-NHPM and handed
over to the beneficiary to serve as a proof for verification for future reference.
→ The beneficiary will also be provided with a booklet/ pamphlet with
details about AB-NHPM and process for availing services.
→ Presentation of this e-card (appendix 2: draft sample design) will not be
mandatory for availing services. However, the e-card may serve as a tool
for reinforcement of entitlement to the beneficiary and faster registration
process at the hospital when needed.

E. Addition of new family members will be allowed. This requires at least one other family
member has been approved by the Insurance Company/Trust. Proof of being part of
the same family is required in the form of-

i) Name of the new member is in the family ration card or State defined family card
ii) A marriage certificate to a family member is available
iii) A birth certificate to a family member is available

2.2. Detailed Steps for Beneficiary Identification and Issuance of

e-card
AB-NHPM will target about 10.74 crore poor, deprived rural families and identified occupational
category of urban workers’ families as per the latest Socio-Economic Caste Census (SECC)
data, both rural and urban. Additionally, all such enrolled families under RSBY that do not
feature in the targeted groups as per SECC data will be included as well.

The main steps for the above exercise are as follows:

A. Preparatory Activities for State/ UT’s:

Responsibility of – State Government

Timeline – within a period of 15 days, after receiving the approval from MoHFW/NHA,
the State/UT may complete the preparatory activities to initiate the implementation and
beneficiary identification process.

The State will need to:

i) Ensure the availability of requisite hardware, software and allied infrastructure

required for beneficiary identification and AB-NHPM e-card printing. Beneficiary
Identification Software/ Application/ platform will be provided free of cost by
MoHFW/NHA. Specifications for these will be provided by MoHFW/NHA.

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

ii) Availability of printed booklets, in abundant quantities at each Contact point, which
will be given to beneficiaries along with the AB-NHPM e-cards after verification.
The booklet/pamphlet shall provide the following details:
→ Details about the AB-NHPM benefits
→ Process of taking the benefits under AB-NHPM and policy period
→ List of the empanelled network hospitals in the district along with address and
contact details (if available)
→ The names and details of the key contact person/persons in the district
→ Toll-free number of AB-NHPM call centre (if available)
→ Details of DNO for any further contact

iii) State/State Health Agency (SHA) shall identify and set-up team(s) which shall have
the capacities to handle hardware and basic software support, troubleshooting
etc.
iv) Training of trainers for this purpose will be organised by MoHFW/NHA.

The State shall ensure availability of above, in order to carry out all the activities
laid down in this guideline.

B. Preparation of AB-NHPM target data

Responsibility of – MoHFW

Timeline – Preparation of SECC data by 15th March

MoHFW has decided to use latest Socio-Economic Caste Census (SECC) data as a
source/base data for validation of beneficiary families under the AB-NHPM. Based on
SECC data, number of families in each State, that will be eligible for central subsidy
under the AB-NHPM, will be identified. The categories in rural and urban that will be
covered under AB-NHPM are given as follows:

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

For Rural

Total deprived Households targeted for AB-NHPM who belong to one of the six
deprivation criteria amongst D1, D2, D3, D4, D5 and D7:

• Only one room with kucha walls and kucha roof (D1)
• No adult member between age 16 to 59 (D2)
• Female headed households with no adult male member between age 16 to 59
(D3)
• Disabled member and no able-bodied adult member (D4)
• SC/ST households (D5)
• Landless households deriving major part of their income from manual casual
labour (D7)
Automatically included-

Households without shelter

• Destitute/ living on alms
• Manual scavenger families
• Primitive tribal groups
• Legally released bonded labour
For Urban

Occupational Categories of Workers

• Rag picker
• Beggar
• Domestic worker
• Street vendor/ Cobbler/hawker / Other service provider working on streets
• Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/
Coolie and another head-load worker
• Sweeper/ Sanitation worker / Mali
• Home-based worker/ Artisan/ Handicrafts worker / Tailor
• Transport worker/ Driver/ Conductor/ Helper to drivers and conductors/ Cart puller/
Rickshaw puller
• Shop worker/ Assistant/ Peon in small establishment/ Helper/Delivery assistant /
Attendant/ Waiter
• Electrician/ Mechanic/ Assembler/ Repair worker
• Washer-man/ Chowkidar

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

The following activities will be carried out for identifying target families for AB-NHPM:

i) AB-NHPM data in defined format by applying inclusion and exclusion criteria shall
be prepared.

ii) Preparation of Rashtriya Swasthya Bima Yojana (RSBY) beneficiary family list
(based on existing RSBY enrolled families) for such families where premium has
been paid by Government of India and data finalized by MoHFW with inputs of
States.

iii) AHL_HH_ID will be considered as Family ID for AB-NHPM targeted families.

iv) Final data will be accessible in a secure manner to only authorised users who will
be allowed to access it online and use it for beneficiary verification.

Example:
A. State implementing RSBY –the scenario could be as follows:

• Number of eligible families in SECC Data = 50 lakhs

• Number of families currently enrolled in RSBY = 52 lakhs
• Total Number of eligible families for AB-NHPM = 52 lakhs

B. State/ UT not implementing RSBY - the scenario could be as follows:

• Number of eligible families in SECC data = 50 lakhs

• Total number of eligible families for AB-NHPM = 50 lakhs

C. State implementing their own scheme – the scenario could be as follows:

• Number of eligible families in SECC Data = 50 lakhs

• Number of families currently covered in State Scheme = 75 lakhs
• Total Number of eligible families for AB-NHPM = 50 lakhs

C. Informing Beneficiaries on what to bring for Identification

Responsibility of – SHA

Timeline – Ongoing

The process requires that Beneficiaries bring

→ Aadhaar
→ Any other valid government id(s) decided by the State if they do not have an
Aadhaar
→ Ration Card or any other family id decided by the State

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

All IEC activities (see detailed IEC guidelines) must work towards education of the
above to ensure it is easy for the beneficiaries to receive care.

D. Beneficiary identification Contact Points – Infrastructure and Locations

Any resident must be able to easily find out if they are covered under the scheme.
This is especially critical in States that are launching only on the basis of AB-NHPM list
(SECC + RSBY). These states are encouraged to create a large number of resident
contact points where they can easily check if they are eligible and obtain an e-card.

The Beneficiary identification contact point will require

→ A computer with the latest browser
→ A QR code scanner
→ A document scanner to scan requisite documents
→ A printer to print the e-Card
→ A web camera for photos
→ Internet connectivity
→ Aadhaar registered device for fingerprint and iris biometrics (only at Hospital
Contact Points)

Only Hardware and software as prescribed by MoHFW/NHA shall be used. Detailed

specifications will be provided in a separate document. Beneficiary identification will be
available as a web and mobile application. Availability as a mobile app will make it easy
to be deployed at larger number of contact points. The DNO shall be responsible for
choosing the locations for contact centres within each village/ward area that is easily
accessible to a maximum number of beneficiary families including the following:

→ CSC
→ PHCs
→ Gram Panchayat Office
→ Empanelled Hospital
→ Or any other contact point as deemed fit by States/UTs

Required hardware and software must be setup in these contact points which will be
authorized to perform Beneficiary identification and issue e-cards.

SHA/ District Nodal Agency will organize training sessions for the operators so that
they are trained in the Beneficiary identification, Aadhaar seeding and AB-NHPM
e-card printing process. Operators are registered entities in the system. All beneficiary
verification requests are tagged to the operator that initiated the request. If the insurer
(Insurance Company/ Trust) rejects multiple requests from a single operator – the
system will bar the operator till further training / remedial measures can be undertaken.

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2.3. Process Flow Chart for Beneficiary Identification

2.4. Identity Document for a Family Member

Aadhaar will be the primary identity document for a family member that has to be produced
under the AB-NHPM scheme. When the beneficiary comes to a contact point, the QR code
on the Aadhaar card is scanned (or an e-KYC is performed) to capture all the details of the
Aadhaar. A demographic authentication is performed with UIDAI to ensure the information
captured is authentic. A live photograph of the member is taken to be printed on the e-card.

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

If the AB-NHPM family member does not have an Aadhaar card and the contact point is a
location where no treatment is provided, the operator will inform the beneficiary that he is
eligible and can get treatment only once without an Aadhaar or an Aadhaar enrolment slip.
They may be requested to apply for an Aadhaar as quickly as possible. A list of the closest
Aadhaar enrolment centres is provided to the beneficiary.

If the AB-NHPM family member does not have an Aadhaar card and the contact point is a
Hospital or place of treatment then -

A. A signed declaration is taken from the Beneficiary that he does not possess an Aadhaar
card and understands he will need to produce an Aadhaar or an Aadhaar enrolment slip
prior to the next treatment
B. The beneficiary must produce an ID document from the list of approved ids by the State
C. The operator captures the type of ID and the fields as printed on the ID including the
Name, Father’s Name (if available), Age, Gender and Address fields
D. A scan of the ID produced is uploaded into the system for verification
E. A photo of the beneficiary is taken
F. The information from this alternate ID is used instead of Aadhaar for matching against
the AB-NHPM record

2.5. Searching the AB-NHPM Database

The AB-NHPM database will be searched based on the information provided in the Member
Identity document. AB-NHPM is based on SECC and it is likely that spellings for Name,
Fathers Name and even towns and villages will be different between the AB-NHPM record
and the identity document. A beneficiary will be eligible for AB-NHPM if the Name and
Location parameters in the beneficiary identity document can be regarded as similar to the
Name and Location parameters in the AB-NHPM record.

The Search system automatically provides a confidence score between the two.

AADHAAR or OTHER GOVERNMENT ID

AB-NHPM BENEFICARY RECORD
Beneficiary Identity Document
Name Geetha Bandhopadhya Name Gita Banarjee
Age 33 Age 40
Gender F Gender F
Father’s <Not Available> Father’s Name Arghya Banarjee
Name
State West Bengal State: West Bengal
District Malda District Malda
Town / Dakshin Chandipur Town / Village Dakshen
Village Chandhipur
NAME MATCH CONFIDENCE SCORE: 94%

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

The Search system will provide multiple ways to find the AB-NHPM beneficiary record. If
there are no results based on Name and Location, the operator should -

A. Search by Ration Card and Mobile No (Information captured during the Additional Data
Collection Drive)

B. Search using the ID printed on the letter sent by post to Beneficiaries (AHL_HH_ID)

C. Reduce some of the parameters like Age, Gender, Sub district, etc and trial with variation
in the spelling of the Name if there are no matching results

D. Try adding the name of the father or family members if there are too many results.

The Search system will show the number of results matched if > 5. The operator is expected
to add more information to narrow results. The actual results will be displayed when the
number matched is 5 or less. The operator has to select the correct record from the list
shown.

2.6. Searching the AB-NHPM Database for Valid RSBY Beneficiaries

The operator is unable to find the person using AB-NHPM search using Name and other
methods described above, then he can search from the valid RSBY database. The RSBY
URN printed on the beneficiary card is used to perform the search. The system fetches
the record from the RSBY database. The operator is presented with the confidence score
between the Beneficiary Identity document and the RSBY record.

2.7. Linking Family Identification Document with the AB-NHPM

Family
One or more Family Identity Cards can be linked with each AB-NHPM Family. While Ration
cards will be the primary family document, States can define additional family documents
that can be used. SECC survey was conducted on the basis of households and there are
possibilities where the household could have multiple ration cards.

Linking a family identification document strengthens the beneficiary identification process

as we can create a confidence score based on the names in family identification document
and AB-NHPM record.

Ration Card or Other Government FAMILY ID AB-NHPM BENEFICARY RECORD

Beneficiary Identity Document
Names of RAM, GEETHA, GOVIND, Names GEETHA,
family members MEENAKUMARI of family MEENAKUMARI, RAM
members
FAMILY MATCH CONFIDENCE SCORE: 92%

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

Linking the family identification document will be mandatory ONLY if the same document
(Ration Card) is also the ID used by the state to cover a larger base. Operators are
encouraged to upload the family document if the name match confidence score is low but
they believe the 2 records are the same

Integration with an online family card database is recommended. In this scenario, the
operator will enter the Family ID No (Ration Card No) and will be able to fetch the names of
the family members from the online database.

If an integration is not possible, the operator will enter the names of the family members as
written in the ID card and upload a scan of the ID card for verification.

2.8. Approval by Insurance Company/Trust

The State can appoint either the Insurance company or Trust to perform the verification of
the data of identified beneficiaries. The team needs to work with a strong Service Level
Agreements (SLA) on turnaround time. Approvals are expected to be provided within 30
minutes back to the operator on a 24x7 basis.
The Approver is presented the Beneficiary Identity Document and the AB-NHPM (or RSBY)
record side by side for validation along with the confidence score. The lowest confidence
score records are presented first.
If the operator has uploaded the Family Identity document it is also displayed along with the
Confidence Score.
The Approver has only 2 choices for each case – Approve or Recommend for Rejection with
Reason.
The System maintains a track of which Operator is Approving / Recommending for rejection.
The Insurance Company/Trust can analyze the approval or rejection pattern of each of the
operators.

A. Acceptance of Rejection Request by State (applicable only in case of Insurance

Company mode of implementation)

The State should setup a team that reviews all the cases recommended for Rejection.
The team reviews the data provided and the reason it has been recommended for
rejection. If the State agrees with the Insurer it can reject the case.
If the State disagrees with the Insurer it can approve the case. The person in the state
making the decision is also tracked in the system. The State review role is also SLA
based and a turnaround is expected in 24 hours on working hour basis.

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

B. Addition of Family Members

The AB-NHPM scheme allows addition of new family members if they became part of
the family either due to marriage or by birth. In order to add a family member, at least
one of the existing family members needs to be verified and the identity document used
for the verification must be Aadhaar.

To add the additional member the family must produce:

- The name of the additional member in a State approved family document like
Ration Card OR
- A birth certificate linking the member to the family OR
- A marriage certificate linking the member to the family.

In order to add a family member, at least one of the existing family members need to be
verified and the identity document used for the verification must be Aadhaar.

C. Monitoring of Beneficiary identification and e-card printing process

Responsibility of – State Government/ SHA

Timeline – Continuous

SG/ SHA will need to closely monitor of the process in order to ascertain challenges, if
any, being faced and resolution of the same. Monitoring of verification process may be
based on following parameters:

→ Number of contact points and manpower deployed/ Number and type of manpower
→ Time taken for issuance of e-card of each member
→ Percentage of families with at least one member having issued e-card out of total
eligible families in AB-NHPM
→ Percentage of members issued e-cards out of total eligible members in AB-NHPM
→ Percentage of families with at least one member verified out of total eligible families
in RSBY data (if applicable)
→ Percentage of members issued e-card out of total eligible members in RSBY data
(if applicable)
→ Percentage of total members where Aadhaar was available and captured and
percentage of members without Aadhaar number
→ Percentage of total members where mobile was available and capture

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

3. Guidelines on Process for Empanelment of

Hospitals

3.1. Basic Principles

For providing the benefits envisaged under the Mission, the State Health Agency (SHA)
through State Empanelment Committee (SEC) will empanel or cause to empanel private
and public health care service providers and facilities in their respective State/UTs as per
these guidelines.

The States are free to decide the mode of verification of empanelment application, conducting
the physical verification either through District Empanelment Committee (DEC) or using the
selected insurance company (Insurance Model), under the broad mandate of the instructions
provided in these guidelines.

3.2. Institutional Set-Up for Empanelment

A. State Empanelment Committee (SEC) will constitute of following members:

→ CEO, State Health Agency – Chairperson,

→ Medical Officer not less than the level of Director, preferably Director In Charge for
Implementation of Clinical Establishment Regulation Act – Member,
→ Two State government officials nominated by the Department – Members,
→ In case of Insurance Model, Insurance company to nominate a representative not
below Additional General Manager or equivalent,

The state government may invite other members to SEC as it may deem fit to assist
the Committee in its activities. The State Government may also require the Insurance
Company to mandatorily provide a medical representative to assist the SEC in its
activities.

