Core Ipd Mou 22 Jan 2014 Final

DEED OF AGREEMENT
This Agreement is entered into on this the «Start_Date» Day of

«Month», «Year»
Between
«Hospital_Name», an institution located in «Address» having their registered

office at «Location» (here in after referred to as “Hospital”, which expression
shall, unless repugnant to the context or meaning thereof, be deemed to mean
and include it's successors and permitted assigns) as party of the FIRST PART
And
ICICI Lombard General Insurance Company Limited, a Company registered

under the provisions of the Companies Act, 1956 and having its registered office
and Corporate
Signed: For, ICICI Lombard GIC Ltd. Signed: For, Service Provider
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Office at ICICI Lombard House, 414 Veer Savarkar Marg, Near Siddhivinayak
Temple, Prabhadevi, Mumbai – 400 025 (hereinafter referred to as “ICICI
General” which expression shall, unless repugnant to the context or meaning
thereof, be deemed to mean and include its successors, affiliate and assigns) as
party of the SECOND PART.
The Hospital and ICICI General are individually referred to as a "Party” or “party"
and collectively as "Parties” or “parties")
WHEREAS
1. Hospital is a health care provider duly recognized and authorized by

government and appropriate authorities to impart heath care services
to the public at large.
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2. ICICI General is a general insurance company providing health
insurance to various state government, employer groups, corporates
and individuals and for this purpose ICICI General has created a
network of service providers.
3. The Hospital is desirous to join the said network of Hospitals and is

willing to extend medical facilities and treatment to Beneficiaries
covered under such health care management plans on the agreed
terms and conditions, and ICICI General is interested in providing its
Beneficiaries with Medical / Hospitalization services.
4. ICICI General has on the basis of representation of the Hospital,

agreed to engage The Hospital as an empanelled Hospital for
providing health services.
5. The Parties hereby desire to record the statements, agreements,

undertakings and covenants on the part of ICICI General &The
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Hospital and also the terms and conditions of this Agreement as
follows:
In this AGREEMENT, unless the context otherwise requires:
1. the masculine gender includes the other two genders and vice versa;
2. the singular includes the plural and vice versa;
3. natural persons include created entities (corporate or incorporate) and vice

versa;
4. marginal notes or headings to clauses are for reference purposes only and
do not bear upon the interpretation of this AGREEMENT.
5. should any condition contained herein, contain a substantive condition, then

such substantive condition shall be valid and binding on the PARTIES not
withstanding the fact that it is embodied in the definition clause.
6. In this AGREEMENT unless inconsistent with, or otherwise indicated by the

context, the following terms shall have the meanings assigned to them
hereunder, namely:
Definition
A. Institution shall for all purpose mean a Hospital.
B. Health Services shall mean all services necessary or required to be

rendered by the Institution under the agreement with an insurer in
connection with “health insurance business” or “health cover” as defined
in regulation 2(f) of the IRDA (Registration of Indian Insurance
Companies) Regulations, 2000 but does not include the business of an
insurer and or an insurance intermediary or an insurance agent.
C. Insured Beneficiaries shall mean the person/s that are covered under
the health insurance scheme of ICICI General.
D. Confidential Information includes all information (whether proprietary

or not and whether or not marked as ‘Confidential’) pertaining to the
business of ICICI General or any of its subsidiaries, affiliates, employees,
Companies, consultants or business associates to which the Institution or
its employees have access to, in any manner whatsoever.
E. Affiliate shall mean and include:

1. ICICI Bank Limited or
2. Any company which is the holding company or subsidiary of ICICI
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Bank Limited or
3. A person under the control of or under common control with ICICI
Bank limited or
4. Any person, in 26% or more of the voting securities of which, ICICI
Bank limited has a direct or beneficial interest.
5. For the purpose of this definition of Affiliate and agreement , “
Control” together with its grammatical variations when used with
respect to any person , means the power to direct the
management and policies of such person , directly or indirectly,
whether through the ownership of the vote carrying securities,
right to appoint member(s) to the board of directors, by contract or
otherwise howsoever; and “person” means a company,
corporation, a partnership, trust and any other entity or
organisation or other body whatsoever.
F. Effective date of agreement: shall mean the date on which the

agreement is executed.
NOW IT IS HEREBY AGREED AS FOLLOWS:
Article 1: Term
This agreement shall be in force from the effective date of this agreement, and
for a period of Three (3) (Term) unless terminated by either parties as per
provisions of Article 18 of this agreement. Upon expiry of the said term the
Agreement shall be renewed automatically for the same term unless terminated
by either party in writing.
Article 2: Scope of services
1. The Hospital undertakes to provide the service in a

precise, reliable and professional manner to the satisfaction of ICICI
General and in accordance with additional instructions issued by ICICI
General in writing from time to time.
2. The Hospital shall treat the Beneficiaries of ICICI

General according to good business practice.
3. The Hospital will extend priority admission

facilities to the Beneficiaries of ICICI General.
4. The Hospital shall ensure that medical

treatment/facility with all due care and accepted standards is extended to
the Beneficiary.
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5. The agreement is subject to the detailed schedule
of fees submitted by the Hospital, which shall be reviewed and accepted
by ICICI General.
6. The Hospital shall allow ICICI General's official to
visit the Beneficiary. ICICI General shall not interfere with the medical
team of the Hospital; however ICICI General reserves the right to discuss
the treatment plan with treating doctor. Further access to medical
treatment records and bills prepared in the Hospital shall be provided to
ICICI General on a case to case basis with prior appointment from the
Hospital.
7. The Hospital shall also endeavor to comply with

future requirement of ICICI General providing for standardized billing, ICD
coding etc and if mandatory by statutory requirement both parties agree
to review the same.
8. The Hospital shall allow ICICI General to conduct

audits of the bills as and when deemed necessary by ICICI General. Such
audits shall be conducted by ICICI General's audit team without prior
intimation to the Hospital.
9. The Hospital shall allow ICICI General to inspect

the premises of the network provider at any time without prior intimation
on regular and ad-hoc basis.
10. The Hospital will convey to its medical consultants

to keep the Beneficiary only for the required number of days of treatment
and carry only the required investigation & treatment for the ailment,
which the Insured Beneficiary is admitted for. Any other incidental
investigation required by the patient on his request needs to be approved
separately by ICICI General and if it is not covered under ICICI General
policy then the same will not be paid by ICICI General and the Hospital
needs to recover it from the Insured Beneficiary.
Article 3: Identification of Beneficiaries
1. The Insured Beneficiaries will be identified by the Hospital on the basis of

an ID card issued to the Insured Beneficiary bearing the logo and the
wordings of ICICI General and a photo identity card.
2. For the ease of the Insured Beneficiary, the Hospital shall display the
recognition and promotional material, network status, and
procedures for admission supplied by ICICI General at prominent
location, preferably at the reception and admission counter and
Casualty/Emergency departments. The Hospital also needs to
inform their reception and admission staff the procedures of
admission and obtaining authorization letter as per the article 4.
The Hospital shall also allow ICICI Lombard to display their
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details.
Article 4: Cashless facility admission procedure by the Network

Provider
The procedure to be followed for providing cashless facility shall be as provided

in Annexure I.
Article 5: Payment terms
1 Hospital will submit all the documents as listed in Article 4 above within 7
days from the date of the discharge of the patient/Insured Beneficiary
and ICICI General will make payment of eligible bills within 26 days from
the date of receipt of such submission. However if required, ICICI General
can call for further document related to treatment to process the case, in
which case the payment may be delayed beyond 26 days as
contemplated herein (Depending on the query response received from
the Hospital)
2 All payments shall be made through direct electronic fund transfer subject
to deduction of tax at source as applicable under the relevant laws.
Further, the payment reconciliation process shall be carried out on a
regular basis.
3 The Hospital must recover any non-covered treatment/ Investigation cost

from the Patient/ Insured Beneficiary.
4 The final docket for onward submission to ICICI General for immediate
payment must contain the documents as mentioned in Article 5 and in
addition to the same shall also provide the following documents:
a. Copy of preauthorization letter, Insured Beneficiary acceptance

letter and duly signed claim form.
b. Original final bill with detailed break up of miscellaneous,
consumables & other charges.
c. Original and complete discharge card/ summary mentioning the
duration of ailment and duration of other disorders like
hypertension or diabetes if any.
d. Original investigation reports with corresponding prescription/
request
e. Pharmacy bill if supplied by Hospital with corresponding request
f. Any other statutory documentary evidence required under law or
policy terms & condition
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g. Status of deposit paid if any by beneficiary.
5. The final docket must be submitted to ICICI General within 90 days of

receipt of authorization from ICICI General. In the event of non
submission of final docket within 90 days, the authorization shall stand
closed and ICICI Lombard General Insurance Co Ltd shall be released of
any liability arising out of the said authorization.
6. All queries raised by ICICI General during the process of settlement of

claim raised by The Hospital should be reverted within a maximum period
of 45 days. In the event of non response to query within 45 days from the
query raised date, the claim shall stand closed and ICICI Lombard General
Insurance Co Ltd shall be released of any liability arising out of the said
authorization.
7. All the claim documents shall be dispatched at the following address of
ICICI Lombard Healthcare:

