Processing of Pending Claims Delayed in Intimation, in Submission on, NMI Query Reply and Delay Due to obtaining Digital Signature
(All Regional Centres ECHS)
PROCESSING OF PENDING CLAIMS DELAYED IN INTIMATION, IN SUBMISSION, NMI QUERY REPLY AND DELAY DUE TO OBTAINING DIGITAL SIGNATURE
1. Refer to the following :-
(a) Our letter No-8/49779/Outsourcing/AG/ECHS dt 11 Jun 14.
(b) Our letter No-8/49770/AG/ECHS dt 09 Jun 15.
(c) Our letter No-8/49779/Outsourcing/AG/ECHS dt 24 Jul 17.
(d) Our letter No-8/49779/Outsourcing/AG/ECHS dt 22 Aug 17.
(e) Our letter No-8/49778/AG/ECHS/Claim/Policy dt 30 Aug 17.
2. Difficulties have been expressed by ECHS beneficiaries, empanelled hospitals, RC’s and Stn HQs at times in adhering to the time lines framed for processing of medical bills vide this HQ letters mentioned above leading to delay in processing and reimbursement of some of the bills. It is also leading to numerous bills getting stuck/Recommended for rejection in the online bill processing system due to inability to adhere to the time lines by the individuals I service hospitals despite reasonable response time being available.
3. The matter has been deliberated at this HQ as per issues raised by the various stakeholders and it has been decided that as an one time measure, waiver to be accorded by the respective Director, Regional Centres for the claims for the following reasons :-
(a) Delay in intimation, submission of online & physical bills for already uploaded I submitted claims & query reply under Need More Info (NMI) claims till 30 Sep 17 unless a hospital has given a certificate that no claim is pending.
(b) Delay in submission/uploading of claims for more than 60 days after 01 Oct 17.
(c) Delay in submission /uploading of claims due to non availability of digital signatures pertaining to bills between 01 Apr 18 to 30 Sep 18.
(d) Delay in intimation to BPA after 01 Oct 17.
4. Waiver to be accorded after detailed examination of genuine and legitimate bills only with highest probity and integrity. The waiver is valid for bills generated upto 31 Dec 18. All actions pertaining to waiver sanction including response by hospitals should be completed latest by 31 Mar 19.
5. All the claims stuck I recommended for rejection for conditions as per Para 3 to be processed and reverted in NMI basket for further processing.
6. The following claims will not be processed for sanction at Regional Centre level :-
(a) Operation/procedure on wrong part as compared to that mentioned in referral for example, if sanction of SEMO exists for Rt Knee but operation has been done on left knee, the claim will be rejected.
(b) Claims raised after expiry of valid MoA unless approval exists from CO ECHS.
(c) Overlapping period of two claims.
(d) All claims of repeated admissions.
7. A certificate stating that the treatment has been given to the valid ECHS beneficiary will be appended by the hospital and countersigned by Dir RC while according the sanction.
8. Please disseminate the information to all stakeholders for information and necessary action please.
9. This has the approval of MD ECHS.