Alternatively, the State/SHA may continue with any existing institution under the
respective state schemes that may be vested with the powers and responsibilities of
SEC as per these guidelines.

The SHAs through State Empanelment Committee (SEC) shall ensure:

→ Empanelment within the stipulated timeline for quick implementation of the

programme;
→ The empanelled provider meets the minimum criteria as defined by the guidelines
for general or specialty care facilities;
→ Empanelment and de-empanelment process transparency;

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

→ Time-bound processing of all applications; and

→ Time-bound escalation of appeals.

It is prescribed that at the district level, a similar committee, District Empanelment

Committee (DEC) will be formed which will be responsible for hospital empanelment
related activities at the district level and to assist the SEC in empanelment and
disciplinary proceedings with regards to network providers in their districts.

B. District Empanelment Committee (DEC) will constitute of the following members

→ Chief Medical Officer of the district

→ District Program Manager – State Health Agency
→ In case of Insurance Model, Insurance company representative

The State Government may require the Insurance Company to mandatorily provide a
medical representative to assist the DEC in its activities.

The structure of SEC and DEC for the two options are recommended as below:

S. SEC Recommended DEC Recommended

Institutional Option
No. Composition Composition
1. Approval of the • Chair: CEO/Officer in • Chair: CMO or
Empanelment Charge of State Health equivalent
application by the Agency
• At least 3 membered
State
• At least 5 membered committee
Committee
• At least one other
doctor other than
CMO
2. Verification of the • Chair: CEO/Officer in • DEC may have
Empanelment Charge of State Health 1 representative
application by the Agency from the insurance
Insurance Company company
• SEC may have 1
and approval by
representative from the
State
insurance company

The DEC will be responsible for:

→ Getting the field verification done along with the submission of the verification
reports to the SEC through the online empanelment portal.

→ The DEC will also be responsible for recommending, if applicable, any relaxation
in empanelment criteria that may be required to ensure that sufficient number of
empanelled facilities are available in the district.

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

→ Final approval of relaxation will lie with SEC

→ The SEC will consider, among other things, the reports submitted by the DEC
and recommendation approve or deny or return to the hospital the empanelment
request.

3.3. Process of Empanelment

A. Empanelment requirements

i) All States/UTs will be permitted to empanel hospitals only in their own State/UT.
ii) In case State/ UT wants to empanel hospitals in another State/UT, they can only
do so till the time that State/ UT is not implementing AB-NHPM. For such states
where AB-NHPM is not being implemented NHA may directly empanel CGHS
empanelled hospitals.
iii) All public facilities with capability of providing inpatient services (Community Health
Centre level and above) are deemed empanelled under AB-NHPM. The State
Health Department shall ensure that the enabling infrastructure and guidelines
are put in place to enable all public health facilities to provide services under AB-
NHPM.
iv) Employee State Insurance Corporation (ESIC) hospitals will also be eligible for
empanelment in AB-NHPM, based on the approvals.
v) For private providers and not for profit hospitals, a tiered approach to empanelment
will be followed. Empanelment criteria are prepared for various types of hospitals
/ specialties catered by the hospitals and attached in Annexure 1.
vi) Private hospitals will be encouraged to provide ROHINI provided by Insurance
Information Bureau (IIB). Similarly public hospitals will be encouraged to have NIN
provided by MoHFW.
vii) Hospitals will be encouraged to attain quality milestones by making NABH (National
Accreditation Board of Health) pre entry level accreditation/ NQAS (National
Quality Assurance Standards) mandatory for all the empaneled hospitals to be
attained within 1 year with 2 extensions of one year each.
viii) Hospitals with NABH/ NQAS accreditation will be given incentivised payment
structures by the states within the flexibility provided by MoHFW/NHA. The
hospital with NABH/ NQAS accreditation can be incentivized for higher package
rates subject to Procedure and Costing Guidelines.
ix) Hospitals in backwards/rural/naxal areas may be given incentivised payment
structures by the states within the flexibility provided by MoHFW/NHA
x) Criteria for empanelment has been divided into two broad categories as given
below.

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

Category 1: General Criteria Category 2: Specialty Criteria

All the hospitals empanelled under Hospitals would need to be empanelled
AB-NHPM for providing general care separately for certain tertiary care packages
have to meet the minimum criteria authorized for one or more specialties (like
established under the Mission detailed in Cardiology, Oncology, Neurosurgery etc.).
Annexure 1. No exceptions will be made This would only be applicable for those
for any hospital at any cost. hospitals who meet the general criteria for the
AB-NHPM.

Detailed empanelment criteria have been provided as Annexure 1.

State Governments will have the flexibility to revise/relax the empanelment criteria based,
barring minimum requirements of Quality as highlighted in Annexure 1, on their local context,
availability of providers, and the need to balance quality and access; with prior approval
from National Health Agency. The same will have to be incorporated in the web-portal for
online empanelment of hospitals.

Hospitals will undergo a renewal process for empanelment once every 3 years or till
the expiry of validity of NABH/ NQAS certification whichever is earlier to determine
compliance to minimum standards.

National Health Agency may revise the empanelment criteria at any point during the
programme, if required and the states will have to undertake any required re-assessments
for the same.

3.4. Awareness Generation and Facilitation

The state government shall ensure that maximum number of eligible hospitals participate in
the AB-NHPM, and this need to be achieved through IEC campaigns, collaboration with and
district, sub-district and block level workshops.

The state and district administration should strive to encourage all eligible hospitals in their
respective jurisdictions to apply for empanelment under AB-NHPM. The SHA shall organise
a district workshop to discuss the details of the Mission (including empanelment criteria,
packages and processes) with the hospitals and address any query that they may have
about the mission.

Representatives of both public and private hospitals (both managerial and operational
persons) including officials from Insurance Company will be invited to participate in this
workshop.

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

3.5. Online Empanelment

A. A web-based platform is being provided for empanelment of hospitals for AB-NHPM.
B. The hospitals can apply through this portal only, as a first step for getting empanelled in
the programme.
C. This web-based platform will be the interface for application for empanelment of
hospitals under AB-NHPM.
D. Following the workshop, the hospitals will be encouraged to initiate the process of
empanelment through the web portal. Every hospital willing to get empanelled will need
to visit the web portal, www.abnhpm.gov.in and create an account for themselves.
E. Availability of PAN CARD number (not for public hospitals) and functional mobile
number of the hospital will be mandatory for creation of this account / Login ID on the
portal for the hospital.
F. Once the login ID is created, hospital shall apply for empanelment through an online
application on the web portal - www.abnhpm.gov.in.
G. Each hospital will have to create a primary and a secondary user ID at the time of
registration. This will ensure that the application can be accessed from the secondary
user ID, in case the primary user is not available for some reason.
H. All the required information and documents will need to be uploaded and submitted by
the hospital through the web portal.
I. Hospital will be mandated to apply for all specialties for which requisite infrastructure
and facilities are available with it. Hospitals will not be permitted to choose specific
specialties it wants to apply for unless it is a single specialty hospital.
J. After registering on the web-portal, the hospital user will be able to check the status
of their application. At any point, the application shall fall into one of the following
categories:

i) Hospital registered but application submission pending

ii) Application submitted but document verification pending
iii) Application submitted with documents verified and under scrutiny by DEC/SEC
iv) Application sent back to hospital for correction
v) Application sent for field inspection
vi) Inspection report submitted by DEC and decision pending at SEC level
vii) Application approved and contract pending
viii) Hospital empanelled
ix) Application rejected
x) Hospital de-empanelled
xi) Hospital blacklisted (2 years)

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

3.6. Role of DEC

A. After the empanelment request by a hospital is filed, the application should be scrutinized
by the DEC and processed completely within 15 days of receipt of application.
B. A login account for a nodal officer from DEC will be created by SEC. This login ID will
be used to download the application of hospitals and upload the inspection report.
C. As a first step, the documents uploaded have to be correlated with physical verification
of original documents produced by the hospital. In case any documents are found
wanting, the DEC may return the application to the hospital for rectifying any errors in
the documents.
D. After the verification of documents, the DEC will physically inspect the premises of the
hospital and verify the physical presence of the details entered in the empanelment
application, including but not limited to equipment, human resources, service standards
and quality and submit a report in a said format through the portal along with supporting
pictures/videos/document scans.
E. DEC will ensure the visits are conducted for the physical verification of the hospital. The
verification team will have at least one qualified medical doctor (minimum MBBS).
F. The team will verify the information provided by the hospitals on the web-portal and will
also verify that hospitals have applied for empanelment for all specialties as available
in the hospital.
G. In case during inspection, it is found that hospital has not applied for one or more
specialties but the same facilities are available, then the hospital will be instructed
to apply for the missing specialties within a stipulated a timeline (i.e. 7 days from the
inspection date).

i) In this case, the hospital will need to fill the application form again on the web
portal. However, all the previously filled information by the hospital will be pre-
populated and hospital will be expected to enter the new information.
ii) If the hospital does not apply for the other specialties in the stipulated time, it will
be disqualified from the empanelment process.
H. In case during inspection, it is found that hospital has applied for multiple specialties,
but all do not conform to minimum requirements under AB-NHPM then the hospital
will only be empanelled for specialties that conform to AB-NHPM norms.
I. The team will recommend whether hospital should be empanelled or not based on
their field-based inspection/verification report.
J. DEC team will submit its final inspection report to the state. The district nodal
officer has to upload the reports through the portal login assigned to him/her.
K. The DEC will then forward the application along with its recommendation to the
SEC.

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

3.7. Role of SEC

A. The SEC will consider, among other things, the reports submitted by the DEC. The
hospital mpanelment request shall be approved, denied or returned to the hospital.
B. In case of refusal, the SEC will record in writing the reasons for refusal and either direct
the hospital to remedy the deficiencies, or in case of egregious emissions from the
empanelment request, either based on documentary or physical verification, direct the
hospital to submit a fresh request for empanelment on the online portal.
C. The SEC will also consider recommendations for relaxation of criteria of empanelment
received from DEC or from the SHA and approve them to ensure that sufficient number
and specialties of empanelled facilities are available in the states.
D. Hospital will be intimated as soon as a decision is taken regarding its empanelment and
the same will be updated on the AB-NHPM web portal. The hospital will also be notified
through SMS/email of the final decision. If the application is approved, the hospital will
be assigned a unique national hospital registration number under AB-NHPM.
E. If the application is rejected, the hospital will be intimated of the reasons on the basis
of which the application was not accepted and comments supporting the decision will
be provided on the AB-NHPM web portal. Such hospitals shall have the right to file a
review against the rejection with the State Health Agency within 15 days of rejection
through the portal. In case the request for empanelment is rejected by the SHA in
review, the hospitals can approach the Grievance Redressal Mechanism for remedy.
F. In case the hospital chooses to withdraw from AB-NHPM, it will only be permitted to re-
enter/ get re-empanelled under AB-NHPM after a period of 6 months.
G. If a hospital is blacklisted for a defined period due to fraud/abuse, after following due
process by the State Empanelment Committee, it can be permitted to re-apply after
cessation of the blacklisting period or revocation of the blacklisting order, whichever is
earlier.
H. There shall be no restriction on the number of hospitals that can be empanelled under
AB-NHPM in a district.

I. Final decision on request of a Hospital for empanelment under AB-NHPM, shall be

completed within 30 days of receiving such an application.

3.8. Fast Track Approvals

A. In order to fast track the empanelment process, hospitals which are NABH/ NQAS
accredited shall be auto-empaneled provided they have submitted the application on
web portal and meet the minimum criteria.
B. In order to fast track the empanelment process, the states may choose to auto-approve
the already empanelled hospitals under an active RSBY scheme or any other state
scheme; provided they meet the minimum eligibility criteria prescribed under AB-NHPM.

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

C. If already empanelled, under this route, should the state allow the auto-approval
mode, the hospital should submit their RSBY government empanelment ID or State
empanelment ID during the application process on the web portal to facilitate on-
boarding of such service providers.
D. The SEC shall ensure that all hospitals provided empanelment under Fast Track
Approval shall undergo the physical verification process within 3 months of approval. If
a hospital is found to have wrongfully empanelled under AB-NHPM under any category,
such an empanelment shall be revoked to the extent necessary and disciplinary action
shall be taken against such an errant medical facility.

3.9. Signing of Contract

A. Within 7 days of approval of empanelment request by SEC, the State Government will
sign a contract with the empanelled hospitals as per the template defined in the tender
document.
B. If insurance company is involved in implementing the scheme in the State, they will also
be part of this agreement, i.e. tripartite agreement will be made between the IC, SHA
and the hospital.
C. Each empanelled hospital will need to provide a name of a nodal officers who will be
the focal point for the AB-NHPM for administrative and medical purposes.
D. Once the hospital is empanelled, a separate admin user for the hospital will be created
to carry out transactions for providing treatment to the beneficiaries.

3.10. Process for Disciplinary Proceedings and De-Empanelment

A. Institutional Mechanism

i) De-empanelment process can be initiated by Insurance Company/SHA after

conducting proper disciplinary proceedings against empanelled hospitals on
misrepresentation of claims, fraudulent billing, wrongful beneficiary identification,
overcharging, charging money from patients unnecessarily, unnecessary
procedures, false/misdiagnosis, referral misuse and other frauds that impact
delivery of care to eligible beneficiaries.
ii) Hospital can contest the action of de-empanelment by Insurance Company
with SEC/SHA. If hospital is aggrieved with actions of SEC/SHA, the former
can approach the SHA to review its decision, following which it can request for
redressal through the Grievance Redressal Mechanism as per guidelines.
iii) In case of implementation through the insurance mode, the SEC and DEC will
mandatorily include a representative of the Insurance Company when deliberating
and deciding on disciplinary proceedings under the scheme.

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

iv) The SEC may also initiate disciplinary proceedings based on field audit reports/
survey reports/feedback reports/ complaints filed with them/ complaints.
v) For disciplinary proceedings, the DEC may consider submissions made by the
beneficiaries (through call centre/ mera hospital or any other application/ written
submissions/Emails etc.) or directions from SEC or information from other sources
to investigate a claim of fraud by a hospital.
vi) On taking up such a case for fraud, after following the procedure defined, the DEC
will forward its report to the SEC along with its recommendation for action to be
taken based on the investigation.
vii) The SEC will consider all such reports from the DECs and pass an order detailing
the case and the penalty provisions levied on the hospital.
viii) Any disciplinary proceeding so initiated shall have to be completed within 30 days.

B. Steps for Disciplinary Proceedings

Step 1 - Putting the provider on “Watch-list”

Based on the claims, data analysis and/or the provider visits, if there is any doubt on
the performance of a Provider, the SEC on the request of the IC or the SHA or on its
own findings or on the findings of the DEC, can put that hospital on the watch list. The
data of such hospital shall be analysed very closely on a daily basis by the SHA/SEC
for patterns, trends and anomalies and flagged events/patterns will be brought to the
scrutiny of the DEC and the SEC as the case may be.

The IC shall notify such service provider that it has been put on the watch-list and the
reasons for the same.

Step 2 – Issuing show-cause notice to the hospital

Based on the activities of the hospital if the insurer/ trust believes that there are clear
grounds of hospital indulging in wrong practices, a showcause notice shall be issued to
the hospital. Hospital will need to respond to the notice within 7 days of receiving it.

Step 3 - Suspension of the hospital

A Provider can be temporarily suspended in the following cases:

i) For the Providers which are on the “Watch-list” or have been issued showcause
notice if the SEC observes continuous patterns or strong evidence of irregularity
based on either claims data or field visit of the hospital or in case of unsatisfactory
reply of the hospital to the showcause notice, the hospital may be suspended from
providing services to beneficiaries under the scheme and a formal investigation
shall be instituted.

