Agreement for electronic reimbursement of medical expenditure at CGHS empanelled Centre and
AMA for Ordnance Factory, Ambajhari, Nagpur
This agreement entered into on _______________________
BETWEEN (Factory)
The General Manager, Ordnance Factory, Ambajhari, Nagpur under Ministry of Defence having its
office at Ambajhari, Nagpur (hereinafter called OFAj, which expression shall, unless repugnant to the
context or meaning thereof, be deemed to mean and include its successors in office and assigns) of the
First Party.
AND (Agency)
Nidh Software having its registered office at G1, Rachana Vrundavan Apartment near Mankapur Flyover
Nagpur 30
Mobile 9665664383 (hereinafter referred to as the Bill Scrutinize Agency (BSA) which
expression shall, unless repugnant to the context or meaning thereof, be deemed to mean and include its
successors, liquidators, administrators and permitted assigns) of the Second Party.
*AND / OR (CGHS empanelled Centre)
( _____________.) Having its registered office at ( __Address__ ) (hereinafter referred to as the CGHS
empanelled Centre which expression shall, unless repugnant to the context or meaning thereof, be
deemed to mean and include its successors, liquidators, administrators and permitted assigns) of the
Third Party.
*AND / OR (Authorized Medical Attendant)
( _____________.) Having its registered office at ( __Address__ ) (hereinafter referred to as the Authorized
Medical Attendant (AMA) which expression shall, unless repugnant to the context or meaning thereof, be
deemed to mean and include its successors, liquidators, administrators and permitted assigns) of the
Forth Party.
*To Strke off whichever is not applicable
WHEREAS, THE OFAj is providing comprehensive medical care facilities to the employees of OFAj
through its set up & AMA, CS (MA) or CGHS empanelled Centre route.
And Whereas OFAj proposed to develop a mechanism to settle claims submitted by CGHS empanelled
hospitals/diagnostic centre/ AMA in a time bound manner by engaging an agency which can process the
claims and submit the same to the factory for making payments to the hospitals/diagnostic centre.
And Whereas M/s (BSA) has offered to process the claims made by AMA, CGHS empanelled
hospital/diagnostic centers. The agency will monitor & scrutinize the documents like Identity card, DFS
card, referral letter, final bills, Estimate, Revised estimate, Reports, Prescriptions, Bills, Implants etc.
Emergency bills, AMA claims etc. BSA will act as a liaison officer between OFAJ Hospital, OFAJ Factory,
CGHS Hospital,and AMA. Agency has to appoint Doctor / Nurses, and other qualified staff who will
check documents & scrutinize all papers. Agency will scrutinize codes & rates as per CGHS rates and
submit comprehensive report with recommendation for payment. On the recommendation of agency,
payment will be made by DFS to the AMA or CGHS recognized private hospitals. BSA will also take
responsibility of less or more payment after final claim sanction by accounts. OFAj(DFS) will recover
(from BSA )any loss/ extra-payment arising out of faulty scrutiny/false document .
1.
SCOPE OF WORK
(This scheme is applicable only to the members of DFS, Membership list will be provided by DFS to the
agency.)
Bill
Scrutinize
Agency
will
monitor
&
acknowledge
intimation
from
CGHS
empanelled
hospital/diagnostic centre where patient has gone for admission or investigation.
Bill Scrutinize Agency will confirm whether the beneficiary is entitled to credit facility or not and after
confirmation only CGHS empanelled hospital/diagnostic centre will allow to give credit.
CGHS empanelled hospital/diagnostic centre will give 100 % credit and no cash will be ask from patient.
Those facilities (treatment and investigations )which
are not covered under CGHS coded items , but
essential for a patient in diagnosis/treatment, in such cases the patient will pay cash and give an
undertaking to that effect . In addition patient will give undertaking to pay for sundry expenses.
For any investigations if item code is not available then the amount will be borne by individuals.
The CGHS empanelled hospital/diagnostic centre, AMA will send bills to BSA in Hard copy and submit
soft copy on line.
All parties will submit documents online as soon as it is generated. i. e. Referral letter By OFAj Hospital,
Medical Advance by Factory, Final bill, Discharge card, by CGHS Hospital.
Agency will maintain a data base of such information of the beneficiaries for future use for minimum
three year.
2.
SUBMISSION OF CLAIMS:
Only member of DFS will be entitled for credit facility in the empanelled hospitals/diagnostic centre.
Such beneficiary will be referred by any Duty Doctor of Ordnance Factory Hospital and countersigned by
CMO,
of OFAj Hospital
for seeking treatment /admission/ investigation in the empanelled
hospitals/diagnostic centre.
In case of emergency, as soon as beneficiary reports to the CGHS empanelled hospitals and patient is
admitted, the said hospital will immediately intimate to CMO Incharge & BSA by issuing “Emergency
Certificate “ either electronically and
by sending documentation ,
giving patient particulars with
photoidentity , diagnosis /probable diagnosis , nature of treatment required, provisional cost estimation
etc.. BSA will check all the particulars and acknowledge entitlement to the CGHS empanelled hospitals
of the same day or the next working day . The list of emergencies are as per CGHS notification.
If the patient is admitted in Non CGHS hospitals in emergency and relatives wants to shift to CGHS
empanelled hospitals, then such patients should be admitted as emergency case and CGHS empanelled
Hospital will inform to CMO In Charge and BSA accordingly.Discretion of CMO incharge will be final
on regularization of emergency cases .
3.
BILLING AND PAYMENT
3.1
Advances to Hospital/Diagnostic Centre
DFS shall make an advance payment initially of an amount of 70 % of the estimate to the
Hospital / Diagnostic Centre on receipt of the estimate through BSA after their scrutiny. DFS
shall exclusively monitor the advance payment to the CGHS emplaned Hospitals and Diagnostic
Centre toward the medical claim.