ICICI Bank Tower, Plot No. 12,
Financial District, Nanakram Guda,
Gachibowli, Hyderabad – 500 032
Andhra Pradesh
Article 6: Standard Discharge Summary
The procedure to be followed for standard discharge summary shall be as

provided in Annexure II.
Article 7: Standard Format for Provider Bills
The standard format for provider bills shall be as provided in Annexure III.
Article 8: Right to Repudiate/Deny a Claim
ICICI General reserves the exclusive right to deny or repudiate a claim without
divesting any such right either on the Hospital or any TPA. It shall be the sole
responsibility of ICICI General to repudiate/deny a claim with due regard to the
terms and conditions of the policy so availed by the Insured.
Article 9: Declarations and Undertakings of a Hospital
1. The Hospital undertakes that they have obtained all the registrations
/licenses /approvals required by law in order to provide the services
pursuant to this agreement and that they have the skills, knowledge and
experience required to provide the services as required in this
agreement.
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2. The Hospital undertakes to comply with all requirement of law in so far as
these apply in accordance to the provisions of the law and the regulations
enacted from time to time, by the local bodies or by the central or the
state govt.
3. The Hospital declares that it has never committed a criminal offence

which prevents it from practicing medicines and no criminal charge has
been established against it by a competent court..
Article 10: General responsibilities and obligations of the Hospital
1. The Hospital shall ensure that no confidential information is shared or

made available by the Hospital or any person associated with the
Hospital to any person or entity not related to the Hospital without prior
written consent of ICICI General.
2. The Hospital shall provide cashless facility to the Insured Beneficiary in

strict adherence to the provisions of the agreement.
3. The Hospital will have the facility covered by proper indemnity policy
including errors, omission and professional indemnity insurance and
agrees to keep such policies in force during entire tenure of the
Agreement. The cost/ premium of such policy shall be borne solely by the
hospital.
4. The Hospital shall endeavor to have an officer/staff appointed in the

administration department and such officer/staff shall assist the Insured
Beneficiaries in respect to various benefits under the different policies
provide by ICICI General in this regard.
5. The Hospital agree to display their status to preferred Insured Beneficiary

of ICICI General at their reception/admission desks along with the display
and other materials supplied by ICICI General whenever possible for the
ease of the Insured Beneficiaries. The Hospital shall also allow ICICI
Lombard to display their details.
Article 11: General responsibilities of ICICI General
ICICI General represents and warrants to the Hospital that:
It has full power capacity and authority to execute deliver and perform
this Agreement and it has taken all necessary action (corporate, statutory or
otherwise) to execute delivery, perform and authorize the execution delivery
and performance of this Agreement and that it is fully empowered to enter into
and execute this Agreement as well as perform all its obligations hereunder.
Neither the making of this Agreement nor compliance with its terms will
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be in conflict with or result in the breach of or constitute a default or require any
consent under any provision of any agreement or other instrument to which
such party is a party or by which it is bound; any judgement injunction, order,
decree or award which is binding upon such Party; and/or such Party’s the
Memorandum and / or Articles of Association.
Throughout the term of this agreement the Insurer shall continue to be an

insurance company under Law to carry on the activities contemplated herein.
Article 12: Non- Exclusivity
ICICI General has a right to avail similar services as contemplated herein from
other institution for the Health services covered under this agreement.
Article 13: Relationship of the Parties
Nothing contained herein shall be deemed to create between the Parties any
partnership, joint venture or relationship of principal and agent or master and
servant or employer and employee or any affiliate or subsidiaries thereof. Each
of the Parties hereto agree not to hold itself or allow its directors
employees/agents/representatives to hold out to be a principal or an agent,
employee or any subsidiary or affiliate of the other.
Article 14: Continuity of Services
Nothing contained herein shall forbid the Hospital from providing continuous
services to ICICI General including but not limited to change in an agreement
entered into between the Hospital and the TPA or change in the TPA.
Article 15: Customer Services and Relations:
The Hospital shall provide bespoke services to the insureds in a precise, reliable
and professional manner and treat the Insured Beneficiaries of ICICI General
according to good business practice. The Hospital shall further ensure that
medical treatment/facility with all due care and accepted standards is extended
to the Insured Beneficiaries and extend priority admission facilities to the
Insured Beneficiaries of ICICI General.
Article 16: Code of Conduct
The Hospital shall scrupulously adhere to and follow the Code of Conduct as set
out in Article 2 to the service level agreement and as may be prescribed and
communicated from time to time. Breach of this sub-clause will entitle the
Company to terminate this Agreement forthwith and without any notice;
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Article 17: Reporting
In the first week of each month, beginning from the first month of the
commencement of this Agreement, the hospital and ICICI General shall
exchange information on their experiences during the month and review the
functioning of the process and make suitable changes whenever required.
However, all such changes have to be in writing and by way of suitable
supplementary agreements or by way of exchange of letters.
All official correspondence, reporting, etc pertaining to this Agreement shall be

conducted with ICICI General at its corporate office at 414, Veer Savarkar Marg,
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai – 400 025
Article 18: Termination
1. ICICI General reserves the right to terminate this agreement by giving 30

days notice if:
1.1. The Hospital violates any of the terms and conditions of this
agreement; or
1.2. ICICI General comes to know of wrong and fraudulent practices; or
1.3. ICICI General comes to know of any misrepresentation; or
1.4. ICICI General observes any inadequacy of service or other non

compliance or default;
1.5. ICICI General observes cases of overstay and over provisioning

without adequate explanation.
However, no such cancellation or modification shall be done by ICICI General

unless the Hospital is given an opportunity of being heard.
2. This agreement may be terminated by either party by giving one month’s

prior written notice by means of registered letter or a letter delivered at
the office and duly acknowledged by the other, provided that this
agreement shall remain effective thereafter with respect to all rights and
obligations incurred or committed by the parties hereto prior to such
termination.
Article 19: PROCEDURE FOR DE-EMPANELLMENT OF NETWORK

PROVIDER
The procedure to be followed for de-empanellment of network provider shall be

as provided in Annexure IV.
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Article 20: Confidentiality
This clause shall survive the termination/expiry of this Agreement.
1. Each party shall maintain confidentiality relating to all matters and issues
dealt with by the parties in the course of the business contemplated by
and relating to this agreement. The Hospital shall not disclose to any
third party, and shall use its best efforts to ensure that its, officers,
employees, keep secret all information disclosed, including without
limitation, document marked confidential, medical reports, personal
information relating to insured, and other unpublished information except
as maybe authorized in writing by ICICI General. ICICI General shall not
disclose to any third party and shall use its best efforts to ensure that its
directors, officers, employees, sub-contractors and affiliates keep secret
all information relating to the hospital including without limitation to the
hospital’s proprietary information, process flows, and other required
details.
2. In Particular the hospital agrees to:

a) Maintain confidentiality and endeavour to maintain confidentiality of
any persons directly employed or associated with health services
under this agreement of all information received by the hospital or
such other medical practitioner or such other person by virtue of this
agreement or otherwise, including ICICI General’s proprietary
information, confidential information relating to insured, medicals/test
reports whether created/handled/delivered by the hospital. Any
personal information relating to a Insured received by the hospital
shall be used only for the purpose of inclusion /preparation
/finalization of medical reports/test reports for transmission to ICICI
General only and shall not give or make available such
information/any documents to any third party whatsoever.
b) Keep confidential and endeavour to maintain confidentiality by its
medical officer, employees, medical staff, or such other persons, of
medical reports relating to Insured, and that the information contained
in these reports remains confidential and the reports or any part of
report is not disclosed/ informed to the Insurance Agent / Advisor
under any circumstances.
c) Keep confidential and endeavour to maintain confidentiality of any
information relating to Insured, and shall not use the said confidential
information for research, creating comparative database, statistical
analysis, or any other studies without appropriate previous
authorization from ICICI General and through ICICI General from the
Insured.
Article 21: Indemnities and other provisions
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1. ICICI General will not be in any way held responsible for the outcome of
treatment or quality of care provided by the Hospital.
2. ICICI General shall not be liable or responsible for any acts, omission or
commission of the Doctors and other medical staff of the Hospital and the
Hospital shall obtain professional indemnity policy on its own cost for this
purpose. The Hospital agrees that it shall be responsible in any manner
whatsoever for the claims, arising from any deficiency in the services or
any failure in providing the services.
3. Notwithstanding anything to the contrary in this agreement neither Party

shall be liable by reason of failure or delay in the performance of its
duties and obligations under this agreement if such failure or delay is
caused by acts of God, Strikes, lock-outs, embargoes, war, riots civil
commotion, any orders of governmental, quasi-governmental or local
authorities, or any other similar cause beyond its control and without its
fault or negligence.
4. The Hospital will indemnify, defend and hold harmless the ICICI General
against any claims, demands, proceedings, actions, damages, costs, and
expenses which the company may incur as a consequence of the
negligence of the former in fulfilling obligations under this Agreement or
as a result of the breach of the terms of this Agreement by the Hospital or
any of its employees or doctors or medical staff.
Article 22: Notices
All notices, demands or other communications to be given or delivered

under or by reason of the provisions of this Agreement will be in writing
and delivered to the other Party:
a) By registered mail;
b) By courier;
In the absence of evidence of earlier receipt, a demand or other

communication to the other Party is deemed given
a) If sent by registered mail, seven working days after posting it;
and
b) If sent by courier, seven working days after posting it; and
The notices shall be sent to the other Party to the above addresses (or to
the addresses which may be provided by way of notices made in the
above said manner):
-if to the Hospital:
Attn:
Tel :
Fax:
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-if to ICICI General
ICICI LOMBARD HOUSE,