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

ii) If a Provider is not in the “Watch-list”, but the SEC observes at any stage that it has
data/ evidence that suggests that the Provider is involved in any unethical Practice/
is not adhering to the major clauses of the contract with the Insurance Company /
involved in financial fraud related to health insurance patients, it may immediately
suspend the Provider from providing services to policyholders/insured patients
and a formal investigation shall be instituted.

A formal letter shall be sent to the concerned hospital regarding its suspension with
mentioning the time frame within which the formal investigation will be completed.

Step 4 - Detailed Investigation

The detailed investigation shall be undertaken for verification of issues raised in
disciplinary proceedings and may include field visits to the providers (with qualified
allopathic doctor as part of the team), examination of case papers, talking with the
beneficiary/ policyholders/insured (if needed), examination of provider records etc. If
the investigation reveals that the report/ complaint/ allegation against the provider is not
substantiated, the Insurance Company/SHA would immediately revoke the suspension
(in case of suspension) on the direction of the SEC. A letter regarding revocation of
suspension shall be sent to the provider within 24 hours of that decision.

Step 5 – Presentation of Evidence to the SEC

The detailed investigation report should be presented to the SEC and the detailed
investigation should be carried out in stipulated time period of not more than 7 days.
The insurance company (Insurance mode)/SHA (Trust Mode) will present the findings
of the detailed investigation. If the investigation reveals that the complaint/allegation
against the provider is correct, then the following procedure shall be followed:

i) The hospital must be issued a “show-cause” notice seeking an explanation for the
aberration.

ii) In case the proceedings are under the SEC, after receipt of the explanation and its
examination, the charges may be dropped or modified or an action can be taken as per the
guidelines depending on the severity of the malafide/error. In cases of de-empanelment,
a second show cause shall be issued to the hospital to make a representation against
the order and after considering the reply to the second showcause, the SEC can pass
a final order on de-empanelment. If the hospital is aggrieved with actions of SEC/SHA,
the former can approach the SHA to review its decision, following which it can request
for redressal through the Grievance Redressal Mechanism as per guidelines.

iii) In case the preliminary proceedings are under the DEC, the DEC will have to forward
the report to the SEC along with its findings and recommendations for a final decision.
The SEC may ask for any additional material/investigation to be brought on record and
to consider all the material at hand before issuing a final order for the same.

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

The entire process should be completed within 30 days from the date of suspension.
The disciplinary proceedings shall also be undertaken through the online portal only.

Step 6 - Actions to be taken after De- empanelment

Once the hospital has been de-empanelled, following steps shall be taken:

i) A letter shall be sent to the hospital regarding this decision.

ii) A decision may be taken by the SEC to ask the SHA/Insurance Company to lodge an
FIR in case there is suspicion of criminal activity.

iii) This information shall be sent to all the other Insurance Companies as well as other
regulatory bodies and the MoHFW/ NHA.

iv) The SHA may be advised to notify the same in the local media, informing all policyholders/
insured about the de-empanelment ensuring that the beneficiaries are aware that the
said hospital will not be providing services under AB-NHPM.

v) A de-empanelled hospital cannot re-apply for empanelment for at least 2 years after
de-empanelment. However, if the order for de-empanelment mentions a longer period,
such a period shall apply for such a hospital.

C. Gradation of Offences

On the basis of the investigation report/field audits, the following charges may be
found to be reasonably proved and a gradation of penalties may be levied by the SEC.
However, this tabulation is intended to be as guidelines rather than mandatory rules
and the SEC may take a final call on the severity and quantum of punishment on a case
to case basis.

Penalties for Offences by the Hospital

Case Issue First Offence Second Offence Third Offence
Illegal cash Full Refund and In addition to actions De-empanelment/
payments by compensation 3 times as mentioned for first black-listing
beneficiary of illegal payment to offence, Rejection of
the beneficiary claim for the case
Billing for Rejection of claim and Rejection of claim and De-empanelment
services not penalty of 3 times the penalty of 8 times the
provided amount claimed for amount claimed for
services not provided, services not provided,
to Insurance Company to Insurance Company
/State Health Agency /State Health Agency

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

Up coding/ Rejection of claim Rejection of claim and De-empanelment

Unbundling/ and penalty of 8 times penalty of 16 times
Unnecessary the excess amount the excess amount
Procedures claimed due to up claimed due to up
coding /unbundling/ coding/unbundling/
Unnecessary Unnecessary
Procedures, to Procedures, to
Insurance Company / Insurance Company /
State Health Agency. State Health Agency
For unnecessary
procedure:

Wrongful Rejection of claim and Rejection of claim and De-empanelment

beneficiary penalty of 3 times the penalty of 8 times the
Identification amount claimed for amount claimed for
wrongful beneficiary wrongful beneficiary
identification to identification to
Insurance Company / Insurance Company /
State Health Agency State Health Agency

Non- In case of minor Suspension until De-empanelment

adherence gaps, warning rectification of gaps and
to AB-NHPM period of 2 weeks for validation by SEC/ DEC
quality and rectification, for major
service gaps, Suspension
standard of services until
rectification of gaps
and validation by SEC/
DEC

All these penalties are recommendatory and the SEC may inflict larger or smaller
penalties depending on the severity/regularity/scale/intentionality on a case to case
basis with reasons mentioned clearly in a speaking order.

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission
Ayushman Bharat - National Health Protection Mission (AB-NHPM) - Guideline

De-empanelment order confirmed after

nd
2 showcause
State Health
Agency

In case of de-empanelment,
order for confirmation
forwarded First
Showcause/Fi
nal Order

SEC
Insurance Company

Network Hospital

SHA

Direction and return of

Investigation Report

Other Sources Investigation Report by DEC

DEC

34

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

Annexure 1: Detailed Empanelment Criteria

CATEGORY 1: ESSENTIAL CRITERIA

A Hospital would be empanelled as a network private hospital with the approval of the respective
State Health Authority if it adheres with the following minimum criteria:

1. Should have at least 10 inpatient beds with adequate spacing and supporting staff as per norms.

i. Exemption may be given for single-specialty hospitals like Eye and ENT.

ii. General ward - @80sq ft per bed, or more in a Room with Basic amenities- bed, mattress,
linen, water, electricity, cleanliness, patient friendly common washroom etc. Non-AC but with
fan/Cooler and heater in winter.

2. It should have adequate and qualified medical and nursing staff (doctors1 & nurses2), physically
in charge round the clock; (necessary certificates to be produced during empanelment).

3. Fully equipped and engaged in providing Medical /Surgical services, commensurate to the
scope of service/ available specialities and number of beds.

i. Round-the-clock availability (or on-call) of a Surgeon and Anaesthetist where surgical

services/ day care treatments are offered.

ii. Round-the-clock availability (or on-call) of an Obstetrician, Paediatrician and Anaesthetist

where maternity services are offered.

iii. Round-the-clock availability of specialists (or on-call) in the concerned specialties

having sufficient experience where such services are offered (e.g. Orthopaedics, ENT,
Ophthalmology, Dental, general surgery (including endoscopy) etc.)

4. Round-the-clock support systems required for the above services like Pharmacy, Blood Bank,
Laboratory, Dialysis unit, Endoscopy investigation support, Post op ICU care with ventilator
support, X-ray facility (mandatory) etc., either ‘In-House’ or with ‘Outsourcing arrangements’,
preferably with NABL accredited laboratories, with appropriate agreements and in close vicinity.

5. Round-the-clock Ambulance facilities (own or tie-up).

6. 24 hours emergency services managed by technically qualified staff wherever emergency

services are offered

1 Qualified doctor is a MBBS approved as per the Clinical Establishment Act/ State government rules & regulations as
applicable from time to time.
2 Qualified nurse per unit per shift shall be available as per requirement laid down by the Nursing Council/ Clinical
Establishment Act/ State government rules & regulations as applicable from time to time. Norms vis a vis bed ratio
may be spelt out.

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 Operational Guidelines on Ayushman Bharat - National Health Protection Mission

i. Casualty should be equipped with Monitors, Defibrillator, Nebulizer with accessories, Crash
Cart, Resuscitation equipment, Oxygen cylinders with flow meter/ tubing/catheter/face mask/
nasal prongs, suction apparatus etc. and with attached toilet facility.

7. Mandatory for hospitals wherever surgical procedures are offered:

i. Fully equipped Operation Theatre of its own with qualified nursing staff under its employment
round the clock.

ii. Post-op ward with ventilator and other required facilities.

8. Wherever intensive care services are offered it is mandatory to be equipped with an Intensive
Care Unit (For medical/surgical ICU/HDU/Neonatal ICU) with requisite staff

i. The unit is to be situated in close proximity of operation theatre, acute care medical, surgical
ward units, labour room and maternity room as appropriate.
ii. Suction, piped oxygen supply and compressed air should be provided for each ICU bed.
iii. Further ICU- where such packages are mandated should have the following equipment:

a) Piped gases
b) Multi-sign Monitoring equipment
c) Infusion of ionotropic support
d) Equipment for maintenance of body temperature
e) Weighing scale
f) Manpower for 24x7 monitoring
g) Emergency cash cart
i) Defibrillator
j) Equipment for ventilation
k) In case there is common Paediatric ICU then Paediatric equipments, e.g.: paediatric
ventilator, Paediatric probes, medicines and equipment for resuscitation to be available

iv. HDU (high dependency unit) should also be equipped with all the equipment and manpower
as per HDU norms.

9. Records Maintenance: Maintain complete records as required on day-to-day basis and is able
to provide necessary records of hospital / patients to the Society/Insurer or his representative as
and when required.

i. Wherever automated systems are used it should comply with MoHFW/ NHA EHR guidelines
(as and when they are enforced)
ii. All AB-NHPM cases must have complete records maintained
iii. Share data with designated authorities for information as mandated

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10. Legal requirements as applicable by the local/state health authority

11. Adherence to Standard treatment guidelines/ Clinical Pathways for procedures as mandated by
NHA from time to time

12. Registration with the Income Tax Department

13. NEFT enabled bank account

14. Telephone/Fax

15. Safe drinking water facilities/Patient care waiting area

16. Uninterrupted (24 hour) supply of electricity and generator facility with required capacity suitable
to the bed strength of the hospital

17. Waste management support services (General and Bio Medical) – in compliance with the bio-
medical waste management act

18. Appropriate fire-safety measures

19. Provide space for a separate kiosk for AB-NHPM beneficiary management (AB-NHPM non-
medical3 coordinator) at the hospital reception

20. Ensure a dedicated medical officer to work as a medical4 co-ordinator towards AB-NHPM
beneficiary management (including records for follow-up care as prescribed)

21. Ensure appropriate promotion of AB-NHPM in and around the hospital (display banners,
brochures etc.) towards effective publicity of the scheme in co-ordination with the SHA/ district
level AB-NHPM team

22. IT Hardware requirements (desktop/laptop with internet, printer, webcam, scanner/ fax, bio-
metric device etc.) as mandated by the NHA

3 The non-medical coordinator will do a concierge and helpdesk role for the patients visiting the hospital, acting as
a facilitator for beneficiaries and are the face of interaction for the beneficiaries. Their role will include helping in
preauthorization, claim settlement, follow-up and Kiosk-management (including proper communication of the
scheme).
4 The medical coordinator will be an identified doctor in the hospital who will facilitate submission of online pre-
authorization and claims requests, follow up for meeting any deficiencies and coordinating necessary and appropriate
treatment in the hospital.

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CATEGORY 2: ADVANCED CRITERIA

Over and above the essential criteria required to provide basic services under AB-NHPM (as
mentioned in Category 1) those facilities undertaking defined speciality packages (as indicated
in the benefit package for specialities mandated to qualify for advanced criteria) should have the
following:

1. These empanelled hospitals may provide specialized services such as Cardiology, Cardiothoracic
surgery, Neurosurgery, Nephrology, Reconstructive surgery, Oncology, Paediatric Surgery,
Neonatal intensive care etc.
2. A hospital could be empanelled for one or more specialities subject to it qualifying to the
concerned speciality criteria for respective packages
3. Such hospitals should be fully equipped with ICCU/SICU/ NICU/ relevant Intensive Care Unit in
addition to and in support of the OT facilities that they have.
4. Such facilities should be of adequate capacity and numbers so that they can handle all the
patients operated in emergencies.
i. The Hospital should have sufficient experienced specialists in the specific identified fields
for which the Hospital is empanelled as per the requirements of professional and regulatory
bodies/ as specified in the clinical establishment act/ State regulations.
ii. The Hospital should have sufficient diagnostic equipment and support services in the specific
identified fields for which the Hospital is empanelled as per the requirements specified in the
clinical establishment act/ State regulations.
5. Indicative domain specific criteria are as under:

A. Specific criteria for Cardiology/ CTVS

1. CTVS theatre facility (Open Heart Tray, Gas pipelines Lung Machine with TCM,
defibrillator, ABG Machine, ACT Machine, Hypothermia machine, IABP, cautery etc.)
2. Post-op with ventilator support
3. ICU Facility with cardiac monitoring and ventilator support
4. Hospital should facilitate round the clock cardiologist services
5. Availability of support speciality of General Physician & Paediatrician
6. Fully equipped Catheterization Laboratory Unit with qualified and trained Paramedics

B. Specific criteria for Cancer Care

1. For empanelment of Cancer treatment, the facility should have a Tumour Board which
decides a comprehensive plan towards multi-modal treatment of the patient or if not
then appropriate linkage mechanisms need to be established to the nearest regional
cancer centre (RCC). Tumor Board should consist of a qualified team of Surgical,

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Radiation and Medical /Paediatric Oncologist in order to ensure the most appropriate
treatment for the patient.
2. Relapse/recurrence may sometimes occur during/ after treatment. Retreatment is often
possible which may be undertaken after evaluation by a Medical/ Paediatric Oncologist/
Tumor Board with prior approval and pre-authorization of treatment.
3. For extending the treatment of chemotherapy and radiotherapy the hospital should
have the requisite Pathology/ Haematology services/ infrastructure for radiotherapy
treatment viz. for cobalt therapy, linear accelerator radiation treatment and brachytherapy
available in-house. In case such facilities are not available in the empanelled hospital
for radiotherapy treatment and even for chemotherapy, the hospital shall not perform
the approved surgical procedure alone but refer the patients to other centres for follow-
up treatments requiring chemotherapy and radiotherapy treatments. This should be
indicated where appropriate in the treatment approval plan.
4. Further hospitals should have following infrastructure for providing certain specialized
radiation treatment packages such as stereotactic radiosurgery/ therapy.
i. Treatment machines which are capable of delivering SRS/SRT
ii. Associated Treatment planning system
iii. Associated Dosimetry systems

C. Specific criteria for Neurosurgery

1. Well Equipped Theatre with qualified paramedical staff, C-Arm, Microscope,
neurosurgery compatible OT table with head holding frame (horse shoe, may field /
sugita or equivalent frame)
2. ICU facility
3. Post-op with ventilator support
4. Facilitation for round the clock MRI, CT and other support bio-chemical investigations

D. Specific criteria for Burns, Plastic & Reconstructive surgery

1. The Hospital should have full time / on - call services of qualified plastic surgeon
and support staff with requisite infrastructure for corrective surgeries for post burn
contractures
2. Isolation ward having monitor, defibrillator, central oxygen line and all OT equipment.
3. Well Equipped Theatre
4. Intensive Care Unit
5. Post-op with ventilator support
6. Trained Paramedics
7. Post-op rehab/ Physiotherapy support/ Phycology support

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E. Specific criteria for /Paediatric Surgery

1. The Hospital should have full time/on call services of paediatric surgeons
2. Well-equipped theatre
3. ICU support
4. Support services of paediatrician
5. Availability of mother rooms and feeding area.
6. Availability of radiological/ fluoroscopy services (including IITV), Laboratory services
and Blood bank

F. Specific criteria for specialized new born care.

1. The hospital should have well developed and equipped neonatal nursey/Neonatal ICU
(NICU) appropriate for the packages for which empanelled, as per norms
2. Availability of radiant warmer/ incubator/ pulse oximeter/ photo therapy/ weighing
scale/ infusion pump/ ventilators/ CPAP/ monitoring systems/ oxygen supply / suction
/ infusion pumps/ resuscitation equipment/ breast pumps/ bilimeter/ KMC (Kangaroo
Mother Care) chairs and transport incubator - in enough numbers and in functional
state; access to hematological, biochemistry tests, imaging and blood gases, using
minimal sampling, as required for the service packages
3. For Advanced Care and Critical Care Packages, in addition to 2. above: parenteral
nutrition, laminar flow bench, invasive monitoring, in-house USG. Ophthalmologist on
call
4. Trained nurses 24x7 as per norms
5. Trained Paediatrician(s) round the clock
6. Arrangement for 24x7 stay of the Mother – to enable her to provide supervised care,
breastfeeding and KMC to the baby in the nursery/NICU and upon transfer therefrom;
provision of bedside KMC chairs
7. Provision for post-discharge follow up visits for counselling for feeding, growth /
development assessment and early stimulation, ROP checks, hearing tests etc

G. Specific criteria for Polytrauma

1. Shall have Emergency Room Setup with round the clock dedicated duty doctors
2. Shall have the full-time service availability of Orthopaedic Surgeon, General Surgeon,
and anaesthetist services
3. The Hospital shall provide round the clock services of Neurosurgeon, Orthopaedic
Surgeon, CT Surgeon, General Surgeon, Vascular Surgeon and other support
specialists as and when required based on the need.

