Central Government has released the guidelines for Claim Settlement under Ayushman Bharat Yojana / Pradhan Mantri Rashtriya Swasthya Suraksha Mission (PMRSSM). All Empanelled Health Care Providers (EHCP) will use an IT system of PMRSSM to manage claims related transactions. The entire process of claim registration, intimation, payment, investigation by EHCP or by Trust / Insurer is paperless.
IT system of PMRSSM will enable online transactions to ensure claim reporting in real time. However, certain districts have internet connectivity problem, so govt. included an offline arrangement in this IT system. PM Rasthriya Swasthya Suraksha Mission eliminates the need of submission of physical paper.
All the 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.
Ayushman Bharat Yojana Claim Payment and Turn-around Time
Whenever a customer raises a claim (has hit Central / State Server) under this PM Yojana, Trust / Insurance Companies must follow the guidelines for claim settlement received from EHCP:-
- Firstly, the Trust / Insurer / IRDAI Complaint Agency appointed by govt. will decide whether to accept or reject the claim received from EHCP. Rejection notice issued to EHCP must clearly state the reason for rejection as EHCP is eligible to appeal against claim rejection.
- If claim is accepted, then Trust / Insurer shall either make payment on the basis of applicable package rate or shall conduct further investigation for claim.
- Either rejection or payment / investigation must be completed in 15 days (Turn Around Time – TAT). For claims outside the State, this process must be completed within 30 calendar days. TAT will start from the date at which claim documents are accessible by Trust / Insurer.
- The EHCP should upload all claim related documents within 24 hours of discharge of beneficiary to avail benefits under PM Swasthya Suraksha Mission
- 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 will have to upload the payment details on the online portal of PMRSSM.
- Claims investigations will be undertaken by a qualified and experienced medical staff/team including at-least 1 MBBS degree holder to confirm nature of disease, illness or accident. Investigating team must not impart any treatment advice to the patients but they are allowed to verify that the medical procedure offered are upto the prescribed Standard Treatment Guidelines.
- The Trust / Insurer must also update the complete details on online PMRSSM IT system for:-
- Claims that are under investigation on a fortnightly basis for review.
- Every claim which is pending beyond TAT duration of 15 days along with reasons.
- The Trust / Insurer may collect at its own cost, complete Claim papers (including diagnostic reports) from the EHCP, (if necessary to audit claims under investigation). This shall not have any bearing on the Claim Payments to
the Empanelled Health Care Provider.
Penalty on Delay in Claim Settlement under PMRSSM
Every delay in the settlement of claims beyond TAT will invite a penalty of 1% of total claimed amount per week. This penalty amount is to given by the Trust / Insurance Companies to the hospitals. For Inter-State claims w.r.t portability of benefits, penalty will be given at 1% per week after 30 days duration.
Pradhan Mantri Rashtriya Swasthya Suraksha Mission – Update of Claim Settlement
The Trust / Insurance Company should update claim settlement data on the portal on a daily basis. After claim payment, they must update this data within 24 hours. If payment data is not updated, then it will be treated as unpaid and EHCP can levy interest on unpaid amount.
Ayushman Bharat Yojana Right to Appeal and Reopening Claims
All Empanelled Health Care Provider possess Right of Appeal against claim rejection if EHCP feels that claim is payable. All details on Right to appeal and reopening claims are present in the official notification.
PMRSSM Claim Settlement Guidelines Notification
All the details of Claim Settlement including claim registration, intimation, payment, investigation and other details are available in the notification given below:-
— PMRSSM Claim Settlement Guidelines
— For all other details, visit the official website abnhpm.gov.in