414 Veer Savarkar Marg,
Near Siddhivinayak Temple,
Prabhadevi,
Mumbai – 400 025
Article 23: Dispute Resolution
1. The provisions of this Agreement shall be governed by, and construed in

accordance with Indian law.
2. Any dispute, controversy or claims arising out of or relation to this

Agreement or the breach, termination or invalidity thereof, shall be
settled by arbitration in accordance with the provisions of the (Indian)
Arbitration and Conciliation Act, 1996.
3. The arbitral tribunal shall be composed of three arbitrators, one arbitrator
appointed by each Party and the third arbitrator shall be appointed by
mutual consent of the arbitrators so appointed.
4. The place of arbitration shall be Mumbai and any award whether interim
or final, shall be made, and shall be deemed for all purposes between the
parties to be made, in Mumbai.
5. The arbitral procedure shall be conducted in the English and any award
shall be rendered in English. The procedural law of the arbitration shall be
Indian law.
6. The award of the arbitrator shall be final and conclusive and binding upon
the Parties, and the Parties shall be entitled (but not obliged) to enter
judgement thereon in any one or more of the courts having jurisdiction.
7. The rights and obligations of the Parties under, or pursuant to, this Clause
including the arbitration agreement in this Clause, shall be governed by
and subject to Indian law.
8. The cost of the arbitration proceeding would be born by the parties on

equal sharing basis.
Article 24: Miscellaneous
This Agreement together with any Annexures attached hereto constitutes the
entire Agreement between the parties and supersedes, with respect to the
matters regulated herein, and all other mutual understandings, accord and
agreements, irrespective of their form between the parties. All Annexures shall
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constitute an integral part of the Agreement.
1. Except as otherwise provided herein, no modification, amendment or waiver

of any provision of this Agreement will be effective unless such modification,
amendment or waiver is approved in writing by the parties hereto.
2. Should specific provision of this Agreement be wholly or partially not legally

effective or unenforceable or later lose their legal effectiveness or
enforceability, the validity of the remaining provisions of this Agreement
shall not be affected thereby.
3. The hospital may not assign, transfer, encumber or otherwise dispose of this
Agreement or any interest herein without the prior written consent of ICICI
General, provided whereas that the ICICI General may assign this Agreement
or any rights, title or interest herein to an Affiliate without requiring the
consent of the hospital.
4. The failure of any of the parties to insist, in any one or more instances, upon
a strict performance of any of the provisions of this Agreement or to exercise
any option herein contained, shall not be construed as a waiver or
relinquishment of such provision, but the same shall continue and remain in
full force and effect.
Article 25: Severability
The invalidity or enforceability of any provisions of this Agreement in any

jurisdiction shall not effect the validity, legality or enforceability of the
remainder of this agreement in such jurisdiction or the validity, legality or
enforceability of this Agreement, including any such provision, in any other
jurisdiction, it being intended that all rights and obligations of the Parties
hereunder shall be enforceable to the fullest extent permitted by law.
Article 26: Captions
The captions herein are included for convenience of reference only and shall be
ignored in the construction or interpretation hereof.
SIGNED AND DELIVERED BY the hospital-

the within
named____________________________, by
the Hand of___________________________
its Authorised Signatory
In the presence of:
1.
2.
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SIGNED AND DELIVERED BY ICICI
LOMBARD GENERAL INSURANCE
COMPLAY LIMITED, the within named ICICI
General, by the hand of ___________ it’s
Authorised Signatory
In the presence of:
1.
2.
Annexure I – Provider Services-Cashless Facility Admission Procedure
4A. Pre-authorization Procedure - Planned Admissions
1. Request for hospitalization shall be forwarded by the provider

immediately after obtaining due details from the treating doctor / beneficiary
in the pre-authorization form prescribed i.e. “request for authorization letter”
(RAL). The RAL shall be sent along with all the relevant details in the
electronic form to the 24-hour authorization /cashless department of the
insurer or its representative TPA along with contact details of treating
physician and the insured. The insurer’s or its representative TPA’s medical
team may consult the treating physician or the insured, if necessary.
2. If the treating physician identifies any

disease/ailment/illness/condition as pre-existing, the treating physician shall
record it and also inform the insured immediately.
3. In the cases where the symptoms appear vague / no effective

diagnosis is arrived at, the medical team of the insurer or its representative
TPA may consult with treating physician /insured, if necessary.
4. The RAL shall reach the authorization department of insurer or its

representative TPA 7 days prior to the expected date of admission, in case of
planned admission.
5. If “clause 4”above is not followed, the clarification for the delay needs
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to be forwarded along with the request for authorization.
6. The RAL form shall be dully filled with clearly mentioning Yes or No
and/or the details as required. The form shall not be sent with nil or blanks
replies.
7. The guarantee of payment shall be given only for the medically

necessary treatment cost of the ailment covered and mentioned in the
request for hospitalization. Non covered items i.e. non-medical items which
are specifically excluded in the policy, like Telephone usage, food provided to
relatives/attendants, Provider registration fees etc shall be collected directly
from the insured. Indicative list of inadmissible items provided as per Annex-
V.
8. The authorization letter by the insurer or its representative TPA shall

clearly indicate the amount agreed for providing cashless facility for
hospitalization.
9. In the event of the cost of treatment increasing the agreed amount,

the provider may check the availability of further limit with the insurer or its
representative TPA.
10. When the cost of treatment exceeds the authorized limit, request for
enhancement of authorization limit shall be made immediately during
hospitalization using the same format as for the initial preauthorization. The
request for enhancement shall be evaluated based on the availability of
further limits and may require to provide valid reasons for the same. No
enhancement of limit is possible after discharge of insured.
11. Further the insurer shall accept or decline such additional expenses
within a maximum of 24 hours of receiving the request for enhancement.
Absence of receiving the reply from the insurer within 24 hours shall be
construed as denial of the additional amount.
12. In case the insured has opted for a higher accommodation / facility
than the one eligible under the policy, the provider shall explain orally the
effect of such option and also take a written consent from the insured at the
time of admission as regard to owing the responsibility of such expenses by
the insured including the proportionate expenses which have a direct
bearing due to up gradation of room accommodation/facility. In all such
cases the insurer shall pay for the expenses which are based on the
eligibility limits of the insured. However provider may charge any advance
amount/security deposit from the insured only in such cases where the
insured has opted for an upgraded facility to the extent of the amounts to be
collected from the insured.
13. Insurance company guarantees payment only after receipt of RAL and
the necessary medical details. The Authorization Letter (AL) shall be issued
within 48hours of receiving the RAL.
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14. In case the ailment is not covered or given medical data is not
sufficient for the medical team of authorization department to confirm the
eligibility, insurer or its representative TPA can deny the authorization.
15. Authorisation letter [AL] shall mention the authorization number and
the amount guaranteed for the procedure.
16. In case the balance sum available is considerably less than the cost of
treatment, provider shall follow their norms of deposit/running bills etc.
However, provider shall only charge the balance amount over and above the
amount authorized under the health insurance policy against the package or
treatment from the insured.
17. Once the insured is to be discharged, the provider shall make a final
request for the preauthorization for any residual amount along with the
standard discharge summary and the standard billing format. Once the
provider receives final pre-authorization for a specific amount, the insured
shall be allowed to get discharged by paying the difference between the pre-
authorised amount and actual bill, if any. Insurer, upon receipt of the
complete bills and documents, shall make payments of the guaranteed
amount to the provider directly.
18. Due to any reason if the insured does not avail treatment at the
Provider after the preauthorization is released, the Provider shall cancel the
Pre-authorisation and intimate to TPA immediately.
19. All the payments in respect of pre-authorised amounts shall be made

electronically by the insurer to the Net work provider as early as possible but
not later than a 30 days from the date of receipt of all claim documents.
20. Denial of authorization (DAL) for cashless is by no means denial of