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4. Shall have dedicated round the clock Emergency theatre with C-Arm facility, Surgical
ICU, Post-Op Setup with qualified staff.
5. Shall be able to provide necessary diagnostic support round the clock including
specialized investigations such as CT, MRI, emergency biochemical investigations.

H. Specific criteria for Nephrology and Urology Surgery

1. Dialysis unit
2. Well-equipped operation theatre with C-ARM
3. Endoscopy investigation support
4. Post op ICU care with ventilator support
5. Sew lithotripsy equipment

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Annexure 2: Process Flow for the Empanelment

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

4. Guidelines on Process for Hospital

Transaction
AB-NHPM would be cashless & paperless at any of the empanelled hospitals. The
beneficiaries shall not be required to pay any charge for the hospitalization expenses. The
benefit also includes pre- and post-hospitalisation expenses. The scheme is an entitlement
based and entitlement of the beneficiary is decided on the basis of family being figured in
SECC database.

The core principle for finalising the Balance Check and providing treatment at empanelled
hospital guidelines for AB-NHPM is to construct a broad framework as guiding posts for
simplifying the service delivery under the ambit of the policy and the technology.

4.1. Decision on IT Platform to be Used for AB-NHPM:

Responsibility of – State Government

IT platform for identification of beneficiaries and transactions at the Empanelled Health Care
Provider (EHCP) will be provided by MoHFW/NHA

For ease of convergence and on boarding, States which have their own IT systems under
their own health insurance/ assurance scheme may be allowed to continue to use their own
IT platform. However, these States will need to map their scheme ID with AB-NHPM ID (AHL
TIN) at the point of care and will need to share real time defined transaction data through
API with the Central server with respect to AB-NHPM beneficiaries. States will need to also
ensure that no family eligible as per SECC criteria of AB-NHPM is denied services under
the scheme and will need to provide undertaking that eligibility under their schemes covers
AB-NHPM targeted families as per SECC

4.2. Preparatory Activities for State/ UT’s:

Responsibility of – State Government

Timeline – within a period of 30 days, after approval of empanelment of health care provider

The State will need to:

A. Ensure the availability of requisite hardware, software and allied infrastructure required
for beneficiary identification, AB-NHPM e-card printing and transactions for delivery of
service at the EHCP. Beneficiary Identification and Transaction Software/ Application/
platform will be provided free of cost by MoHFW/NHA. Specifications for these will be
provided by MoHFW/NHA.

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B. Ensure that a Medical Officer as Nodal Officer at EHCP for AB-NHPM has been
nominated.
C. Ensure appointment of Ayushman Mitra for the EHCP.
D. Ensure that a dedicated helpdesk for AB-NHPM at a prominent place at the EHCP.
E. Availability of printed booklets, in abundant quantities at the helpdesk, which will be
given to beneficiaries along with the AB-NHPM e-cards, if beneficiary has not been
issued the AB-NHPM e-card earlier.
F. State/ State Health Agency (SHA) shall identify and set-up team(s) which shall have the
capacities to handle hardware and basic software support, troubleshooting etc.
G. Training of EHCP staff and Ayushman Mitras by the SHA/ Insurer.

The State shall ensure availability of above, in order to carry out all the activities laid
down in this guideline.

4.3. Process for Beneficiary Identification, Issuance of AB-NHPM

e-card and Transaction for Service Delivery
Responsibility of – EHCP through Ayushman Mitra or another authorised person

Timeline – Ongoing

A. Beneficiary Verification & Authentication.

i) Member may bring the following to the AB-NHPM helpdesk:
- Letter from MoHFW/NHA
- RSBY Card
- Any other defined document as prescribed by the State Government
ii) Ayushman Mitra/Operator will check if AB-NHPM e-Card/ AB-NHPM ID/ Aadhaar
Number is available with the beneficiary
iii) In case Internet connectivity is available at hospital
- Operator/Ayushman Mitra identifies the beneficiary’s eligibility and verification
status from AB-NHPM Central Server
- If beneficiary is eligible and verified under AB-NHPM, 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 per the parameters defined in the software) and will be
issued a AB-NHPM e-Card for getting the cashless treatment

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

- 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

iv) In case Internet connectivity is not available at hospital.

- AB-NHPM Registration Desk at Hospital will call Central Helpline and using IVRS
enters AB-NHPM 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

v) In case of emergency or in case person does not show AB-NHPM e-Card/ID or

Aadhaar Card/Number and claims to be AB-NHPM 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-NHPM beneficiary proof will be supplied within specified time
before discharge otherwise beneficiary will pay for the treatment to the Hospital.

vi) If eligibility, verification and authentication are successful, beneficiary should be allowed
for treatment.

These details captured will be available at SHA/ Insurance Company/ Trust level for
their approval. Once approved, the beneficiary will be considered as successfully
identified and verified under AB-NHPM

4.4. Package Selection

A. The operator will check for the specialty for which the hospital is empanelled. Hospitals
will only be allowed to view and apply treatment package for the specialty for which they
are empanelled.
B. Based on diagnosis sheet provided by doctor, operator should be able to block Surgical
or Non-Surgical benefit package(s) using AB-NHPM IT system.
C. Both surgical and non-surgical packages cannot be blocked together, either of the type
can only be blocked.
D. As per the package list, the mandatory diagnostics/documents will need to be uploaded
along with blocking of packages.

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E. The operator can block more than one package for the beneficiary. A logic will be built in
for multiple package selection, such that reduced payment is made in case of multiple
packages being blocked in the same hospitalization event.
F. Certain packages as mentioned will only be reserved for Public EHCPs as decided
by the SHA. They can be availed in Private EHCPs only after a referral from a Public
EHCP is made.
G. Packages as indicated may have differential pricing for NABH/ NQAS and Non-NABH/
NQAS, for Hospitals running PG/ DNB Course, for rural and urban EHCPs and for
EHCPs in aspirational districts as identified by NITI Aayog.
H. If a registered mobile number of beneficiary family is available, an SMS alert will be
sent to the beneficiary notifying him of the packages blocked for him.
I. At the same time, a printable registration slip needs to be generated and handed over
to the patient or patient’s attendant.
J. If for any reason treatment is not availed for any package, the operator can unblock the
package before discharge from hospital.

4.5. Pre-authorisation
A. There would be defined packages which will require pre-authorization from the insurance
company/ trust. In case any inpatient treatment is not available in the packages defined,
then hospital will be able to provide that treatment upto Rs. 50,000 to the beneficiary
only after the same gets approved by the Insurance company/ trust and will be reflected
as unspecified package. Under both scenarios, the operator should be able to initiate a
request to the insurance company/trust for pre-authorization using the web application.
B. The hospital operator will send all documents required for pre-authorization to
the insurance company/trust using the Centralized AB-NHPM/ States transaction
management application.
C. The documents exchanged will not be stored on the AB-NHPM server permanently.
Only the information about pre-authorization request and response received will be
stored on the central server. It is the responsibility of the insurance company/ Trust to
maintain the documents at their end.
D. The documents needed may vary from package to package and hence a master list of
all documents required for all packages will be available on the server.
E. The request as well as approval of the form will be done using the AB-NHPM IT system
or using API exposed by AB-NHPM (Only one option can be adopted by the insurance
Co.), or using State’s own IT system (if adopted by the State).
F. In case of no or limited connectivity, the filled form can also be sent to the insurance
company/ trust either through fax/ email. However, once internet connectivity is
established, the form should also be submitted using online system as described above.

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G. The insurance company/ trust will have to approve or reject the request latest by 6
hours. If the insurance company/ trust fails to do so, the request will be considered
deemed to be approved after 6 hours by default.
H. In case of an emergency or delay in getting the response for pre-authorization request
due to technical issues, provision will be there to get the pre-authorization code over the
phone from Insurance Company/ Trust or the call centre setup by Insurance Company/
Trust. The documents required for the processing, may be sent using the transaction
system within stipulated time.
I. In case of emergency, insurance company/ trust will provide the pre-authorization code
generated through the algorithm/ utility provided by MoHFW/NHA-NIC.
J. Pre-authorization code provided by the Insurer/ Trust will be entered by the operator
and will be verified by the system.
K. If pre-authorization request is rejected, Insurance Company/ Trust will provide the
reasons for rejection. Rejection details will be captured and stored in the transaction
database.
L. If the beneficiary or the hospital are not satisfied by the rejection reason, they can
appeal through grievance system.

4.6. Balance Check, Treatment, Discharge and Claim Request

A. Based on selection of package(s), the operator will check from the Central AB-NHPM
Server if sufficient balance is available with the beneficiary to avail services
B. States using their own IT system for hospital transaction will be able to check and
update balance from Central AB-NHPM server using API
C. If balance amount under available covers is not enough for treatment, then remaining
amount (treatment cost - available balance), will be paid by beneficiary (OOP expense
will also be captured and stored)
D. The hospital will only know if there is sufficient balance to provide the selected treatment
in a yes or no response. The exact amount will not be visible to the hospital
E. SMS will be sent to the beneficiary registered mobile about the transaction and available
balance
F. List of diagnostic reports recommended for the blocked package will be made available
and upload of all such reports will be mandatory before discharge of beneficiary
G. Transaction System would have provision of implementation of Standard Treatment
Guidelines for providing the treatment
H. After the treatment, details will be saved and beneficiary will be discharged with a
summary sheet
I. Treatment cost will be deducted from available amount and will be updated on the
Central AB-NHPM Server

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J. The operator fills the online discharge summary form and the patient will be discharged.
In case of mortality, a flag will be raised against the deceased member declaring him as
dead or inactive
K. At the same time, a printable receipt needs to be generated and handed over to the
patient or patient’s attendant
L. After discharge, beneficiary gets a confirmation and feedback call from the AB-NHPM
call centre; response from beneficiary will be stored in the database
M. Data (Transaction details) should be updated to Central Server and accessible to
Insurance Company/ Trust for Claim settlement. Claim will be presumed to be raised
once the discharge information is available on the Central server and is accessible to
the Trust/ Insurance Company
N. SMS will be sent to beneficiary registered mobile about the transaction and available
balance
O. After every discharge, claims would be deemed to be raised to the insurance company/
Trust. An automated email alert will be sent to the insurance company/trust specifying
patient name, AB-NHPM ID, registration number & date and discharge date. Details
like Registration ID, AB-NHPM ID, date and amount of claim raised will be accessible
to the insurance company/trust on AB-NHPM System/ State IT system. Also details like
Registration-ID, AB-NHPM-ID, Date and amount of claim raised, date and amount of
claim disbursement, reasons for different in claims raised and claims settled (if any),
reasons for rejection of claims (if any) will be retrieved from the insurance company/
trust through APIs
P. Once the claim is processed and the hospital gets the payment, the above-mentioned
information along with payment transaction ID will be updated on central AB-NHPM
system by the insurance company/trust for each claim separately
Q. Hospital Transaction Management Module would be able to generate a basic MIS
report of beneficiary admitted, treated and claim settled and in process and any other
report needed by Hospitals on a regular basis
R. Upon discharge, beneficiary will receive a feedback call from the Call centre where he
can share his feedback about his/her hospitalisation experience. Beneficiary can also
provide the feedback through “mera hospital” or similar application
S. Hospital will have the responsibility to inform DHA and SHA in writing if they deny
services to the beneficiary alongwith the reason for denying the services

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4.7. Monitoring of Transaction Process at EHCP

Responsibility of – SHA and Insurance Company/ Trust

Timeline – Continuous

SHA and Insurance Company/ Trust will need to have very close monitoring of the process
in order to ascertain challenges, if any, being faced and resolution of the same. Some
examples of the parameters on which monitoring may be based are as follows:

A. Number of EHCP and Ayushman Mitras

B. Time taken for verification and issuance of e-card of each member
C. Time taken for approval of verification of beneficiaries
D. Percentage of families with at least one member having issued e-card out of total
eligible families in SECC
E. Number of admissions per family
F. Grievances received against Ayushman Mitras or EHCP
G. Proportion of Emergency pre-authorisation requests
H. Percent of conviction of detected fraud.
I. Share of pre-authorisation and claims audited
J. Claim repudiation/ denial/ disallowance ratio
K. AB-NHPM Beneficiary satisfaction

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4.8. Transaction Process Flow

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5. Guidelines on Claim Settlement Process

All Empanelled Health Care Providers (EHCP) will make use of IT system of AB-NHPM
to manage the claims related transactions. IT system of AB-NHPM has been developed
for online transactions and all stakeholders are advised to maintain online transactions
preferably to ensure the claim reporting in real time. However, keeping in mind the connectivity
constraints faced by some districts an offline arrangement has also been included in the IT
system that has to be used only when absolute. The AB-NHPM strives to make the entire
claim management paperless that is at any stage of claim registration, intimation, payment,
investigation by EHCP or by the Trust/Insurer the need of submission of a physical paper
shall not be required. This mean that this claim data will be sent electronically through IT
system to the Central/ State server. The NHA, SHA, Insurer (if applicable), and EHCP shall
be able to access this data with respect to their respective transaction data only.

Once a claim has been raised (has hit the Central/State server), the following will need to be
adhered to by the Trust/Insurance Companies regarding claim settlement:

5.1. Claim Payments and Turn-around Time

The Trust/Insurer shall follow the following process regarding the processing of claims
received from the EHCP:

A. The Trust/Insurer or the agency (IRDAI compliant only) appointed by it shall decide on
the acceptance or rejection of any claim received from an EHCP. Any rejection notice
issued by the Trust/Insurer or the agency to EHCP shall clearly state that rejection is
subject to the EHCP’s right to appeal against rejection of the claim.
B. If a claim is not rejected, the Trust/Insurer shall either make the payment (based on the
applicable package rate) or shall conduct further investigation into the claim received
from EHCP.
C. The process specified in clause a and b above (rejection or payment/investigation) in
relation to claim shall be carried out in such a manner that it is completed (Turn-around
Time, TAT) shall be no longer than 15 calendar days (irrespective of the number of
working days). For claims outside the State, a time of 30 calendar days will be provided.
D. The EHCP is expected to upload all claim related documents within 24 hours of
discharge of the beneficiary.
E. The counting of days for TAT shall start from the date on which all the claim documents
are accessible by the Trust/Insurer or its agency.
F. The Trust/Insurer shall make claim payments to each EHCP against payable claims on
a weekly basis through electronic transfer to such EHCP’s designated bank account.
Insurer is then also required to provide the details of such payments against each paid
claim on the online portal (IT System of AB-NHPM).

