Arogya Raksha Yojana

 

 

GUIDE LINE TO THE NETWORK HOSPITALS
  1. All Arogya Raksha Yojana Network Hospitals (NWH) shall display a board with “Arogya Raksha Yojana” in Kannada at a prominent location at the entrance of the NWH and at the reception.
  2. Under the Plan, the beneficiaries are entitled to Free Out Patient services. No amount shall be collected as Registration Charges or Consultation Charges.
  3. Diagnostic tests are to be billed as per the special diagnostic rates fixed for the Plan. Any investigation other than those listed shall be charged at only 50% of the NWH rate.
  4. The beneficiary is entitled to surgical treatment free of cost from the list of surgeries recognized under the Plan.
  5. Package Rates have been fixed for all the surgeries under the list. This comprises all the charges including Admission Charge, Bed Charge, Nursing Charge, Operation Theatre Charge, Procedure Charge, ICU/CCU Charge, Anesthesia Charge, Instrument Charge, Cost of Consumables and Medicines, Professional fees of the Surgeon, costs incurred during related routine investigations and hospitalization for surgical treatment.
  6. The package rates mentioned are all exclusive of implants and prosthesis. Cost of these, if used by way of treatment or on request of the patient should be recovered from the beneficiary at the time of discharge and is not to be included in the claim.
  7. All the beneficiaries under the Arogya Raksha Yojana Health Plan are entitled only for General Ward Admission. However, if the Beneficiary opts for admission to a ward higher than his entitlement, the difference in the charges shall have to be collected by the NWH directly from the Beneficiary.
  8. On no account shall any amount be collected from the beneficiary when admitted for surgical procedure. The NWH shall provide necessary medicines, consumables and disposables of standard quality and will not have the Arogya Raksha Yojana Beneficiaries purchase them.
  9. Any expenses on Diagnostics and Medicines incurred by the Individual Beneficiary after discharge from the NWH shall not form a part of this package and all such expenses will have to be borne by the Beneficiary.
  10. No specific time for ‘inpatient’ stay is prescribed to the NWH for surgical procedures.
  11. A avail of inpatient medical treatment not leading to the surgery at the NWH under the following conditions:

* Maximum of one admission for each beneficiary/ year. If the membership is a family membership,   then group is eligible for admissions equivalent to half the number of members /year.

* Maximum of 3 days of stay to be reimbursed to the NWH, for each admission.

* If admission is in ICU, the patient shall pay for the medicines, consumables and investigations

* Investigations during admission for medical treatment will be done at Arogya Raksha Plan rates.

* The NWH will be reimbursed on actuals but the total amount claimed for each admission including   routine investigations, professional fees and bed charges shall not exceed Rs 650/-.

* Medicines and consumables have to be procured by beneficiary.

 
PROCEDURE FOR EXTENDING TREATMENT


* The beneficiary presents himself at the Arogya Raksha Yojana Counter at the NWH with Arogya   Raksha Yojana Identity Card.

* The Arogya Raksha Yojana coordinator of the NWH will verify the documents produced to   ascertain the authenticity of the identity.

* The beneficiary seeking the facility will be informed of his eligibility limits and the standard   exclusions as applicable under the Plan

* The beneficiary will then be extended Free Out-patient consultation facility as per the Arogya   Raksha Yojana Plan. No registration or OPD fees will be collected from the beneficiary for the   OPD facility.

  1. If the Consultant does not recommend any investigation and advises only medication, the beneficiary buys medicines from the Pharmacy. The individual beneficiary shall bear the costs of such medicines purchased from the pharmacy.
  2. If the Consultant recommends Investigation: The beneficiary undergoes investigations at special discounted Arogya Raksha Yojana rates.
  3. If the Consultant decides the requirement of a Surgery/in-patient medical treatment for the beneficiary:

A. The coordinator at the NWH shall send the Preauthorization to the Implementing Agency for     authorization along with a photocopy of the Arogya Raksha Yojana I.D Card.
B. The Implementing Agency shall respond at the earliest, to the coordinator at NWH giving     clearance for the surgical/in-patient medical treatment.
C. In case of emergency, the Coordinating Officer at NWH shall take verbal sanction from the     Implementing Agency and proceed with the treatment. The Preauthorization for the same shall     be sent to the Implementing Agency within 24 hours.
D. The beneficiary shall then be admitted in the general ward of the NWH and the treatment will be     extended.
E. The NHW in turn will make a claim to the implementing agency in the prescribed format     enclosing the prescribed documents.

 
PROCESS FOR SUBMITTING CLAIMS

The claims must be accompanied by
  1. Photocopy of the Arogya Raksha Yojana I.D. Card
  2. Original claim form with the signature of the beneficiary.
  3. Final split – up bill – with the signature of the beneficiary raised in the name of the “Arogya Raksha Yojana Trust.”
  4. Original authorization issued by Implementing agency
  5. Original discharge summary
  6. Operation Note from treating Doctor (Incase of surgery)


Additional documentation for medical admissions:

  1. Original Investigation and Lab Reports
  2. List of consumables used
  3. List of medicines prescribed

The Network Hospital will be reimbursed by the Arogya Raksha Yojana administration on the standardized and Pre-decided Package Rates. All bills are to be raised in the name of the “Arogya Raksha Yojana Trust”.

Non-compliance to the Arogya Raksha Yojana Guide lines shall result in forfeiture of the recognition as Arogya Raksha Yojana NWH.
Any legal liability arising out of services rendered shall be the sole responsibility of the NWH.

The Coordinator appointed by the Implementing Agency, shall interact with NWH on a regular basis.


IMPORTANT POINTS TO REMEMBER
  • It is important for ary members to produce their ary cards at the reception of the network hospital to be able to use the scheme. A hospital cannot process claims without a card.
  • Ary members are entitled to get treatment only in the general ward of a recognized network hospital.
  • In case of emergency surgery the member should produce the card within 24 hours after admission.
  • Members should keep a photocopy of the card in a safe place so as to expedite replacement in case of loss of cards.