treatment by the health facility. The provider shall deal with such case as per
their normal rules and regulations.
21. Insurer shall not be liable for payments to the providers in case the
information provided in the “request for authorization letter” and subsequent
documents during the course of authorization, is found incorrect or not
disclosed.
22. Provider, Insurer and its representative TPA shall ensure that the
procedure specified in this Schedule is strictly complied in all respects.
4B. Preauthorization Procedure - Emergency Admissions
1. Request for hospitalization shall be forwarded by the provider

immediately after obtaining due details from the treating doctor / beneficiary
in the pre-authorization form prescribed i.e. “request for authorization letter”
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(RAL). The RAL shall be sent along with all the relevant details in the
electronic form to the 24-hour authorization /cashless department of the
insurer or its representative TPA along with contact details of treating
physician and the insured. The insurer’s or its representative TPA’s medical
team may consult the treating physician or the insured, if necessary.
2. The insurer or its representative TPA may continue to discuss with

treating doctor till conclusion of eligibility of coverage is arrived at. However,
any life saving, limb saving, sight saving, emergency medical attention
cannot be withheld or delayed for the purpose of waiting for pre-
authorisation. Provider meanwhile may consider treating him by taking a
token deposit or as per their norms.
3. Once a pre-authorization is issued after ascertaining the coverage,

provider shall refund the deposit amount to the insured if taken barring a
token amount to take care of non covered expenses.
4C. Preauthorization Procedure - RTA / MLCs
1. If requesting a pre-authorisation for any potential medico-legal

case including Road Traffic Accidents, the Provider shall indicate the same in
the relevant section of the standard form.
2. In case of a road traffic accident and or a medico legal case, if

the victim was under the influence of alcohol or inebriating drugs or any
other addictive substance or does intentional self injury, it is for the Provider
to inform this circumstance of emergency to the insurer or its representative
TPA.
4D. Authorization letter (AL)
1. Authorization letter shall mention the amount, guaranteed

class of admission, eligibility, of the patient or various sub limits for rooms
and board, surgical fees etc. wherever applicable, as per the benefit plan for
the patient.
2. The Authorization letter will also mention validity of dates

for admission and number of days allowed for hospitalization, if any. The
Provider shall see that these rules are strictly followed; else the AL will be
considered null and void.
3. In the event the room category, if any, is not available the

same shall be informed to the insurer or its representative TPA and the
insured. For such cases, if the insured is admitted to a class of
accommodation higher than what he is eligible for, the provider shall collect
the necessary difference, if any, in charges from the insured.
4. The AL has a limited period of validity - which is 15 days

from the date of sending the authorization.
19
_____________________________ ________________________
5. AL is not an unconditional guarantee of payment. It is
conditional on facts presented – when the facts change the guarantee
changes.
4E Reauthorization
1. Where there is a change in the line of treatment - a fresh authorization

shall be obtained from the insurer immediately - this is called a
reauthorization.
2. The same pre-authorisation form shall be used for the reauthorization,

and the same turnaround times as specified shall apply.
4F. Discharge Procedure
1. The following documents shall be included in the list of documents to

be sent along with the claim form to the insurer or its representative TPA.
These shall not be given to the insured:
a. Original pre authorization request form,

b. Authorization letter,
c. Original Discharge Card & Final Hospital Bill
d. All original investigation reports, prescription & pharmacy receipt etc
2. Where the insured requires the discharge card/reports he or she can

be asked to take photocopies of the same at his or her own expenses and
these have to be clearly stamped as “Duplicate, originals are submitted to
insurer”.
3. The discharge card/Summary shall mention the duration of ailment

and duration of other disorders like hypertension or diabetes and operative
notes in case of surgeries. The clinical detail shall be sufficiently and
justifiably informative.
4. Signature of the insured on final Provider bill shall be obtained.
5. In the event of death or incapacitation of the insured, the signature of

the nominee or any of insured’s of the family who represents the insured as
such subject to reasonable satisfaction of Provider shall be sufficient for the
insurer to consider the claim.
6. Standard Claim form duly filled in shall be presented to the insured for
signing and identity of the insured shall be confirmed by the provider.
Network Provider agrees to comply with the present & future requirements of
20
_____________________________ ________________________
insurers like standardized pre-authorization form/discharge summary/billing,
ICD-10 coding etc. In case Network Provider doesn’t have such facility at their
end, they agree to get such services outsourced to a competent agency at their
own cost.
4G. Billing Procedure
1. The Provider shall submit original invoices directly to insurer or its

representative TPA and such invoices shall contain, at the minimum,
following information:
a) the insured's full name and date of birth;

b) the policy number;
c) the insured's address;
d) the admitting consultant;
e) the date of admission and discharge;
f) the procedure performed and procedure code according to ICD-10 PCS or
any other code as specified by the Authority from time to time;
g) the diagnosis at the time of treatment and diagnosis code according to
ICD-10 or any other code as specified by the Authority from time to time;
h) whether this is an interim or final bill/account;
i) the description of each Service performed, together with associated
Charges, the agreed standard billing codes associated with each Service
performed and dates on which items of Service were provide; and.
j) the insured's signature (in original).
2. The Provider shall submit the following documents with the final invoice:
Original pre-authorization form; and signed copy of authorization letter issued

by insurer or TPA
a) fully completed claim form or the relevant claim section of the pre-
authorisation letter, signed by the insured and the treating consultant for
the treatment performed;
b) original and complete discharge summary in standard form and billing

form in the standard form, including the treating Consultant's operative
notes;
c) original investigation reports with corresponding prescription/request;
d) pharmacy bill with corresponding prescription/request:
e) any other relevant and/or statutory documentary evidence required
under law or by the insured's policy; and
f) photocopy of the insured's photo identification (e.g. voter's Smart card/
ID card, passport or driving license etc).
g) Evidence of use of Implants/Lens, like bar coded stickers in original.
h) Invoice in support of Implant cost
21
_____________________________ ________________________
3. The Provider shall submit the final invoice and all supporting
documentation required within 2 days of the discharge date Service network
provider may endeavor to provide all claim records electronically including
indoor case record.
Annex II - Standard Discharge Summary
The provider should make sufficient arrangements so as to conform to the

format & guidelines herein to the standard Discharge Summary & Provider Bills
for speedy settlement of bills.
4.8 STANDARD DISCHARGE SUMMARY
1. Components of standardization:
a) List of standard contents in the discharge summary

b) Standard guidelines for preparing a discharge summary so that the
22
_____________________________ ________________________
interpretation of the terms in the document and the information provided
is uniform.
2. Standard Contents of Discharge Summary Format:
a) Patient’s Name*:
b) Telephone No / Mobile No*:
c) IPDNo:
d) Admission No:
e) Treating Consultant/s Name, contact numbers and Department/Specialty :
f) Date of Admission with Time:
g) Date of Discharge with Time:
h) MLC No/FIR No*:
i) Provisional Diagnosis at the time of Admission:
j) Final Diagnosis at the time of Discharge:
k) ICD-10 code(s) or any other codes, as recommended by the Authority,
for Final diagnosis*:
l) Presenting Complaints with Duration and Reason for Admission:
m) Summary of Presenting Illness:
n) Key findings, on physical examination at the time of admission:
o) History of alcoholism, tobacco or substance abuse, if any:
p) Significant Past Medical and Surgical History, if any*:
q) Family History if significant/relevant to diagnosis or treatment:
r) Summary of key investigations during Hospitalization*:
s) Course in the Hospital including complications if any*:
t) Advice on Discharge*:
u) Name & Signature of treating Consultant/ Authorized Team Doctor:
v) Name & Signature of Patient / Attendant*:
GUIDE NOTES FOR FILLING DISCHARGE SUMMARY FORMAT:
a) The patient’s name shall be the official name as appearing in the

insurance policy document and the attendants should be made aware
that it cannot be changed subsequently, because in some cases the
attendants give the nick names which are different from documented
names. As a matter of abundant precaution, all personal information
should be shown to the patient/attendant and validated with their
signatures.
b) The contact numbers shall be specifically those of the patient and if

pertaining to attendant, the same should be mentioned.
c) Where applicable, copy of MLC/FIR needs to be attached
23
_____________________________ ________________________
d) Desirable not mandatory
e) Significant past medical and surgical history shall be relevant to present
ailment and shall provide the summary of treatment previously taken,
reports of relevant tests conducted during that period. In case history is
not given by patient, it should be specified as to who provided the same.
f) Summary of key investigations shall appear chronologically consolidated

for each type of investigation. If an investigation does not seem to be a
logical requirement for the main disease/line of treatment, the admitting
consultant should justify the reason for carrying out such
test/investigation.
g) The course in the hospital shall specify the line of treatment, medications
administered, operative procedure carried out and if any complications
arise during course in the hospital, the same should be specified. If
opinion from another doctor from outside hospital is obtained, reason for
same should be mentioned and also who decided to take opinion i.e.
weather the admitting and treating consultant wanted the opinion as
additional expertise or the patient relatives wanted the opinion for their
reassurance.
h) Discharge medication, precautions, diet regime, follow up consultation

etc should be specified. If patient suffers from any allergy, the same shall
be mentioned.
i) The signatures/Thumb impression in the Discharge Summary shall be