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G. All claims investigations shall be undertaken by a qualified and experienced medical

staff/team, with at least one MBBS degree holder, appointed by the Trust/Insurer
or its representative, to ascertain the nature of the disease, illness or accident
and to verify the eligibility thereof for availing the benefits under this Agreement
and relevant Cover Policy. The Trust/Insurer’s medical staff shall not impart any
advice on any treatment or medical procedures or provide any guidance related to
cure or other care aspects. However, the Trust/Insurance Company can ensure that the
treatment was in conformity to the Standard Treatment Guidelines, if implemented.
H. The Trust/Insurer will need to update the details on online portal (IT system of AB-
NHPM) of:
i) All claims that are under investigation on a fortnightly basis for review; and
ii) Every claim that is pending beyond 15 days, along with its reasons for delay in
processing such Claim.
iii) The Trust/Insurer may collect at its own cost, complete Claim papers (including
diagnostic reports) from the EHCP, if required for audit purposes for claims under
investigation. This shall not have any bearing on the Claim Payments to the
Empanelled Healthcare Provider.

5.2. Penalty on Delay in Settlement of Claims

There will be a penalty for delay in settlement of claims by the Trust/Insurance Companies
beyond the turnaround time of 15 days. A penalty of 1 % of claimed amount per week for
delay beyond 15 days to be paid directly to the hospitals by the Trust/Insurance Companies.
In case of Inter-State claims with respect to portability of benefits, penalty of 1 % of claimed
amount per week for delay beyond 30 days to be paid directly to the hospitals by the Trust/
Insurance Companies.

5.3. Update of Claim Settlement

The Trust/Insurance Company will need to update the claim settlement data on the portal on
a daily basis and this data will need to be updated within 24 hours of claims payment. Any
claim payment which has not been updated shall be deemed to have been unpaid and the
interest, as applicable, shall be charged thereon.

5.4. Right of Appeal and Reopening of Claims

A. The Empanelled Health Care Provider shall have a right of appeal against a rejection of
a Claim by the Trust/Insurer, if the Empaneled Healthcare Provider feels that the Claim
is payable. An appeal may be made within thirty (30) days of the said rejection being
intimated to the hospital to the District-level Grievance Committee (DGC).

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B. The Trust/Insurer and/or the DGC can re-open the Claim, if the Empanelled Healthcare
Provider submits the proper and relevant Claim documents that are required by the
Trust/Insurer.
C. The DGC may suo moto review any claim and direct either or both the Trust/Insurer and
the health care provider to produce any records or make any deposition as it deems fit.
D. The Trust/Insurer or the healthcare provider may refer an appeal with the State-level
Grievance Committee (SGC) on the decision of the DGC within thirty days (30) failing
which the decision shall be final and binding. The decision of the SGC on such appeal
is final and binding.
E. The decisions of the DGC and SGC shall be a speaking order stating the reasons for
the decision
F. If the DGC (if there is no appeal) or SGC directs the Trust/Insurer to pay a claim
amount, the Trust/Insurer shall pay the amount within 15 days. Any failure to pay the
amount shall attract an interest on the delayed payment @ 1% for every week or part
thereof. If the Trust/Insurer does not pay the amount within 2 months they shall pay a
fine of Rs. 25,000/- for each decision of DGC not carried out and Rs. 50,000 for each
non-compliance of decision of SGC. This amount shall be remitted to the State Health
Agency.

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6. Guidelines on Grievance Redressal

Grievance Department has to be manned by dedicated resources to address the grievances from
time to time as per the instructions of the NHA. The District authorities shall act as a frontline for the
redressal of Beneficiaries’/ Providers/ other Stakeholder’s grievances. The District authorities shall
also attempt to solve the grievance at their end. The grievances so recorded shall be numbered
consecutively and the Beneficiaries / Providers shall be provided with the number assigned to
the grievance. The District authorities shall provide the Beneficiaries / Provider with details of the
follow-up action taken as regards the grievance as and when the Beneficiaries require it to do so.
The District authorities shall also record the information in pre-agreed format of any complaint /
grievance received by oral, written or any other form of communication.

Under the Grievance Redressal Mechanism of AB-NHPM, following set of three tier Grievance
Redressal Committees have been set up to attend to the grievances of various stakeholders at
different levels:

District Grievance Redressal Committee (DGRC)

The District Grievance Redressal Committee (DGRC) will be constituted by the State Health Agency
(SHA) in each district within 15 days of signing of MoU with the Insurance Company.

• The District Magistrate or an officer of the rank of Addl. District Magistrate, who shall be the
Chairperson of the DGRC.
• The CMO/ CMOH/ DM&HO/ DHO or equivalent rank officer shall be the Convenor of the DGRC.
• Representatives from the district level offices of the Departments of Rural Development.
• The District Coordinator of the Insurer.
• The District Grievance Nodal Officer (DGNO).
• The DGRC may invite other experts for their inputs for specific cases.

Note: DGNO shall try to resolve the complaint by forwarding the same to Action Taking Authority
(ATA). If the complaint is not resolved or comments are not received over the same within 15 days
of the complaint, then the matter may be referred to DGRC.

State Grievance Redressal Committee (SGRC)

The State Grievance Redressal Committee (SGRC) will be constituted by the State Health Agency
within 15 days of signing of MoU with the Central Government.

• CEO of State Health Authority / State Nodal Agency shall be the Chairperson of the SGRC.
• Representatives of the Departments of Rural Development, Women & Child Development,
Labour, Tribal Welfare.
• Director Health Services.

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Operational Guidelines on Ayushman Bharat - National Health Protection Mission

• Medical Superintendent of the leading state level government hospital.

• The State Grievance Nodal Officer (SGNO) of the SHA shall be the Convenor of SGRC.
• The SGRC may invite other experts for their inputs on specific cases.

Note: In case of any grievance between SHA and Insurance Company, SGRC will be chaired by the
Secretary of Department of Health & Family Welfare of the State. If any party is not in agreement
with the decision of DGRC, then they may approach the SGRC against the decision of DGRC.

National Grievance Redressal Committee (NGRC)

The NGRC shall be formed by the MoHFW, GoI at the National level. The constitution of the NGRC
shall be determined by the MoHFW in accordance with the Scheme Guidelines from time to time.
Proposed members for NGRC are:

1. CEO of National Health Agency (NHA) - Chairperson

2. JS , Ministry of Health & Family Welfare- Member
3. Additional CEO of National Health Agency (NHA)- Member Convenor
4. Executive Director, IEC, Capacity Building and Grievance Redressal
5. NGRC can also invite other experts/ officers for their inputs in specific cases

CEO (NHA) may designate Addl. CEO (NHA) to chair the NGRC

Investigation authority for investigation of the grievance may be assigned to Regional

Director- CGHS/Director Health Services/ Mission director NHM of the State/UT concerned.

NGRC will consider:

a. Appeal by the stakeholders against the decisions of the State Grievance Redressal Committees
(SGRCs)
b. Also, the petition of any stakeholder aggrieved with the action or the decision of the State Health
Agency / State Government
c. Review of State-wise performance based monthly report for monitoring, evaluation and make
suggestions for improvement in the Scheme as well as evaluation methodology
d. Any other reference on which report of NGRC is specifically sought by the Competent Authority.

The Meetings of the NGRC will be convened as per the cases received with it for consideration or
as per the convenience of the Chairman, NGRC.

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6.1. Grievance Settlement of Stakeholders

If any stakeholder has a grievance against another one during the subsistence of the policy
period or thereafter, in connection with the validity, interpretation, implementation or alleged
breach of any provision of the scheme, it will be settled in the following way by the Grievance
Committee:

A. Grievance of a Beneficiary

i) Grievance against insurance company, hospital, their representatives or any

functionary

If a beneficiary has a grievance on issues relating to entitlement, or any other AB-

NHPM related issue against Insurance Company, hospital, their representatives
or any functionary, the beneficiary can call the toll free call centre number 14555
(or any other defined number by the State) and register the complaint. Beneficiary
can also approach DGRC. The complaint of the beneficiary will be forwarded to
the relevant person by the call centre as per defined matrix. The DGRC shall take
a decision within 30 days of receiving the complaint.

If either of the parties is not satisfied with the decision, they can appeal to the SGRC
within 30 days of the decision of the DGRC. The SGRC shall take a decision on
the appeal within 30 days of receiving the appeal. The decision of the SGRC on
such issues will be final.

Note: In case of any grievance from beneficiary related to hospitalisation of

beneficiary (service related issue of the beneficiary) the timelines for DGRC
to take decision is within 24 hours from the receiving of the grievance.

ii) Grievance against district authorities

If the beneficiary has a grievance against the District Authorities or an agency of

the State Government, it can approach the SGRC for resolution. The SGRC shall
take a decision on the matter within 30 days of the receipt of the grievance. The
decision of SGRC shall be final.

B. Grievance of a Health Care Provider

i) Grievance against beneficiary, insurance company, their representatives or any

other functionary

If a Healthcare Provider has any grievance with respect to beneficiary, Insurance

Company, their representatives or any other functionary, the Healthcare Provider
will approach the DGRC. The DGRC should be able to reach a decision within 30
days of receiving the complaint.

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Step I- If either of the parties is not satisfied with the decision, they can go to the
SGRC within 30 days of the decision of the DGRC, which shall take a decision
within 30 days of receipt of appeal.

Step II- If either of the parties is not satisfied with the decision, they can go to the
NGRC within 30 days of the decision of the SGRC, which shall take a decision
within 30 days of receipt of appeal. The decision of NGRC shall be final.

C. Grievance of insurance company

i) Grievance against district authorities/ health care provider

If Insurance Company has a grievance against District Authority / Healthcare

Provider or an agency of the State Government, it can approach the SGRC for
resolution. The SGRC shall decide the matter within 30 days of the receipt of the
grievance.

In case of dissatisfaction with the decision of the SGRC, the affected party can file
an appeal before NGRC within 30 days of the decision of the SGRC and NGRC
shall take a decision within 30 days of the receipt of appeal after seeking a report
from the other party. The decision of NGRC shall be final.

6.2. Functions of Grievance Redressal Committees

A. Functions of the DGRC:

The DGRC shall perform all functions related to handling and resolution of grievances
within their respective Districts. The specific functions will include:

i) Review grievance records.

ii) Call for additional information as required either directly from the Complainant or
from the concerned agencies which could be the Insurer or an EHCP or the SHA
or any other agency/ individual directly or indirectly associated with the Scheme.
iii) Conduct grievance redressal proceedings as required.
iv) If required, call for hearings and representations from the parties concerned while
determining the merits and demerits of a case.
v) Adjudicate and issue final orders on grievances.
vi) In case of grievances that need urgent redressal, develop internal mechanisms for
redressing the grievances within the shortest possible time, which could include
but not be limited to convening special meetings of the Committee.
vii) Monitor the grievance database to ensure that all grievances are resolved within
30 days.

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B. Functions of the SGRC:

The SGRC shall perform all functions related to handling and resolution of all grievances
received either directly or escalated through the DGRC. The specific functions will
include:

i) Oversee grievance redressal functions of the DGRC including but not limited to
monitoring the turnaround time for grievance redressal.
ii) Act as an Appellate Authority for appealing against the orders of the DGRC.
iii) Perform all tasks necessary to decide on all such appeals within 30 days of
receiving such appeal.
iv) Adjudicate and issue final orders on grievances.
v) Nominate District Grievance Officer (DGO) at each District.
vi) Direct the concerned Insurance Company to appoint District Nodal Officer of each
district.

C. Functions of the NGRC:

The NGRC shall act as the final Appellate Authority at the National level.
i) The NGRC shall only accept appeals against the orders of the SGRC of a State.
ii) The decision of NGRC will be final.

6.3. Lodging of Grievances/ Complaints

A. If any stakeholder has a complaint (complainant) against any other stakeholder during
the subsistence of the Policy Cover Period or thereafter, in connection with the validity,
interpretation, implementation or alleged breach of the Insurance Contract between the
Insurer and the SHA or a Policy or of the terms of their agreement (for example, the
Services Agreement between the Insurer and an Empanelled Health Care Provider),
then such complainant may lodge a complaint by online grievance redressal portal or
letter or e-mail.

B. For this purpose, a stakeholder includes: any AB-NHPM Beneficiary; an empanelled

health care provider (EHCP); a De-empanelled Health Care Provider; the Insurer or its
employees; the SHA or its employees or nominated functionaries for implementation of
the Scheme (DNOs, State Nodal Officer, etc.); and any other person having an interest
or participating in the implementation of the Scheme or entitled to benefits under the
AB-NHPM Cover.

C. A complainant may lodge a complaint in the following manner:

i) directly with the DGNO of the district where such stakeholder is located or where
such complaint has arisen and if the stakeholder is located outside the Service
Area, then with any DGNO located in the Service Area; or

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ii) with the SHA: If a complaint has been lodged with the SHA, they shall forward
such complaint to the concerned DGNO.

D. Upon a complaint being received by the DGNO, the DGNO shall decide whether the
substance of the complaint is a matter that can be addressed by the stakeholder against
whom the complaint is lodged or whether such matter requires to be dealt with under
the grievance redressal mechanism.

E. If the DGNO decides that the complaint must be dealt with under the grievance
redressal mechanism, the DGNO shall refer such complaint to the Convener of the
relevant Grievance Redressal Committee.

F. If the DGNO decides that the complaint need not be dealt with under the grievance
redressal mechanism, then the procedures set out in various process/guidelines shall
apply.

6.4. Redressal of Complaints

A. The DGNO shall enter the particulars of the complaint on the Web-based Central
Complaints and Grievance Management System (CCGMS) established by the MoHFW.
B. The CCGMS will automatically: (i) generate a Unique Complaint Number (UCN); (ii)
categorize the nature of the complaint; and (iii) an e-mail or letter to be sent to the
appropriate stakeholder to which such category of complaint is to be referred (including
updating on phone).
C. Once the UCN is generated, the DGNO shall send or cause to be sent an
acknowledgement email/phone call to the complainant and provide the complainant
with the UCN. Upon receipt of the UCN, the complainant will have the ability to track the
progress of complaint resolution online through CCGMS and use the same at the time
of calling the helpline for allowing easy retrieval of the specific complaint data.
D. The stakeholder against whom a complaint has been lodged must send its comments/
response to the complainant and copy to the DGNO within 15 days. If the complaint
is not addressed within such 15-day period, the DGNO shall send a reminder to such
stakeholder for redressal within a time period specified by the DGNO.
E. If the DGNO is satisfied that the comments/ response received from the stakeholder will
addresses the complaint, then the DGNO shall communicate this to the complainant by
e-mail and update the CCGMS.
F. If the DGNO is not satisfied with the comments/ response received or if no comments/
response are received from the stakeholder despite a reminder, then the DGNO shall
refer such complaint to the Convener of the relevant Grievance Redressal Committee
depending on the nature of the complaint after which the procedures set out shall apply.

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6.5. Grievance Redressal Mechanism

Upon escalation of a complaint for grievance redressal the following procedures shall apply:

A. The DGNO/SGRC shall update the CCGMS to change the status of the complaint to
a grievance, after which the CCGMS shall categorize the grievance and automatically
refer it to the Convenor of the relevant Grievance Redressal Committee by way of
e-mail.
B. The Convenor of the relevant Grievance Redressal Committee shall place the grievance
before the Grievance Redressal Committee for its decision at its next meeting.
C. Each grievance shall be addressed by the relevant Grievance Redressal Committee
within a period of 30 days of receipt of the grievance. For this purpose, each Grievance
Redressal Committee shall be convened at least once every 30 days to ensure that
all grievances are addressed within this time frame. Depending on the urgency of the
case, the Grievance Redressal Committee may decide to meet earlier for a speedier
resolution of the grievance.
D. The relevant Grievance Redressal Committee shall arrive at a reasoned decision within
30 days of receipt of the grievance. The decision of the relevant Grievance Redressal
Committee shall be taken by majority vote of its members present. Such decision shall
be given after following the principles of natural justice, including giving the parties a
reasonable opportunity to be heard.
E. If any party to a grievance is not satisfied with the decision of the relevant Grievance
Redressal Committee, it may appeal against the decision within 30 days to the relevant
Grievance Redressal Committee or other authority having powers of appeal.
F. If an appeal is not filed within the 30-day period, the decision of the original Grievance
Redressal Committee shall be final and binding.
G. A Grievance Redressal Committee or other authority having powers of appeal shall
dispose of an appeal within 30 days of receipt of the appeal. The decision of the
Grievance Redressal Committee or other authority with powers of appeal shall be
taken by majority vote of its members. Such decision shall be given after following the
principles of natural justice, including giving the parties a reasonable opportunity to be
heard. The decision of the Grievance Redressal Committee or other authority having
powers of appeal shall be final and binding.

6.6. Proceedings Initiated by the State Health Authority, State

Grievance Redressal Committee, the National Health Authority
The SHA, SGRC and/ or the National Health Authority (NHA) shall have the standing to
initiate suo moto proceedings and to file a complaint on behalf of itself and AB-NHPM
Beneficiaries under the Scheme.

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A. Compliance with the Orders of the Grievance Redressal Committees

i) The Insurer shall ensure that all orders of the Grievance Redressal Committees
by which it is bound are complied with within 30 days of the issuance of the order,
unless such order has been stayed on appeal.

ii) If the Insurer fails to comply with the order of any Grievance Redressal Committee
within such 30-day period, the Insurer shall be liable to pay a penalty of Rs. 25,000
per month for the first month of such non-compliance and Rs. 50,000 per month
thereafter until the order of such Grievance Redressal Committee is complied
with. The Insurer shall be liable to pay such penalty to the SHA within 15 days of
receiving a written notice.

iii) On failure to pay such penalty, the Insurer shall incur an additional interest at the
rate of one percent of the total outstanding penalty amount for every 15 days for
which such penalty amount remains unpaid.

B. Complaints/ Suggestions received through Social Media/Call centre

As Social Media channels will be handled by NHA, hence, the complaints/ suggestions
raised through Social Media channels like, Facebook, twitter handles, etc. will be routed
to the respective SGNO by NGNO (National Grievance Nodal Officer). SGNO needs to
register the same on the Grievance portal and publish a monthly report on the action
taken to the NGNO.

Complaint may also be lodged through Call center by beneficiary. Call center needs to
register the details like complaint details in the defined format and forward the same
to State Grievance Nodal Officer of the State concerned. SGNO needs to upload the
details of the complaint on the grievance portal and allocate the same to the concerned
District. The Complaint / grievance will be redressed as per guidelines.

Note: Matrix for grievance referral under the Scheme is presented in the table below:

Aggrieved Grievance Referred To

Indicative Nature of Grievance
Party Against
• Denied treatment
• Money sought for treatment, despite
Sum Insured under AB-NHPM Cover
AB-NHPM being available Hospital DGNO
Beneficiary • Demanding more than Package Rate/
Pre-Authorized Amount, if Sum Insured
under AB-NHPM Cover is insufficient
or exhausted

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Aggrieved Grievance Referred To

Indicative Nature of Grievance
Party Against
• AB-NHPM Card retained by
Empanelled Health Care Provider
• Medicines not provided against OPD
Benefits or follow-up care
• Claims rejected by Insurer or full Claim
amount not paid
• Suspension or de-empanelment of
Empanelled
Empanelled Health Care Provider Insurer/ SHA DGNO
Health Care
• Hospital IT Infrastructure not
Provider
functioning Insurer not assisting in
solving issue or not accepting manual
transaction
• No space provided for District Office DNO SGNO
• AB-NHPM Beneficiary Database not
updated for renewal Policy Cover
Insurer SHA SGRC
Period
• Premium not received within
prescribed time
Inter State/UT (Portability issues)

• Denied treatment
• Money sought for treatment, despite DGNO of
Sum Insured under AB-NHPM Cover the State/
being available UT where
• Demanding more than Package Rate/ Beneficiary
AB-NHPM Pre-Authorized Amount, if Sum Insured Hospital is applying/
Beneficiary under AB-NHPM Cover is insufficient availing
or exhausted benefits of AB-
• AB-NHPM Card retained by NHPM (other
Empanelled Health Care Provider than parent
• Medicines not provided against OPD State/UT)
Benefits or follow-up care
• Claims rejected by Insurer or full Claim SGRC of both
amount not paid parent State/
Empanelled
Insurer/ SHA UT and State/
Health Care
UT where the
Provider
claim is raised
State/UT

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7. Guidelines on Release of Premium/ Grant-in-

Aid

7.1. Financing
A. The maximum ceiling of the estimated grant-in-aid payable for the implementation of
Ayushman Bharat - National Health Protection Mission will be decided by the Government
of India and this would be shared as per the sharing pattern ratio guidelines issued by
Ministry of Finance in vogue, from time to time. The existing sharing pattern is of 60:40
sharing pattern ratio basis between the Central Government and the States Government
/ Union Territories, for States and Union Territories which are other than North-Eastern
& Three Himalayan States and Union Territories, which does have Legislation;

B. For North-Eastern and Three Himalayan states (viz. Jammu and Kashmir, Himachal
Pradesh and Uttarakhand), the sharing pattern ratio between the Central and State
Governments will be 90:10;

C. For Union Territories, without Legislation, the Central Government may provide upto
100% of Grant-in-Aid on a case to case basis.

The Central & State Government / UT shall open two separate designated escrow
account viz. Premium / Grant-in-Aid and Administrative Expense. In addition, out of the
annual administrative expense component of Rs. 50 per family, the Central Government
will also pay it’s respective share based upon the sharing pattern ratio applicable for
that particular States / UTs.

In case the State is implementing, AB-NHPM, the Central Government’s Share of

Administrative Expenses will be paid separately in addition to the grant-in-aid / premium
payment by the Central Government in advance through the separate designated
escrow account opened for this purpose, after the State Government / Union Territory
has released their share of administrative expenses into separate designated escrow
account also opened by the States / UTs for this purpose.

7.2. Implementation under Insurance Mode

A. Release of Grant-in-Aid/Premium Payment

i) A flat premium per family, irrespective of the number of members under AB-NHPM
in that family, will be determined through open tendering process.

ii) The State Government / Union Territories shall upfront release their respective
share of premium (grant-in-aid) for the eligible beneficiary families considered for
the implementation of AB-NHPM into the separate designated escrow account,

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from where it shall be paid to the Insurance Company on a per family basis. Upon
releasing of States’ / UT’s share, the States / UTs shall send the proposal to the
Central Government for release of respective Central Government’s Share of
Premium (Grant-in-Aid) along with prescribed documents.

iii) The modalities that will be adhered for release of premium for the implementation
of AB-NHPM will be as under:

I – Number of Eligible Beneficiary Families

The premium for the targeted beneficiary families as per the eligibility criteria of
AB-NHPM based on the SECC Database or the number of beneficiary families
mapped with the SECC Database (in case a different database, other than SECC
Database is used by the States / UTs), as the case may be.

II – Stage of Release of Premium:

State Health Agency (SHA) will, on behalf of the Beneficiary Family Units that
are targeted / identified by the SHA and covered by the Insurer, pay the Premium
(Grant-in-Aid) for the benefit cover to the Insurer in accordance with the following
schedule:

a. First installment of Premium for all States and UTs-

The Insurer, upon the issue of policy, shall raise an invoice for the first
installment of the Premium payable for the Beneficiary Family Units that are
targeted or identified by the SHA. Thereupon, the State / UT shall upfront
release 45% of their respective share viz. (out of 10% / 40%), depending
upon category of State/UT based on the number of eligible families that have
been targeted / identified by the SHA and the data for whom has been shared
with Insurance Company along with their respective administrative expense
share into the separate designated escrow account opened by the States /
UTs for the implementation of AB-NHPM.

However, in case of Union Territories without legislation, where the Central

Government shall pay 45% of its respective share of premium (viz. out of
100%) through the designated escrow account into the designated Escrow
Account of the State / UT within 21 working days from the receipt of duly
completed proposal (including and not limited to all information / clarifications
demanded by Central Government).

Thereafter, within 15 working days from the release of their respective

share, the State / UT shall raise the proposal for release of proportionate
share of Central Government’s Share of Premium along with the proposal,

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documentary proof for release of State’s / UT’s Share of Premium (Grant-

in-Aid) and requisite documentary evidences & compliance of applicable
financial provisions. The Central Government will release 45% of its respective
share depending upon category of State/UT based on the number of eligible
families that have been targeted / identified by the SHA within 21 working
days from the receipt of duly completed proposal from the State / UT.

Illustration: Rs. 500/- Annual Premium / Family decided in open tendering

process. The calculation of premium per family for 1st Installment shall be
done as under:

A. In case of North Eastern and 3 Himalayan States

1st Installment of State Government’s Share of Premium:

Rs. 500/- X 45% (Out of total 10% Share i.e. Rs. 50.00) = Rs. 22.50

1st Installment of Central Government’s Share of Premium:

Rs. 500/- X 45% (Out of total 90% Share i.e. Rs. 450.00) = Rs. 202.50

Total 1st installment = Rs. 22.50 + Rs. 202.50 = Rs. 225.00 (paid through
State’s / UT’s Escrow Account to the Insurance Company)

B. In case of Other States and Union Territories with Legislation

1st Installment of State Government’s / UT’s Share of Premium:

Rs. 500/- X 45% (Out of total 40% Share i.e. Rs. 200.00) = Rs. 90.00

1st Installment of Central Government’s Share of Premium:

Rs. 500/- X 45% (Out of total 60% Share i.e. Rs. 300.00) = Rs. 135.00

Total 1st installment = Rs. 90.00 + Rs. 135.00 = Rs. 225.00 (paid through
State’s / UT’s Escrow Account to the Insurance Company)

C. In case of Union Territories without Legislation (#)

1st Installment of Central Government’s Share of Premium:

Rs. 500/- X 45% (Out of total 100% Share i.e. Rs. 500.00) = Rs. 225.00

(Paid through UT’s Escrow Account to the Insurance Company)

(#) 100% of Premium and Administrative Cost is borne by Central

Government.

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Thereafter, upon the receipt of Central Government’s Share of Premium, the

State / UT shall release the aforesaid installment of premium within 7 working
days through the designated Escrow Account to the Insurance Company
under intimation to the Central Government

b. Second installment for all States and UTs:

The Insurer upon the completion of 2nd quarter shall raise an invoice for the
second installment of the Premium payable for the Beneficiary Family Units for
which first installment was released earlier. The State / UT (with Legislature),
within 15 working days upon the receipt of invoice from the insurance company,
shall release their 2nd installment of premium i.e. 45% of their respective share
viz. (out of 10% / 40%) into the designated escrow account. Thereafter, within 15
working days from the release of their respective share, the State / UT shall raise
the proposal for release of proportionate share of Central Government’s Share
of Premium along with the proposal, documentary proof for release of State’s /
UT’s Share of Premium (Grant-in-Aid) and requisite documentary evidences &
compliance of applicable financial provisions. The Central Government will release
45% of its respective share depending upon category of State/UT based on the
number of eligible families that have been targeted / identified by the SHA within
21 working days from the receipt of duly completed proposal from the State / UT.

Illustration: Rs. 500/- Annual Premium / Family decided in open tendering process.
The calculation of premium per family for 2nd Installment shall be done as under:

A. In case of North Eastern and 3 Himalayan States

2nd Installment of State Government’s Share of Premium:
Rs. 500/- X 45% (Out of total 10% Share i.e. Rs. 50.00) = Rs. 22.50
2nd Installment of Central Government’s Share of Premium:
Rs. 500/- X 45% (Out of total 90% Share i.e. Rs. 450.00) = Rs. 202.50
Total 2nd installment = Rs. 22.50 + Rs. 202.50 = Rs. 225.00 (paid through State’s
/ UT’s Escrow Account to the Insurance Company)

B. In case of Other States and Union Territories with Legislation

2nd Installment of State Government’s / UT’s Share of Premium:
Rs. 500/- X 45% (Out of total 40% Share i.e. Rs. 200.00) = Rs. 90.00
2nd Installment of Central Government’s Share of Premium:
Rs. 500/- X 45% (Out of total 60% Share i.e. Rs. 300.00) = Rs. 135.00
Total 2nd installment = Rs. 90.00 + Rs. 135.00 = Rs. 225.00 (paid through State’s
/ UT’s Escrow Account to the Insurance Company)

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C. In case of Union Territories without Legislation (#)

2nd Installment of Central Government’s Share of Premium:
Rs. 500/- X 45% (Out of total 100% Share i.e. Rs. 500.00) = Rs. 225.00 (paid
through UT’s Escrow Account to the Insurance Company)
(#) 100% of Premium and Administrative Cost is borne by Central
Government.

Thereupon, the receipt of Central Government’s Share of Premium, the State /

UT shall release the second installment of premium within 7 working days through
the designated Escrow Account to the Insurance Company under intimation to the
Central Government.

c. Third Installment for all States and UTs:

Upon completion of 10 Months of Policy, the Insurer shall submit the Claim
Settlement Report along with the invoice for the last installment of the Premium
payable for the Beneficiary Family Units for which the first and second installment
was released earlier. The State / UT (with Legislative) Government shall, upon
receipt of the Claim Settlement report from the Insurance Company / Real Time
Data available with States / UTs and upon due satisfaction of permissible claim
settlement ratio, release the remaining due premium of 10% or the proportionate
premium based upon the claim settlement scenario, as the case may be, within 15
working days into the escrow account. Thereupon, within 15 working days of their
release of premium, shall raise the proposal to the Central Government for the
release of 10% of Premium or the proportionate premium based upon the claim
settlement scenario, as the case may be into the escrow account as last tranche
of premium to the Insurance Company.

Illustration: Rs. 500/- Annual Premium / Family decided in open tendering process.
The calculation of premium per family for 3rd Installment shall be done as under:

A. In case of North Eastern and 3 Himalayan States

3nd Installment of State Government’s Share of Premium:
Rs. 500/- X 10% (Out of total 10% Share i.e. Rs. 50.00) = Rs. 5.00
3rd Installment of Central Government’s Share of Premium:
Rs. 500/- X 10% (Out of total 90% Share i.e. Rs. 450.00) = Rs. 45.00
Total 3rd installment = Rs. 5.00 + Rs. 45.00 = Rs. 50.00 (paid through State’s /
UT’s Escrow Account to the Insurance Company)

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B. In case of Other States and Union Territories with Legislation

3rd Installment of State Government’s / UT’s Share of Premium:
Rs. 500/- X 10% (Out of total 40% Share i.e. Rs. 200.00) = Rs. 20.00
3rd Installment of Central Government’s Share of Premium:
Rs. 500/- X 10% (Out of total 60% Share i.e. Rs. 300.00) = Rs. 30.00
Total 3rd installment = Rs. 20.00 + Rs. 30.00 = Rs. 50.00 (paid through State’s /
UT’s Escrow Account to the Insurance Company)

C. In case of Union Territories without Legislation (#)

3rd Installment of Central Government’s Share of Premium:
Rs. 500/- X 10% (Out of total 100% Share i.e. Rs. 500.00) = Rs. 50.00 (paid
through UT’s Escrow Account to the Insurance Company)
(#) 100% of Premium and Administrative Cost is borne by Central
Government.