that of the patient because generally the patient is discharged after
having improved. In other cases like Death summary or transfer notes in
case of terminal illness, the attendant can sign, the inability of the
patient to sign should be recorded by the attending doctor.
Annexure III - Standard Format For Provider Bills
1. Components of standardization: Standardization involves three

components
a. Bill Format
b. Codes for billing items and nomenclature.
c. Standard guidelines for preparing the bills.
2. Format Specified: The bill is expected to be in two formats
24
_____________________________ ________________________
a. The summary bill and
b. The detailed breakup of the bills.
3. Explanation and Guidelines: Summary Bill
a. The summary format is annexed in the Schedule-III A

b. The bill shall be generated on the letter head of the provider and in A4
size to aid scanning.
c. The summary bill shall not have any additional items (only9)
d. The provider has to mention the service tax number in case they
charge service tax to the insurance company.
e. The payer mentioned in the bill as to be necessarily the insurance
company and not the TPA.
f. In case of package charged for any procedure/treatment, the
provider is expected to mention the amount in serial no 9 only. Items
beyond the package are to be mentioned in serial numbers 1 to 8.
g. The patient/attendant signature is mandatory on the summary bill
h. The additional guidelines to fill the summary format shall be as below:
Field Name Remarks
Provider Name Legal entity name and not the trade name
Provider Registration Registration number of the provider with local authorities. Once the
Number clinical establishments ( registration and regulation) bill, 2007 is
passed, then registration number under this act
Address Address of the Facility where member is admitted. A provider can

have more than one facility.
IP No Unique number identifying the particular hospitalization of the

member
Patient Name Full name of the patient
Payer Name Name of the insurance company with whom the member is insured.
In case of cash patient then the field is to be left blank. If the bill is
raised to more than one insurer then the primary insurer who has
given cashless is to be mentioned. The name of insurance company
needs to be mentioned and not the TPA.
Member address Full address of the member
Bill Number Bill number of the provider
Bill Date Date on which the bill is generated.
PAN Number PAN Number Mandatory
25
_____________________________ ________________________
Service Tax Regn No Registration number from service tax authorities. Mandatory in
case service tax is charged in the bill.
Date of admission Date of admission of the member in case of IPD cases. In case of
Day care procedures, this is the date of procedure.
Date of discharge Date of discharge of the member in case of IPD cases. In case of
Day care procedures, this is the date of procedure(same as date of
admission)
Bed Number Bed number in which the patient is admitted. In case the member
is admitted under more than one bed number, all the numbers have
to be mentioned.
SL No 1 of billing All items under the primary head Rs.'100000' in the detailed bill
Summary have to be summarized into this. In case the procedure is
packages, then only bills amount beyond the package needs to be
mentioned here.
mentioned here.
SL No 3 billing Summary All items under the primary head Rs.'300000' in the detailed bill
have to be summarized into this. In case the procedure is
mentioned here.
mentioned here.
mentioned here.
mentioned here.
mentioned here.
26
_____________________________ ________________________
mentioned here.
summary have to be summarized into this. If more than one procedure is
done, the total amount of the two procedures needs to be
summarized
Total Bill amount Sum total of all items 1 to 9 in the bill
Amount paid by the Amount of bill paid by the member including co-pay, deductible,
member non-medical items etc include discount offered to member, if any,
Amount charged to Payer Amount payable by insurance company
Discount Amount Amount offered as discount to the insurance company
Service Tax Service Tax chargeable to insurance company
Amount payable Total amount payable by Insurance Company including service tax
Amount in words Above amount in words for the sake of clarity
patients signature Signature of the patient or the attendant of the patient needs to be
mandatorily taken
Authorized signatory The signature of the authorized signatory at the provider
4. Explanation and Guidelines - Detailed Breakup of the Bill
i. The summary format is annexed in Schedule –III – B

ii. The Bill shall be generated on the letter head of the provider and in A4
size paper to aid scanning.
iii. The billing has to be done at level 2 or 3
iv. In case of medicines/consumables, the relevant level code has to be
mentioned (40100, 401002) and the text should indicate the actual
medicine used
v. If providers have outsourced the pharmacy to external vendors, in
such cases the providers can attach the original bills separately.
However, the summary of this original bill has to be mentioned in the
summary bill.
vi. In case of pharmacy returns the same code originally used is to be
used with a negative sign in the units.
vii. In case of cancellation of any service the same code originally used is
to be used with a negative sign indicating reversal.
viii. The date on which the service is rendered is to be mentioned in the
bill. This would be
a. the date of requisition in case of investigations
b. date of consultation for professional fees
c. date of requisition in case of pharmacy/consumables
27
_____________________________ ________________________
irrespective of when they were used
d. date of return of pharmacy items for pharmacy returns
ix. The additional guidelines to fill the summary format shall be as below,
except that the first section of the bill is same as the bill summary
referred in 3 above.
Field Name Remarks
Date Date on which service is rendered. For example, this is the date of
investigation, date of procedure etc.
Code Level 2 or 3 code of the billing item as per the codes (Part ii)
Particulars Text explanation of the item charged
Rate Per unit price (per day room rent, per consultation charge)
Unit No of units charged (hours, days, number as appropriate)
Amount Rate* units(s)
Schedule-III
I. Schedules: Schedule-III A
SUMMARY BILL FORMAT
Provider Name Bill Number
Provider registration Bill Date

No.
Address PAN Number
IP No Service Tax Regn No
Patient Name Date of Admission
Payer Name xxxx Insurance Company Ltd Date of Discharge
Member Address Bed Number
Billing Summary
SL No Primary Code Particulars Amount
28
_____________________________ ________________________
1 100000 Room & Nursing Charges
2 200000 ICU Charges
3 300000 OT Charges
4 400000 Medicine & Consumables
5 500000 Professional Fees’
6 600000 Investigation Charges
7 700000 Ambulance Charges
8 800000 Miscellaneous Charges
9 900000 Package Charge
Total Bill Amount 0
Amount paid by member 0
Amount charged to Payer 0
Discount Amount 0
Service Tax 0
Amount payable 0
Amount in Words Rupees Zero Only
Patients Signature Authorized

Signatory
Schedule-III B
DETAILED BREAKUP FORMAT
PART-1
29
_____________________________ ________________________
Bill Number
Provider Name
Provider Regn No. Bill Date
Address PAN Number
IP No Service Tax Regn No
Patient Name Date of Admission
Payer Name xxxx Insurance Company Ltd Date of Discharge
Member Address Bed Number
Billing Details
SL Date Code Particulars Rate No’s (Unit) Amount
No
1 101001 General Ward Charges 500 1 500
2 401001 XXX medicine 50 2 100
3 401001 XXX Medicine return 50 -1 -50
30
_____________________________ ________________________
PART-II
Level 1 Level 1 Level 2 Code Level 2 Level 3 Level 3 Remarks

Code Code
100000 Room & Nursing

Charges
100000 Room & Nursing 101000 Room Charges

Charges
100000 Room & Nursing 101000 Room Charges 101001 General

Charges Ward
charges
100000 Room & Nursing 101000 Room Charges 101002 Semi-

Charges private
room
charges
100000 Room & Nursing 101000 Room Charges 101003 Single

Charges Room
charges
100000 Room & Nursing 101000 Room Charges 101004 Single

Charges Deluxe
room
charges
100000 Room & Nursing 101000 Room Charges 101005 Deluxe

Charges room
charges
100000 Room & Nursing 101000 Room Charges 101006 Suite

Charges charges
100000 Room & Nursing 101000 Room Charges 101007 Electricity

Charges charges
100000 Room & Nursing 101000 Room Charges 101008 Bed Sheet
Charges charges
100000 Room & Nursing 101000 Room Charges 101009 Hot water
Charges charges
100000 Room & Nursing 101000 Room Charges 101010 Establishm

Charges ent charges
100000 Room & Nursing 101000 Room Charges 101011 Alpha/Wate

Charges r Bed
charges
100000 Room & Nursing 101000 Room Charges 101012 Attendant

Charges Bed
31
_____________________________ ________________________
charges
100000 Room & Nursing 102000 Nursing Charges

Charges
100000 Room & Nursing 102000 Nursing Charges 102001 Nursing

Charges fees
100000 Room & Nursing 102000 Nursing Charges 102002 Dressing

Charges
100000 Room & Nursing 102000 Nursing Charges 102003 Nebulizatio

Charges n
100000 Room & Nursing 102000 Nursing Charges 102004 Injection

Charges charges
100000 Room & Nursing 102000 Nursing Charges 102005 Infusion

Charges pump
charges
100000 Room & Nursing 102000 Nursing Charges 102006 Aya

Charges Charges
100000 Room & Nursing 102000 Nursing Charges 102007 Blood

Charges Transfusion
Charges
100000 Room & Nursing 103000 Duty Doctor fee

Charges
100000 Room & Nursing 103000 Duty Doctor fee 103001 Duty
Charges Doctor fee
100000 Room & Nursing 103000 Duty Doctor fee 103002 RMO Fees
Charges
100000 Room & Nursing 104000 Monitor Charges