Thereafter, upon the receipt of Central Government’s Share of Premium, the State
/ UT shall release the last installment of premium within 7 working days through
the designated Escrow Account to the Insurance Company under intimation to the
Central Government.

iv) If in case, the State / UT is has not deposited its due share of premium into the escrow
account, then a penal interest would be levied @ 1% per week for the number of week
delay and part thereof on the State / UT. Similarly, penal interest provision shall also be
applicable on the Central Government. The counter Government viz. State or Central
/ UT shall have the right to own such penal interest amount for adjusting in their future
payable respective share of premium.

v) If in case, if any interest is earned by SHA on Central Government’s Share of Premium

released into the Escrow account, the Central Government shall have the first right
of claim on such interest earned amount and shall have to be transferred back to
the Central Government / adjusted in future payment of the Central Government, as
the case may be. Similarly, interest provision shall also be applicable for the State
Government too.

vi) The State Health Agency shall send the proposal to the Central Government for the
release of Central Government’s Share of Premium within 15 (Fifteen) working days
of receipt of the Insurer’s invoice along & release of their share of premium, along
with requisite documents (viz. Details of Eligible Identified Beneficiary Families,
Documentary Proof for release of State Government’s Share, etc] and compliance of
Applicable Financial Rules.

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vii) In case the insurance company is not paid the premium from the escrow account within
the stipulated time of 7 (seven) Business Days, then for such unwarranted delay, the
States / UTs shall be solely liable to pay a penal interest of 1% per week to the Insurance
Company starting from after 15 days.

B. Refund of Premium / Grant-in-Aid

The Insurer will be required to refund premium as stipulated below if they fail to reach
the claim ratio specified in comparison with the premium paid (excluding GST & Other
taxes / Duties) below in the full period of insurance policy period. The premium refund
shall be as per the formula below:

i) The SHA shall issue a letter to the Insurer stating the Insurer’s average Claim Ratio for
all 24/36 months of Policy Cover Period (depending on renewal for third year) for the
State/UT. In the letter, the SHA shall indicate the amount of premium that the Insurer
shall be obliged to refund. The amount of premium to be refunded shall be calculated
based on the provisions as mentioned below.

ii) After adjusting a defined percent for expenses of management (including all costs
excluding only service tax and any cess, if applicable) and after settling all claims, if
there is surplus: 100 percent of leftover surplus should be refunded by the Insurer to the
SHA within 30 days. The percentage that will be need to be refunded will be as per the
following:

In category A States

i. Administrative cost allowed 12% if claim ratio less than 60%.

ii. Administrative cost allowed 15% if claim ratio between 60-70%.
iii. Administrative cost allowed 20% if claim ratio between 70-80%.

In Category B States

i. Administrative cost allowed 10% if claim ratio less than 60%.

ii. Administrative cost allowed 12% if claim ratio between 60-70%.
iii. Administrative cost allowed 15% if claim ratio between 70- 85%. 
iii) The entire surplus as determined through formula mentioned above should be
refunded by the insurer to the SHA within 30 days.
iv) If the Insurer delays payment of or fails to pay the refund amount within 30 days
from the date of communication by SHA, then the Insurer shall be liable to pay
interest at the rate of one percent of the refund amount due and payable to the
SHA for every 7 days of delay beyond such 30 day period.
v) If the Insurer fails to refund the Premium within such 90-day period and/ or the

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default interest thereon, the SHA shall be entitled to recover such amount as a
debt due from the Insurer through means available within law.

Note: List of Category A and Category B:

Category A Arunachal Pradesh, Goa, Himachal Pradesh, Jammu and

Kashmir, Manipur, Meghalaya, Mizoram, Nagaland, NCT Delhi,
States/ UTs
Sikkim, Tripura, Uttarakhand and 6 Union Territories (Andaman
and Nicobar Islands, Chandigarh, Dadra and Nagar Haveli,
Daman and Diu, Lakshadweep and Puducherry)
Category B Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana,
Jharkhand, Karnataka, Kerala, Madhya Pradesh, Maharashtra,
States
Odisha, Punjab, Rajasthan, Tamil Nadu, Telangana, Uttar
Pradesh and West Bengal

C. Sharing of Excess Claim Settlement Amount

This Clause shall be applicable only in case the claim settlement ratio exceeds 120%
(115% in case of bigger states) in any policy period. Under such instance, the excess
amount over and above 120% (115% in case of bigger states) shall be initially shared
in equal proportion between the insurance company and State Government / Union
Territory.

Thereupon, out of the excess burden amount, which the State Government / Union
Territory has borne, the Central Government shall share the burden in line with the
sharing pattern ratio. However, the total contribution of the Central Government along
with the premium share and excess burden amount of claim shall not exceed the
maximum ceiling amount of Share of Central Government, applicable for that particular
States / UTs, respectively.

Any amount over and above the Central and State Government’s contribution amount
shall have to be borne by the Insurance Company, respectively.

D. Penalty Provision on Delay of Premium

If in case, the State / UT has not deposited its due share of premium into the escrow
account, then a penal interest would be levied @ 1% per week for the number of week
delay and part thereof on the State / UT. Similarly, penal interest provision shall also be
applicable on the Central Government. The counter Government viz. State or Central
/ UT shall have the right to own such penal interest amount for adjusting in their future
payable respective share of premium.

In case the insurance company is not paid the premium from the escrow account within
the stipulated time of 7 (seven) Business Days, then for such unwarranted delay, the

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States / UTs shall be solely liable to pay a penal interest of 1% per week to the Insurance
Company starting from after 15 days.

E. Submission and Approval of Proposal

Before the start of implementation of AB-NHPM, the States / UTS will have will have to
send their proposal to the Central Government and execute the Memorandum of
Understanding with the Central Government indicating their modus operandi for the
implementation of AB-NHPM. Further, for States / UTs, who are implementing through
Insurance Mode, shall also upon the completion of the tendering process, send their
proposal for the approval of Central Government in order to enable them to execute the
insurance contract with the selected insurance company.

F. Compliance with Section 64VB of Insurance Act

The Insurer hereby acknowledges, confirms and undertakes that the Premium payment
mechanism as mentioned above is acceptable to them / in compliances with Section
64VB of the Insurance Act.

G. No Separate Fees, Charges or Premium

The Insurer shall not charge any Beneficiary Family Unit or any of the Beneficiaries
any separate fees, charges, commission or premium, by whatever name called, for
providing the benefits. However, the aforesaid provision shall not be applicable, if in
case, the beneficiary is required to take treatment above the amount of benefit cover of
Rs. 5,00,000 .

7.3. Implementation under Trust Mode

A. Release of Grant-in-Aid

i) The Central Government’s Share of Grant-in-Aid will be paid in the same ratio
as mentioned in Section 7.1 for the total actual expenditure incurred towards the
treatment of AB-NHPM Beneficiary Families, subject to the maximum annual
permissible ceiling share of Central Government decided by Government of India,
whichever is less.

ii) The proposal for release of Central Government’s Share of Grant-in-Aid shall be
made by the State Government, upon release of its matching share of contribution,
along with the certified expenditure statement for the treatment cost and other
requisite documents as specified under General Financial Rules, 2017.

iii) The grant-in-aid for the implementation of AB-NHPM will be decided as under:

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a. In 1st Year: The first tranche of grant-in-aid of 50% out of the annual maximum
ceiling of Central Government’s Share of Grant-in-Aid, shall be released as
advance through Escrow Account for the total targeted beneficiary families as
per the SECC Database or the number of beneficiary families mapped with the
SECC Database, as the case may be. The second tranche of 25% will be also
be paid as advance by the end of second quarter, subject to the submission
of documentary proof of utilisation of at least 75% of the earlier released first
installment to the SHA. Further, the last tranche of grant-in-aid as full and
final release shall be made upon receipt of the Utilisation Certificate of the
earlier released tranches in the last quarter and actual amount of certified
expenditure incurred by the States/UT.

b. For 2nd Year and onwards: The first tranche of grant-in-aid of 50%, out of
the total Central Government’s Share of Grant-in-Aid, shall be released
as advance through Escrow Account based upon the actual total actual
expenditure incurred in the previous year towards the treatment of AB-NHPM
Beneficiary Families, subject to the maximum annual permissible ceiling
decided by Government of India, whichever is less, as the case may be. The
second tranche of 25% will be also be paid as advance by the end of second
quarter, subject to the submission of documentary proof of utilisation of at
least 75% of the earlier released first installment to the SHA. Further, the last
tranche of grant-in-aid as full and final release shall be made upon receipt of
the Utilisation Certificate of the earlier released tranches in the last quarter.

B. Submission and Approval of Proposal

Before the start of implementation of AB-NHPM, the States / UTS will have will have
to send their proposal to the Central Government and execute the Memorandum of
Understanding with the Central Government indicating their modus operandi for the
implementation of AB-NHPM.

7.4. Incentivising States / Union Territories for Cost Saving

effectiveness5
This Clause shall be applicable only in case the where the gross annual effective cost for
implementation of AB-NHPM (pertaining to eligible AB-NHPM’s beneficiary families] is
coming under the maximum ceiling limit as decided by Government of India, in any of the
mode of implementation viz. trust mode or insurance mode or mixed model.

Under such instance, 100% of the cost savings attained of Central Government’s Share of
Premium shall be additionally paid to the State Government / Union Territories, which shall

5 This clause is subject to approval of the National Governing Council of AB-NHPM

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be mandatorily used for the development / improvement of Health Infrastructure Facilities.

This incentive will be provided only if State Government will be able to ensure that at least
30% of claim amount comes back to the Government hospitals from second year of the
implementation of the scheme. If, it is observed that the cost saving incentive amount is
utilized for any other purpose then the purpose of development / improvement of Health
Infrastructure Facilities, then a penal interest @ 1% per week or part thereof, shall be levied
until the period such amount is refunded back to the Central Government by the State / UT.

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8. Guidelines on Use of Claim Amount Earned by

Public Hospitals Under AB-NHPM

8.1. Background
All such public hospitals empanelled under AB-NHPM to provide inpatient services to the
eligible beneficiary families will be reimbursed by the insurance companies/trusts for the
services rendered by them as per package rates under AB-NHPM as claim amount.

The claim amount earned by public hospitals under AB-NHPM shall be retained locally at the
hospital level. The hospital level Chikitsa Prabandhan Samiti (CPS)/Hospital Management
Committee (HMC)/Rogi Kalyan Samiti (RKS) shall be responsible for utilisation of this claim
amount. In principal, the amount has to be spent on improvement of the infrastructure and
services in the hospital itself whereby improving the overall infrastructure and quality of care.

8.2. Guidelines for the use of claim amount by public hospitals

A. Respective empanelled AB-NHPM public hospital shall maintain a dedicated bank
account and books for the amount accrued as claim under the scheme. The bank
account opening and maintenance shall be as per the general applicable rules in this
matter and shall not require any special approval.
B. All the withdrawals and reimbursements from the account for all AB-NHPM related
matters shall be done by approved banking instrument (Cheque/draft/bank order) only.
Cash payments should not be done.
C. Upto 25% of the total claim amount can be earmarked for payment of incentive to the
hospital staff.
D. The remaining claim can be used for improving the overall infrastructure (critical gap
funding), functioning of the hospital, quality of services and delivery of services.
E. This claim amount can be used for the following but not limited to the following:

i. Payment of remuneration of Ayushman Mitra.

ii. Local purchase of consumables and medicines which is not available at the State
health department stores department supply/State Medical Services Corporation
supply but as per the overall guidelines of the State in regards to procurement
of the medicines (to the extent possible only the generic medicines should be
prescribed and procured).
iii. Local purchasing of services related to diagnostics and investigations which are
not available in the hospital.
iv. Hiring of services of clinical specialists and non-clinical man power such as
technicians, computer operators, etc.

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v. Any other clinical or non-clinical services of patient centric nature.

All local purchasing must be done by entering into well negotiated rates with the
supplier as per the applicable rules in this matter. All hiring should be done as per
the NHM rules as far as possible.
The State Health Agency (SHA) can modify and add to the guidelines for specific
use of the utilisation of the claim amount.

F. The State Health Agency shall formulate specific guidelines for utilisation of amount
for payment of incentive to hospital staff. An indicative list for the team of clinical and
non-clinical specialist that shall be rewarded with incentive for service delivery under
AB-NHPM is as below-

i. Surgeon/Medical Specialist/Physician, the principal person treating the patient

ii. Assistant Surgeon/ other medical specialist involved (such as paediatrician in
delivery cases)
iii. Anaesthetists/ Other specialists which are involved in the care
iv. On call/ on roster physician
v. Staff nurse and nursing assistants
vi. Lab technicians or technicians of imaging or rehabilitative departments
vii. Others (such as involved in ancillary patient care)

SHA may like to formulate a state specific guideline for distribution of incentive amount
based on their local condition. Any specific issues that may arise with respect to
distribution of incentive amount or utilisation of this claim amount by public hospitals be
presented before the SHA for their resolution.

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9. Guidelines on Portability of Benefits

An Empanelled Health Care Provider (EHCP) under AB-NHPM in any state should provide services
as per AB-NHPM guidelines to beneficiaries from any other state also participating in AB-NHPM.
This means that a beneficiary will be able to get treatment outside the EHCP network of his/her
Home State.

Any empanelled hospital under AB-NHPM will not be allowed to deny services to any AB-NHPM
beneficiary. All interoperability cases shall be mandatorily under pre-authorisation mode and pre-
authorisation guidelines of the treatment delivery state in case of AB-NHPM implementing States /
UTs or indicative pre-authorisation guidelines as issued by NHA, shall be applicable.

9.1. Enabling Portability

To enable portability under the scheme, the stakeholders need to be prepared with the
following:

A. States: Each of the States participating in AB-NHPM will sign MoU with Central
Government which will allow all any the hospital empanelled hospitals by that state
under AB-NHPM to provide services to eligible beneficiaries of other States from across
the country. Moreover, the state shall also be assured that its AB-NHPM beneficiaries
will be able to access services at all AB-NHPM empanelled hospitals seamlessly in
other states across India.
B. Empanelled hospitals: The Empanelled Hospital shall have to sign a tripartite contract
with its insurance company and State Health Agency (in case of Insurance Model)
or with the Trust which explicitly agrees to provide AB-NHPM services to AB-NHPM
beneficiaries from both inside and outside the state and the Insurance Company/Trust
agrees to pay to the EHCP through the inter-agency claim settlement process, the
claims raised for AB-NHPM beneficiaries that access care outside the state in AB-
NHPM empanelled healthcare provider network.
C. Insurance companies/Trusts: The Insurance Company (IC) signs a MOU with all
other IC’s and Trusts in the States / UTs under AB-NHPM to settle the interoperability
related claims within 30 days. The final payment to EHCP where the beneficiary was
treated will be made by the Insurance Company or Trust of his/her home state.
D. IT systems: The IT System will provide a central clearinghouse module where all
inter-insurance, inter trust and trust-insurance claims shall be settled on a monthly/
bi-monthly basis. The IT System will also maintain a Balance Check Module that will
have data pushed on it in real time from all participating entities. The central database
shall also be able to raise alerts/triggers based on suspicious activity with respect to
the beneficiary medical claim history based on which the treatment State shall take
necessary action without delay.

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E. Grievance Redressal: The Grievance Redressal Mechanism will operate as in normal

cases except for disputes between Beneficiary of Home State and EHCP or IC of
Treatment State and between Insurance Companies/Trusts of the Home State and
Treatment State. In case of dispute between Beneficiary and EHCP or IC, the matter
shall be placed before the SHA of the treatment state. In cases of disputes between IC/
Trust of the two states, the matter should be taken up by bilateral discussions between
the SHAs and in case of non-resolution, brought to the NHA for mediation. The IC/
Trusts of Home State should be able to raise real time flags for suspect activities with
the Beneficiary State and the Beneficiary State shall be obligated to conduct a basic
set of checks as requested by the Home State IC/Trust. These clauses have to be built
in into the agreement between the ICs and the Trusts. The NHA shall hold monthly
mediation meetings for sorting out intra-agency issues as well as sharing portability
related data analytics.

F. Fraud Detection: Portability related cases will be scrutinized separately by the NHA
for suspicious transactions, fraud and misuse. Data for the same shall be shared with
the respective agencies for necessary action. The SHAs, on their part, must have a
dedicated team for conducting real time checks and audits on such flagged cases with
due diligence. The IC working in the state where benefits are being provided shall also
be responsible for fraud prevention and investigation.

9.2. Implementation Arrangements of Portability

A. Packages and Package Rates: The Package list for portability will be the list of
mandatory AB-NHPM packages released by the NHA and package rates as applicable
and modified by the Treatment State will be applicable. The Clause for honouring these
rates by all ICs and Trusts shall have to be built into the agreement.

- Clauses for preauthorization requirements and transaction management system

shall be as per the treatment state guidelines.
- The beneficiary wallet, reservation of procedures for public hospitals as well as
segmentation (into secondary/tertiary care or low cost/high cost procedures) shall
be as per the home state guidelines.
- Therefore, for a patient from Rajasthan, taking treatment in Tamil Nadu for CTVS
in an EHCP – balance check and reservation of procedure check will be as per
Rajasthan rules, but TMS and preauthorization requirements shall be as per TN
rules. The hospital claim shall be made as per TN rates for CTVS by the TN SHA
(through IC or trust) and the same rate shall be settled at the end of every month
by the Rajasthan SHA (through IC or trust).

B. Empanelment of Hospitals: The SHA of every state in alliance with AB-NHPM shall
be responsible for empanelling hospitals in their territories. This responsibility shall

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include physical verification of facilities, specialty related empanelment, medical audits,

post procedure audits etc.

- For empanelment of medical facilities that are in a non AB-NHPM state, any AB-
NHPM state can separately empanel such facilities. Such EHCP shall become a
member of provider network for all AB-NHPM implementing states. NHA can also
empanel a CGHS empaneled provider for AB-NHPM in non AB-NHPM state.
- Each SHA which empanels such a hospital shall be separately and individually
responsible for ensuring adherence of all scheme requirements at such a hospital.
C. Beneficiary Identification: In case of beneficiaries that have been verified by the
home state, the treatment state EHCP shall only conduct an identity verification and
admit the patient as per the case.

- In case of beneficiaries that have not been so verified, the treatment EHCP shall
conduct the Beneficiary Identification Search Process and the documentation for
family verification (ration card/family card of home state) to the Home State Agency
for validation.
- The Home State Agency shall validate and send back a response in priority with
a service turnaround time of 30 minutes. In case the home agency does not send
a final response (IC/Trust check), deemed verification of the beneficiary shall
be undertaken and the record shall be included in the registry. The home state
software will create a wallet for such a family entry.
- The empanelled hospital will determine beneficiary eligibility and send the linked
beneficiary records for approval to the Insurance company/trust of Treatment State
which in turn will send the records to the Insurance company/trust in the home
State of beneficiary. The beneficiary approval team of the Insurance company/
trust in the home State of beneficiary will accept/reject the case and convey the
same to the Insurance company/trust in the State of hospital which will then inform
the same to the hospital. In case the beneficiary has an E-Card (that is, he/she has
already undergone identification earlier), after a KYC check, the beneficiary shall
be accepted by the EHCP.
- If the NHA and the SHA agree to provide interoperability benefits to the entire
Home State Beneficiary List, the identification module shall also include the Home
State Beneficiary Database for validation and identification of eligible beneficiaries.

D. Balance Check: After identification and validation of the beneficiary, the balance check
for the beneficiary will be done from the home State. The balance in the home State
shall be blocked through the necessary API and updated once the claim is processed.
The NHA may provide a centralised balance check facility.

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E. Claim Settlement: A claim raised by the empanelled hospital will first be received by
the Trust/Insurer of the Treatment State which shall decide based on its own internal
processes. The approval of the claim shall be shared with the Home State Insurance
Company/Trust which can raise an objection on any ground within 3 days. In case the
Home State raises no objection, the Treatment State IC/Trust shall settle the claim with
the hospital. In case the Home State raises an objection, the Treatment State shall
settle the claim as it deems fit. However, the objection of the Home State shall only be
recommendatory in nature and the Home State shall have to honour the decision of the
Treatment State during the time of interagency settlement.

F. Fraud Management: In case the Trust/Insurer of the home State of beneficiary has
identified fraudulent practices by the empanelled hospital, the Trust/Insurer should
inform the SHA of the Treatment State of EHCP along with the supporting documents/
information. The SHA of the Treatment State shall undertake the necessary action on
such issues and resolution of such issues shall be mediated by the NHA during the
monthly meetings.

G. Expansion of Beneficiary Set: In case, there is an alliance between AB-NHPM and

any State Scheme or AB-NHPM has been expanded in the Home State, the above
process for portability may be followed for all beneficiaries of the Home State.

H. IT Platform: The states using their own platform shall have to provide interoperability
with the central transaction and beneficiary identification system to operationalize
guidelines for portability for AB-NHPM.

I. Modifications: The above guidelines may be modified from time to time by the National
Health Agency and shall apply on all the states participating in the National Health
Protection Mission.

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10. Structure and Tasks of State Health Agency

for Implementation of AB-NHPM in Assurance
Mode
In order to facilitate the effective implementation of the AB-NHPM, the State Government shall
set up the State Health Agency (SHA) or designate this function under any existing agency/ trust/
society designated for this purpose, such as the state nodal agency for RSBY or a trust/ society
set up for a health insurance program. SHA can either implement the scheme directly (Assurance
mode) or it can use an insurance company to implement the scheme.

The SHA shall be responsible for delivery of the services under AB-NHPM at the State level. For such
States that want to implement the AB-NHPM directly through a Trust/ Society without intermediation
of an insurance company, the scope and tasks of SHA are much wider. The State Health Agency is
responsible for complete implementation of the AB-NHPM in the State.

10.1. Tasks of the State Health Agency

All key functions relating to delivery of services under AB-NHPM shall be performed by
the SHA viz. data sharing, verification/validation of families and members, awareness
generation, monitoring etc. The SHA shall perform following activities through staff of SHA
or by hiring an Implementation Support Agency (ISA):

- Policy related issues of State Health Protection/ Insurance scheme and its linkage to
AB-NHPM
- Selection of ISA, if needed
- Awareness generation and Demand creation
- Aadhaar seeding and issuing print out of E-card to validated AB-NHPM Beneficiaries
- Empanelment of network hospitals which meet the criteria including field verification
- Monitoring of services provided by health care providers
- Fraud and abuse control
- Punitive actions against the providers
- Pre-authorisation of claims or monitoring of pre-authorizations which are approved by
ISA
- Administration of hospital claims
- Payment of claims
- Carrying out medical and claims audits
- Package price revisions or adaptation of AB-NHPM list
- Adapting AB-NHPM treatment protocols for listed therapies to state needs, as needed

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- Adapting operational guidelines in consultation with NHA, where necessary

- Forming grievance redressal committees and overseeing the grievance redressal
function
- Capacity development planning and undertaking capacity development initiatives
- Development of proposals for policy changes – e.g. incentive systems for public
providers and implementation thereof
- Management of funds through the escrow account set up for releasing grant-in-aid
under AB-NHPM
- Data analytics
- Evaluation through independent agencies
- Convergence of AB-NHPM with State funded health insurance/ protection scheme (s)
- Alliance of State scheme with AB-NHPM
- Setting up district level offices and hiring of staff for district
- Oversee district level offices
- Preparation of periodic reports based on scheme data and implementation status
- Implementing incentive systems for field functionaries & public providers in line with
national guidance
- Any other such activity required for effective functioning of AB-NHPM in the State

10.2. Additional Tasks in Assurance Mode

In addition to the tasks to be done by State Health Agency in the insurance company mode,
following additional tasks will need to be done by the SHA in the assurance mode:

A. Field Verification of Hospitals for Empanelment – Once the interested hospitals

apply for hospital empanelment through the online portal, a field verification needs to be
done to check the veracity of the information provided by the hospitals. SHA, through
their district team will need to get this field verification done.

B. Claim Management and Audits – This involves receiving the claims from the hospital,
analysing the claims, taking a decision on accepting or rejecting the claims and finally
making payments of claims to the hospitals. It will also involve carrying out claims and
medical audit either after receiving the claims or concurrently at the hospital itself. This
can be done in two ways:

1. Option 1: Through internal team – SHA can have an internal team of experts for
carrying out all the tasks related to claims management.

a. Team of 4-6 persons for claim management with relevant experience

b. Team of 3-5 doctors to work together with claim management team

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2. Option 2: Through external agency – SHA can also hire an external agency
called ISA for claim management process and related activities. For this purpose,
SHA will need to carry out a tendering process to hire such agency. The model
tender document for hiring of ISA shall be provided separately. The ISA selected
for this purpose must be IRDAI compliant. The SHA will sign a contract with the
ISA detailing clear key performance indicators. ISA will provide a dedicated team
for carrying out the claim management process. ISA will also provide a team for
carrying out claims and medical audit either after receiving the claims from the
hospitals or concurrently at the hospital.

10.3. Constitution of SHA

The day-to-day operations of the SHA will be administered by a Chief Executive Officer
appointed by the State Government. The CEO will look after all the operational aspects
of the implementation of the scheme in the State and shall be supported by a team of
specialists (dealing with specific functions). The CEO/ operations team will be counselled
and overseen by a governing council set up at the State level. The suggested composition
of Governing Council is as follows:

S. No. Name / Designation Position

1 Chief Secretary Chairperson, ex-officio
2 Principal Secretary to Government, Health & Family Vice Chairperson,
Welfare Department ex officio
3 Secretary, Finance Department Member, ex officio
4 Secretary, Department of Rural Development Member, ex officio
5 Secretary, Department of Housing and Urban Affairs Member, ex officio
6 Secretary, Department of IT Member, ex officio
7 Secretary, Department of Labour Member, ex officio
8 MD, NHM or Commissioner, Health Department Member, ex officio
9 Director of Medical Education or his/her nominee Member, ex officio
10 Director of Health Services or his/her nominee Member, ex officio
11 CEO (SHA) Member Secretary,
ex officio
12 Representative of NHA Special Invitee
13 1 Subject matter experts as nominated by the State Special Invitee
Government

10.4. Operational Core Team for SHA including additional staff in

Assurance mode
The Chief Executive Officer (CEO) will look after all the operational aspects of the
implementation of the scheme and shall be supported by a team of specialists (dealing with

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specific functions). The SHA should hire a core team to support the Chief Executive Officer
in discharge of different functions. For States implementing the scheme in assurance mode,
they have two options, as mentioned above.

a. Option 1 – They can hire the same number of staff as the States with insurance mode,
additionally staff for beneficiary identity verification. For rest of the functions they can
hire an ISA.
b. Option 2 – Instead of hiring an ISA they can hire additional staff in the team itself to
carry out the additional functions. For option 2, the following additional staff will need to
be hired in the team:

No. in Category A No. in Category B

Position Responsibility
State State
Insurance Assurance Insurance Assurance
Mode Mode Mode Mode
• Pre-authorization process
Claim
• Claims management
Management 1 6 2 8
Team • Ensuring payment of
claims to the hospitals
• Carrying out medical audit
Audit Team 0 3 0 6
• Carrying out claims audit
Operations • Field operations under the
Management scheme 2 4 3 6
Team • Programme management
• Monitoring & evaluation of
scheme
Monitoring & • Monitoring functioning
Evaluation of key vendors including 2 4 4 6
Team hospitals, Field personnel,
• Monitoring achievement
of goals of the scheme
• Designing policy for
State Schemes and
Policy Team 1 2 1 2
convergence thereof with
AB-NHPM
• Data availability, integrity
IT Support, and security
Data and
• MIS coordination 2 5 3 8
Fraud Control
Team • Management of IT
hardware & software

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• Co-ordination for smooth

Beneficiary beneficiary verification
Verification process 2 4
Team • Manage issues related to
beneficiary verification
• Oversee Grievance
Grievance redressal mechanisms
Redressal • Undertake beneficiary 1 2 2 4
Team communications.
• Local grievance redressal
• Designing standard
packages and hospitals
empanelment criterion for
additionalities like State
Medical schemes such that they
Management are complimentary to AB- 2 6 4 8
& Quality NHPM
Team • Empanelment of Hospital
• Quality & Patient safety
• Punitive action against
hospitals
• Strategic communication
IEC Team 1 2 2 4
planning and execution
Capacity • Training & capacity
Development building planning and 1 3 2 6
Team organization
• Fund management
• Managing initial corpus &
funding of trust
Finance • Managing finance &
Management admin processes 2 6 5 9
Team • Claim settlement
• Payments
• Budgeting & accounting
• Internal and external audit
Administrative • General administration of
1 3 2 6
Team the programme

*States have been categorized based on AB-NHPM target population size as below, in two
groups, where group B may need more than one official for the same role.

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Category State Names

A Arunachal Pradesh, Goa, Himachal Pradesh, Jammu and Kashmir, Manipur,
Meghalaya, Mizoram, Nagaland, NCT Delhi, Sikkim, Tripura, Uttarakhand
and 6 Union Territories (Andaman and Nicobar Islands, Chandigarh, Dadra
and Nagar Haveli, Daman and Diu, Lakshadweep and Puducherry)
B Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana, Jharkhand,
Karnataka, Kerala, Madhya Pradesh, Maharashtra, Odisha, Punjab,
Rajasthan, Tamil Nadu, Telangana, Uttar Pradesh, West Bengal

10.5. Structure at District Level

In addition to the state level posts, a District implementation unit (DIU) will also be required
to support the implementation in every district included under the scheme. A DIU shall be
created which would be chaired by the Deputy Commissioner/ District Magistrate/ Collector
of the district. This Unit is to coordinate with the Implementing Agency (ISA/ Insurer) and
the Network Hospitals to ensure effective implementation and also send review reports
periodically. DIU will also work closely and coordinate with District Chief Medical officer and
his/ her team.

Proposed staffing pattern of the DIU as follows:

Post Role Status No.

District Nodal Program Officer designated by Regular state 1 per district
Officer (AB- the State. Regular state official official, may
NHPM) and responsible for the AB-NHPM be part-time
implementation in the district. role
District Program Responsible for monitoring the Contractual, 1 per district
Coordinator implementation of the scheme full time
Aadhaar seeding, validation of
beneficiaries, awareness, spot
checks, and capacity building.
District Supporting hospitals and Contractual, 1 per district
Information implementing agencies (ISA) with full time
Systems Manager use of the information system,
troubleshooting, report-generation
and ensuring uptime of system
functionality.
District Grievance Managing complaint and grievances Contractual, 1 per district
Manager at the district level. Also responsible full time
for organising meetings of District
Grievance Committees

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In addition to the additional staff at the State level, at the district level also additional staff will
need to be hired by the SHA in option 2 without ISA.

Post Role Status No.

District Person responsible for Contractual, 1 per district
Coordinator implementation of the Scheme in full time
each of the districts.
District medical Responsible for medical audits, Contractual, 1 per district
officer fraud control etc. full time

Note: State Nodal Agency may combine more than one of the above tasks in the TORs
of the same individual as per its requirements.

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