Charges
100000 Room & Nursing 104000 Monitor Charges 104001 Pulse if used in
Charges Oxymeter normal
charges Room
200000 ICU Charges
200000 ICU Charges 201000 ICU Charges
200000 ICU Charges 201000 ICU Charges 201001 Burns Ward
200000 ICU Charges 201000 ICU Charges 201002 HDU

charges
200000 ICU Charges 201000 ICU Charges 201003 ICCU
32
_____________________________ ________________________
charges
200000 ICU Charges 201000 ICU Charges 201004 Isolation

ward
charges
200000 ICU Charges 201000 ICU Charges 201005 Neuro ICU

Charges
200000 ICU Charges 201000 ICU Charges 201006 Pediatric/ne

onatal ICU
charges
200000 ICU Charges 201000 ICU Charges 201007 Post

Operative
ICU
200000 ICU Charges 201000 ICU Charges 201008 Recovery

Room
200000 ICU Charges 201000 ICU Charges 201009 Surgical

ICU
200000 ICU Charges 202000 ICU Nursing If ICU

charges nursing
charged
separatel
y
200000 ICU Charges 202000 ICU Nursing 202001 Nursing If ICU

charges fees nursing
charged
separatel
y
200000 ICU Charges 202000 ICU Nursing 202002 Dressing If ICU

charges nursing
charged
separatel
y
200000 ICU Charges 202000 ICU Nursing 202003 Nebulizatio If ICU

charges n nursing
charged
separatel
y
200000 ICU Charges 202000 ICU Nursing 202004 Injection If ICU

charges charges nursing
charged
separatel
y
200000 ICU Charges 202000 ICU Nursing 202005 Infusion

charges pump
33
_____________________________ ________________________
charges
200000 ICU Charges 203000 Monitor charges
200000 ICU Charges 203000 Monitor charges 203001 Monitor

charges
200000 ICU Charges 203000 Monitor charges 203002 Pulse If used

Oxymeter in ICU
charges
200000 ICU Charges 203000 Monitor charges 203003 Cardiac

Monitor
charges
200000 ICU Charges 204000 Monitor charges 203004 IABP

charges
200000 ICU Charges 204000 Monitor charges 203005 photothera

py charges
200000 ICU Charges 204000 ICU Supplies &

equipment
200000 ICU Charges 204000 ICU Supplies & 204001 oxygen

equipment charges
200000 ICU Charges 204000 ICU Supplies & 204002 Ventilator

equipment charges
200000 ICU Charges 204000 ICU Supplies & 204003 suction

equipment pump
charges
200000 ICU Charges 204000 ICU Supplies & 204004 Bipap

equipment charges
200000 ICU Charges 204000 ICU Supplies & 204005 Pacing Temporar
equipment Charges y
Pacemar
ker
200000 ICU Charges 204000 ICU Supplies & 204006 Defibrillator

equipment Charges
300000 OT Charges
300000 OT Charges 301000 OT rent
300000 OT Charges 301000 OT rent 301001 Major OT

charge
300000 OT Charges 301000 OT rent 301002 Major OT

charge
34
_____________________________ ________________________
300000 OT Charges 301000 OT rent 301003 Cath Lab
Charges
300000 OT Charges 301000 OT rent 301004 Theatre

charges
300000 OT Charges 301000 OT rent 301005 Labour

Room
charges
300000 OT Charges 302000 OT Equipment

charges
300000 OT Charges 302000 OT Equipment 302001 C-arm

charges
300000 OT Charges 302000 OT Equipment 302002 Endoscopy

charges
300000 OT Charges 302000 OT Equipment 302003 Laparosco

pe charges
300000 OT Charges 302000 OT Equipment 302004 Equipment If not

charges specified
35
_____________________________ ________________________
300000 OT Charges 302000 OT Equipment 302005 Monitor For OT
charges monitoring
300000 OT Charges 302000 OT Equipment 302006 Instrument For OT

charges Instrument
300000 OT Charges 303000 OT Drugs &

Consumables
300000 OT Charges 303000 OT Drugs & 303001 OT Drugs

Consumables
300000 OT Charges 303000 OT Drugs & 303002 Implants

Consumables
300000 OT Charges 303000 OT Drugs & 303003 OT Includes

Consumables Consumable guidewires,
s catheter etc
300000 OT Charges 303000 OT Drugs & 303004 OT

Consumables Materials
300000 OT Charges 303000 OT Drugs & 303005 OT Gases

Consumables
300000 OT Charges 303000 OT Drugs & 303006 Anesthetic

Consumables drugs
300000 OT Charges 304000 OT

Sterilization
300000 OT Charges 304000 OT 304001 CCSD

Sterilization Charges
400000 Medicine &

Consumables
charges
400000 Medicine & 401000 Medicine &

Consumables Consumables
charges charges
400000 Medicine & 401000 Medicine & 401001 Ward OT drugs

Consumables Consumables Medicines under OT
charges charges charges
400000 Medicine & 401000 Medicine & 401002 Ward

Consumables Consumables Consumable
charges charges s

Consumables Consumables disposables
charges charges
36
_____________________________ ________________________
Consumables Consumables Materials
charges charges
400000 Medicine & 401000 Medicine & 401005 Vaccination

Consumables Consumables drugs
charges charges
500000 Professional fees

charges
500000 Professional fees 501000 Visit charges

charges
500000 Professional fees 501000 Visit charges 501001 Consultation

charges Charges
500000 Professional fees 501000 Visit charges 501002 Medical

charges supervision
charges
500000 Professional fees 501000 Visit charges 501003 professional

charges fees
500000 Professional fees 502000 Surgery

charges Charges
500000 Professional fees 502000 Surgery 502001 Surgeons

charges Charges charges
500000 Professional fees 502000 surgery 502002 Assistant Include

charges Charges surgeons fee standby
surgeon
500000 Professional fees 503000 Anesthetists

charges fee
500000 Professional fees 503000 Anesthetists 503001 Anesthetists

charges fee fee
500000 Professional fees 503000 Anesthetists 503002 OT standby Providers

charges fee charges charge for
standby
anesthetist
500000 Professional fees 504000 Intensivist 504000

charges Charges
500000 Professional fees 505000 Technician 505000 OT/Cath Lab

charges Charges technician
500000 Professional fees 505000 Physiotherapy

charges
500000 Professional fees 504000 Procedure
37
_____________________________ ________________________
charges charges
500000 Professional fees 504000 Procedure 504001 Bedside Catheteriza

charges charges procedures tion,
Central IV
Line,
Tracheosto
my,
Venesection
500000 Professional fees 504000 Procedure 504002 suture

charges charges charges
600000 Investigation
charges
600000 Investigation 601000 Bio chemistry Serum

charges Sodium,
Ueres etc
600000 Investigation 602000 Cardiology for

charges charges procedures
like echo,
ECG etc
600000 Investigation 603000 Haemotology cross

charges charges matching
etc
600000 Investigation 604000 Microbiology blood

charges charges culture,
C&S
600000 Investigation 605000 Neurology for EMG

charges EEG etc
600000 Investigation 606000 Nuclear PET CT,

charges medicine Bone scan
etc
600000 Investigation 607000 pathology

charges charges
600000 Investigation 608000 Radiology X-ray, CT,

charges services MRI etc
600000 Investigation 609000 Serology

charges charges
600000 Investigation 610000 Medical Chrosomal

charges Genetics Analysis etc
600000 Investigation charges 611000 Profiles Profiles

instead of
individual
38
_____________________________ ________________________
tests(Lipid
profile, LFT
etc)
700000 Ambulance charges
700000 Ambulance charges 701000 Ambulance

Charges
800000 Miscellaneous charges
800000 Miscellaneous charges 801000 Admission

charges
800000 Miscellaneous charges 802000 Attendant

food charges
800000 Miscellaneous charges 803000 Patient food

charges
800000 Miscellaneous charges 804000 Registration

charges
800000 Miscellaneous charges 805000 MRD Charges
800000 Miscellaneous charges 806000 Documentati

on charges
800000 Miscellaneous charges 807000 Telephone

charges
800000 Miscellaneous charges 808000 Bio Medical

Waste
Charges
800000 Miscellaneous charges 809000 Taxes Luxury Excluding VAT

Tax/Surc & Service Tax
harge/Se
rvice
charge
900000 Package Charges To be used

only in case
of packages
900000 Package Charges 901000 Cardiac ICD-10- CABG To be used

Surgery PCS only in case
of packages
900000 Package Charges 902000 Cardiology ICD-10- PTCA To be used

Packages PCS only in case
of packages
900000 Package Charges 903000 Cath Lab ICD-10- CAG To be used

PCS only in case
39
_____________________________ ________________________
of packages
900000 Package Charges 904000 Dental ICD-10- Root To be used

Procedures PCS Canal only in case
Treatmen of packages
t
900000 Package Charges 905000 ENT ICD-10- FESS To be used

PCS only in case
of packages
900000 Package Charges 906000 Gastroenterol ICD-10- Gastrect To be used

ogy PCS omy – only in case
Partial of packages
900000 Package Charges 907000 General ICD-10- Inguinal To be used

Surgery PCS hernia only in case
of packages
900000 Package Charges 908000 Gynecology ICD-10- LSCS To be used

PCS only in case
of packages
900000 Package Charges 909000 Nephrology ICD-10- Nephrect To be used

PCS omy only in case
of packages
900000 Package Charges 910000 Neuro ICD-10- Cranioto To be used

Surgery PCS my only in case
of packages
900000 Package Charges 911000 Oncology ICD-10- IMRT To be used only

procedures PCS in case of
packages
900000 Package Charges 912000 Ophthalmolo ICD-10- Cataract To be used only

gy PCS in case of
procedures packages
900000 Package Charges 913000 Orthopaedic ICD-10- Bilateral To be used only

Surgery PCS TKR in case of
packages
900000 Package Charges 914000 Plastic ICD-10- Skin To be used only

Surgery PCS Grafting in case of
packages
900000 Package Charges 915000 Pulmonology ICD-10- Pleural To be used only

Packages PCS Tapping in case of
packages
900000 Package Charges 916000 Urology ICD-10- ERCP To be used only

PCS in case of
40
_____________________________ ________________________
packages
900000 Package Charges 917000 Vascular ICD-10- Embolect To be used only

Surgery PCS omy in case of
packages
Annexure IV – De-Empanelment of Providers
41
_____________________________ ________________________
Steps 1 - Putting the Provider on “Watch-list”
1. Based on the claims data analysis and/ or the Provider visits, if there is
any doubt on the performance of a Provider, the Insurance Company can
put that Provider on the watch list.
2. The data of such Provider shall be analyzed very closely on a daily basis
by the Insurance Company for patterns, trends and anomalies.
Step 2 - Suspension of the Provider
3. A Provider can be temporarily suspended in the following cases:
a. For the Providers which are in the “Watch-list” if the Insurance Company
observes continuous patterns or strong evidence of irregularity based on
either claims data or field visit of Providers, the Provider shall be suspended
from providing services to policyholders/insured patients and a formal
investigation shall be instituted.
If a Provider is not in the “Watch-list”, but the insurance company 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.
4. A formal letter shall be send to the Provider regarding its suspension with
mentioning the Time frame within which the formal investigation will be
completed.
Step 3 - Detailed Investigation
5. The Insurance Company can launch a detailed investigation into the

activities of a Provider in the following conditions:
a. For the Providers which have been suspended.

b. Receipt of complaint of a serious nature from any of the
stakeholders.
6. The detailed investigation may include field visits to the Providers,

examination of case papers, talking with the policyholders/insured (if
needed), examination of Provider records etc.
7. If the investigation reveals that the report/ complaint/ allegation against

the Provider is not substantiated, the Insurance Company would
immediately revoke the suspension (in case it is suspended). A letter
regarding revocation of suspension shall be sent to the Provider within
24 hours of that decision.
42
_____________________________ ________________________
Step 4 - Action by the Insurance Company
7. If the investigation reveals that the complaint/allegation against the

Provider is correct then following procedure shall be followed:
a) The Provider must be issued a “show-cause” notice seeking an

explanation for the aberration.
b) After receipt of the explanation and its examination, the charges may be
dropped or an action can be taken.
c) The action could entail one of the following based on the seriousness of
the issue and other factors involved:
d) A warning to the concerned Provider, ii. De-empanelment of the Provider.
8. The entire process should be completed within 30 days from the date of
suspension.
Step 5 - Actions to be taken after De-empanelment
9. Once a Provider has been de-empanelled by insurer, following steps shall

be taken:
a) A letter shall be sent to the Provider regarding this decision.

b) An FIR shall be lodged against the Provider by the insurer at the earliest
in case the de-empanellement is on account of fraud or fraudulent
activity.
c) This information shall be sent to all the other Insurance Companies which
are doing health insurance business.
d) The Insurance Company which had de-empanelled the Provider may be
advised to notify the same in the local media, informing all
policyholders/insured about the de-empanelment, so that the
beneficiaries do not utilize the services of that particular Provider.
e) If the Provider appeals against the decision of the Insurance Company,
the aforementioned actions shall be subject to the dispute resolution
process agreed in the service level agreement.
43
_____________________________ ________________________
Annexure V – Indicative List of Commonly Excluded Items
Indicative List of commonly excluded Items
Items
A. Toiletries /Cosmetics/Personal Recommendations

Sr Comfort or Convenience Items
No
A1 Hair removing cream charges Not Payable
Baby Charges (unless
Not Payable
A 2 specified/indicated)
A 3 Baby food Not Payable
A 4 Baby utilities charges Not Payable
A 5 Baby set Not Payable
A 6 Baby Bottles Not Payable
A 7 Bottle Not Payable
A 8 Brush Not Payable
A 9 Cosy Towel Not Payable
A 10 Hand Wash Not Payable
A 11 Moisturiser Paste Brush Not Payable
A 12 Powder Not Payable
A 13 Razor Not Payable
A 14 Towel Not Payable
A 15 Shoe Cover Not Payable
A 16 Beauty Services Not Payable
A 17 Buds Not Payable
A 18 Barber charges Not Payable
A 19 Caps Not Payable
A 20 Cold pack/hot pack Not Payable
A 21 Carry bags Not Payable
A 22 Cradle charges Not Payable
A 23 Comb Not Payable
Disposable razor charges (for site
Payable
A 24 preparations)
A 25 Eau-De-Cologne/Room freshners Not Payable
A 26 Eye pad Not Payable
A 27 Eye shield Not Payable
A 28 Email/Internet charges Not Payable
Food charges (other than Patient's Diet
Not Payable
A 29 Provided by Hospital)
A 30 Foot cover Not Payable
A 31 Gown Not Payable
A 32 Laundry charges Not Payable
A 33 Mineral water Not Payable
A 34 Oil charges Not Payable
A 35 Sanitary pad Not Payable
44
_____________________________ ________________________
A 36 Slippers Not Payable
A 37 Telephone charges Not Payable
A 38 Tissue paper Not Payable
A 39 Tooth paste Not Payable
A 40 Tooth Brush Not Payable
A 41 Guest services Not Payable
A 42 Bed pan Not Payable
A 43 Bed under pad charges Not Payable
A 44 Camera cover Not Payable
A 45 Care free Not Payable
A 46 Cliniplast Not Payable
A 47 Crepe bandage Not Payable
A 48 Curapore Not Payable
A 49 Diaper of any type Not Payable
Not Payable(however if CD is specifically
DVD,CD charges
A 50 sought by insurer/TPA then payable)
A 51 Eyelet Collar Not Payable
A 52 Face mask Not Payable
A 53 Flexi mask Not Payable
A 54 Gause soft Not Payable
A 55 Gauze Not Payable
A 56 Hand holder Not Payable
A 57 Hansaplast/Adhesive Bandages Not Payable
A 58 Lactogen/Infant food Not Payable
B. Items which form part of hospital
services where separate
consumables are not payable but
the service is
Payable under OT charges,Not Payable
Ward & theatre booking charges
B1 separately
Rental charged by the hospital
Anthroscopy & Endoscopy instruments payable.Purchase of Instruments not
B2 payable
Microscope cover
B3 separately
Surgical blades,harmonic scalpel,shaver
B4 separately
Surgical drill
B5 separately
Eye kit
B6 separately
Eye drape
B7 separately
Payable under Radiology charges,not as
X- ray film
B8 consumables
Payable under Investigation charges,not
Sputum cup
B9 as consumables
Boyles apparatus charges
B 10 separately
Blood grouping and cross matching of
Part of cost of blood,not payable
B 11 donors samples
45
_____________________________ ________________________
B 12 Savlon Not payable- part of dressing charges
Band aids,bandages,sterile
Not payable -part of dressing charges
B 13 injections,needles.syringes
B 14 Cotton Not payable -part of dressing charges
B 15 Cotton bandages Not payable -part of dressing charges
Not payable- payable by the patient when
Micropore/Surgical tape prescribed,otherwise included as dressing
B 16 charges
B 17 Blade Not Payable
Not Payable-part of hospital
Apron services/disposable linen to be part of
B 18 OT/ICU charges
Not Payable(service is charged by
Torniquet hospitals,consumables cannot be
B 19 separetly charged)
B 20 Orthobundle,Gynaec bundle Part of dressing charges
B 21 Urine container Not Payable
C. Elements of Room Charge

C1 HVAC Not payable- part of room charges
C2 House keeping charges Not payable- part of room charges
Service charges where nursing charge
Not payable- part of room charges
C 3 also charged
C 4 Television & Air conditioner charges Not payable- part of room charges
C 5 Surcharges Not payable- part of room charges
C 6 Attendant charges Not payable- part of room charges
C 7 IM/IV injection charges Part of nusing charges ,not payabe
Part of laundry/house keeping charges,not
Clean sheet
C8 payable separately
Extra diet of patient(other than that Patient diet provided by hospital is
C9 which forms part of bed charges) payable
C 10 Blanket/warmer blanket Not payable- part of room charges
D. Administrative or Non medical

charges
D1 Admission Kit Not payable
D2 Birth certificate Not payable
Blood reservation charges & ante natal
Not payable
D 3 booking charges
D 4 Certificate charges Not payable
D 5 Courier charges Not payable
D 6 Conveyance charges Not payable
D 7 Diabetic chart charges Not payable
Documentation charges/Administrative
Not payable
D 8 Expenses
D 9 Discharge procedure charges Not payable
D 10 Daily chart charges Not payable
D 11 Entrance pass/Visitors pass charges Not payable
Expenses related to prescription on To be claimed by patient under post
D 12 discharge Hospitalisation where admissible
46
_____________________________ ________________________
D 13 File opening charges Not payable
Incidental expenses/Misc.charges (Not
Not payable
D 14 explained)
D 15 Medical certificate Not payable
D 16 Maintainance charges Not payable
D 17 Medical records Not payable
D 18 Preparation charges Not payable
D 19 Photocopies charges Not payable
D 20 Patient indentification band/Name tag Not payable
D 21 Washing charges Not payable
D 22 Medicine box Not payable
Payable upto 24 hrs.shifting charges not
Mortuary charges
D 23 payable
D 24 Medico legal case charges(MLC charges) Not payable
E. External Durable Devices

E 1 Walking Aids charges Not payable
E 2 Bipap Machine Not payable
E 3 Commode Not payable
E 4 CPAP/CPAD equipments Device not payable
E 5 Infusion pump-cost Device not payable
Oxygen cylinder (for usage outside the
Not payable
E 6 hospital)
E 7 Pulseoxymeter Charges Device not payable
E 8 Spacer Not payable
E 9 Spirometre Device not payable
E 10 SPo2 probe Not payable
E 11 Nebulizer kit Not payable
E 12 Steam inhaler Not payable
E 13 Armsling Not payable
E 14 Thermometer Not payable
E 15 Cervical collar Not payable
E 16 Splint Not payable
E 17 Diabetic foot ware Not payable
E 18 Knee braces(long/short/hinged) Not payable
E 19 Knee immobilizer/shoulder immobilizer Not payable
Payable for any ICU .Patient requiring
more than 3 days in ICU,all patients with
Nimbus bed or water or air bed charges Paraplegia,quadriplegia for any reason
and at reasonable cost of approximately
E 20 Rs 200/day
E 21 Ambulance collar Not payable
E 22 Ambulance equipment Not payable
E 23 Microsheild Not payable
F.Items Payable if supported by a

prescription
Betadine/hydrogen May be payable when prescribed for
peroxide/spirit/dettol/savlon/disinfectant patient,not payable for hospital usage in
F1 s etc. OT or ward or for dressings in hospital
47
_____________________________ ________________________
Private nurses charges-Special nursing Post hospitalisation nursing charges not
F2 charges payable
Nutrition planning charges-Dietician Not payable separately, patient diet part
F3 charges-Diet charges of room charge
Cream powder lotion(toileteries are not
payable,only prescribed medical Payable when prescribed
F4 pharmaceuticals payable)
Upto 5 electrodes are required for every
case visiting OT or ICU.For longer stay in
ECG electrodes ICU, May require a change and at least
one set every second day must be
F5 payable.
Sterilized gloves payable/unsterilized
Gloves
F6 gloves not payable
F7 HIV kit Payable-pre operative screening
If used during hospitalisation is payable
Nebulisation kit
F8 reasonably
Routine Vaccination not payable/post bite
Vaccination charges
F9 vaccination payable
G.Part of Hospital's own cost & not

payable
G1 AHD Not payable-Part of Hospital's internal cost
G2 Alcohol swabs Not payable-Part of Hospital's internal cost
G3 Scrub solution/sterillium Not payable-Part of Hospital's internal cost
H Others
H 1 Vaccine charges for Baby Not Payable
H 2 Aesthetic treatment/Surgery Not Payable
H 3 TPA charges Not Payable
H 4 Visco belt charges Not Payable
Any kit with no details mentioned
Not Payable
H 5 (delivery kit,orthokit,Recovery kit,etc.)
H 6 Examination gloves Not Payable
H 7 Kidney tray Not Payable
H 8 Mask Not Payable
H 9 Ounce glass Not Payable
Not Payable,except for telemedicine
Outstation consultant's/Surgeon's fees
H 10 consultations where covered by policy
H 11 Oxygen mask Not Payable
H 12 Paper gloves Not Payable
H 13 Referal Doctor's fee Not Payable
Not payable pre hospitalisation or post
Accu Check (Glucometery/Strips) hospitalisation/reports and charts
H 14 required/Device not payable
H 15 Pan can Not payable
H 16 Softnet Not payable
H 17 Trolly cover Not payable
H 18 Urometer,Urine jug Not payable
H 19 Ambulance Payable-Ambulance from home to hospital
or interhospital shifts is payable/RTA as
48
_____________________________ ________________________
specific requirement is payable
Payable- Maximum of 3 in 48 hrs. and
Tegaderm/Vasofix safety
H 20 then 1 in 24 hrs.
Payable where medicaly necessary till a
Urine bag
H 21 reasonable cost.Maximum 1 per 24 hrs
H 22 Softovac Not payable
Essential for case like CABG etc. Where it
Stockings
H 23 should be paid
49
_____________________________ ________________________

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DEED OF AGREEMENT

This Agreement is entered into on this the «Start_Date» Day of

«Hospital_Name», an institution located in «Address» having their registered

ICICI Lombard General Insurance Company Limited, a Company registered

1. Hospital is a health care provider duly recognized and authorized by

3. The Hospital is desirous to join the said network of Hospitals and is

4. ICICI General has on the basis of representation of the Hospital,

5. The Parties hereby desire to record the statements, agreements,

In this AGREEMENT, unless the context otherwise requires:

2. the singular includes the plural and vice versa;

3. natural persons include created entities (corporate or incorporate) and vice

5. should any condition contained herein, contain a substantive condition, then

6. In this AGREEMENT unless inconsistent with, or otherwise indicated by the

A. Institution shall for all purpose mean a Hospital.

B. Health Services shall mean all services necessary or required to be

D. Confidential Information includes all information (whether proprietary

E. Affiliate shall mean and include:

F. Effective date of agreement: shall mean the date on which the

NOW IT IS HEREBY AGREED AS FOLLOWS:

Article 2: Scope of services

1. The Hospital undertakes to provide the service in a

2. The Hospital shall treat the Beneficiaries of ICICI

3. The Hospital will extend priority admission

4. The Hospital shall ensure that medical

7. The Hospital shall also endeavor to comply with

8. The Hospital shall allow ICICI General to conduct

9. The Hospital shall allow ICICI General to inspect

10. The Hospital will convey to its medical consultants

Article 3: Identification of Beneficiaries

1. The Insured Beneficiaries will be identified by the Hospital on the basis of

Article 4: Cashless facility admission procedure by the Network

The procedure to be followed for providing cashless facility shall be as provided

Article 5: Payment terms

3 The Hospital must recover any non-covered treatment/ Investigation cost

a. Copy of preauthorization letter, Insured Beneficiary acceptance

5. The final docket must be submitted to ICICI General within 90 days of

6. All queries raised by ICICI General during the process of settlement of

ICICI Lombard Healthcare:

Article 6: Standard Discharge Summary

The procedure to be followed for standard discharge summary shall be as

Article 7: Standard Format for Provider Bills

Article 8: Right to Repudiate/Deny a Claim

Article 9: Declarations and Undertakings of a Hospital

3. The Hospital declares that it has never committed a criminal offence

Article 10: General responsibilities and obligations of the Hospital

1. The Hospital shall ensure that no confidential information is shared or

2. The Hospital shall provide cashless facility to the Insured Beneficiary in

4. The Hospital shall endeavor to have an officer/staff appointed in the

5. The Hospital agree to display their status to preferred Insured Beneficiary

Article 11: General responsibilities of ICICI General

ICICI General represents and warrants to the Hospital that:

Throughout the term of this agreement the Insurer shall continue to be an

Article 12: Non- Exclusivity

Article 14: Continuity of Services

Article 15: Customer Services and Relations:

Article 16: Code of Conduct

All official correspondence, reporting, etc pertaining to this Agreement shall be

Article 18: Termination

1. ICICI General reserves the right to terminate this agreement by giving 30

1.2. ICICI General comes to know of wrong and fraudulent practices; or

1.3. ICICI General comes to know of any misrepresentation; or

1.4. ICICI General observes any inadequacy of service or other non

1.5. ICICI General observes cases of overstay and over provisioning

However, no such cancellation or modification shall be done by ICICI General