Remaining amount of final bill will be paid within 90 days by DFS (after sanction of Local
Account Office )
4.
Payment to Hospital/Diagnostic Centre
On receipt of claims (soft copy) from the CGHS empanelled hospitals /diagnostic centre, the BSA
will check the following aspects for settling the claims as per existing guidelines of OFAj and
forward his report to OFAJ for final settlement / payment of bills :-
(a)
Appropriateness of treatment including screening of patients records to identify
unnecessary admission and unwarranted treatment.
(b)
Whether the planned treatment has been shown as emergency treatment.
(c)
The genuineness of
diagnostic (investigation )/ medical / surgical procedures/
treatment / management , done by the CGHS Empanelled hospital .
(d)
Whether the treatment/services have been provided as per the approved rates, package
rates best suited to the beneficiary.
(e)
Whether the patient was kept admitted for a period which was not necessary.
(f)
Whether genuine patient with proper entitlement is admitted or not .
(g)
Will check genuineness of all claims
After screening and checking BSA will give approval and upload/ send approved claims to
the OFAj electronically (through E-mail) for release of provisional ( 70% of total bill ) payment
to the empanelled hospitals/diagnostic centre. The provisional payment is subjected to
review/scrutiny and will be adjusted accordingly in final settlement. In case of disputes of the
claims , payment will be withheld until matter is settled.
OFAj (DFS) shall deduct the admissible amount (that is 2% of total bill amount toward payment
to BSA or minimum Rs 20 / of bill raised by CGHS empanelled Hospital or any other tax levied
by govt ). or as defined by OFAj for payment made to these Hospitals /Diagnostics centre on 1st
of every month).
On receipt of claims (soft & hard copy) from CGHS empanelled hospitals /diagnostic centre,
scrutinized by BSA,
OFAj (DFS) shall review BSA documents before the Final Payment /
settlement of claims made to the CGHS emplaned Hospital. Final bill will be paid by DFS with in
fifteen days.
5.
DURATION
The Agreement shall be for an initial period of three years which may further be extended as
mutually agreed.
6.
MANAGEMENT INFORMATION SYSTEM SERVICES (MIS)
The BSA shall provide Software for E- reimbursement of RME and its maintenance.
BSA will provide information regarding the Reports / statistics as per requirement of the OFAj /
CGHS empanelled hospitals/diagnostic centre / AMA on a monthly basis. BSA will maintain
necessary electronic infrastructure for smooth running of the system .
7.
Bill Scrutiny Agency
The BSA will charge processing fee at the rate of 2% of CGHS Hospital’s claim bill amount and
service tax thereon with a minimum of Rs20/- per bill . OFAj (DFS) reserve the right to revise the
charges from time to time.
8.
GENERAL CONDITIONS
Nothing under the Agreement shall be construed as establishing or creating between the parties
any relationship of Master and Servant or Principal and Agent between the OFAj and the BSA.
The BSA shall not represent or hold itself out as agent of the OFAj except to the extent of its
duties or activities provided under this Agreement.
The OFAj will not be responsible in any way for the BSA and its employees for any accident,
injury or damage sustained or suffered by them or their agent or any third party resulting from
or by any operation conducted by and on behalf of the BSA or in the course of doing this work or
perform their duties under this Agreement or otherwise.
The BSA shall indemnify the Government against all actions, suits, claims and demands brought
or made against it in respect of anything done or committed to be done by the BSA in execution
of or in connection with the work of this Agreement and against any loss or damage to the
Government in consequence to any action or suit being brought against the BSA for anything
done or committed to be done in the course of the execution of this Agreement. The BSA will
abide by the job safety measures prevalent in India and will indemnify the OFAj from all
demands or responsibilities arising from accidents or loss of life, the cause of which is BSA’s
negligence. The BSA will pay all claims arising from such incidents without any extra cost to
OFAj and will not hold the OFAj responsible or obligated. The Government may at its discretion
and entirely the cost of the BSA defend such suit, either jointly with the BSA or single in case the
latter chooses not to defend the case. The above clauses are with reference to BSA employees
/agent /contractor /representatives.
The BSA shall notify the Government of any material change in their status in particular where
such change would have an impact on the performance of obligations under this Agreement.
The BSA shall not claim any additional charges for postage, couriers, conveyance, TA/DA and
other expenses under any other head except as provided in clauses 4. The bills and documents
received by BSA will be submitted by it to OFAj on a monthly basis.
9.
CONFIDENTIALITY
The BSA will treat all data and information about the OFAj obtained in the execution of its
responsibilities, in strict confidence and will not reveal such information to any other party
without the prior written approval of the OFAj.
BSA will maintain software, hoisting and domain name on his own and can not charge any extra
cost to OFAj.
10.
NOTICES
Any notice given by one party to the other pursuant to this Agreement shall be sent to other party in
writing by registered post or by facsimile and confirmed by original copy by post to the other Party’s
address as below:The General Manager, Ordnance Factory, Ambajhari, Nagpur-440021.
A notice shall be effective when served or on the notice effective date, whichever is later.
IN WITNESS WHEREOF of the parties have caused this Agreement to be executed on the
day………month………….. and the year…………… first above mentioned in presence of the
following
AGM/ADMIN
CMO I/C O.F. HOSPITAL
CHAIRMAN
CHIEF ADVISO R
DISTRESS FUND MANAGEMENT
DISTRESS FUND MANAGEMENT
COMMITTEE
COMMITTEE
JT GM / ADMIN
LABOUR WELFARE COMMISSIONER
SECRETARY
ADMINISTRATOR
DISTRESS FUND MANAGEMENT
DISTRESS FUND MANAGEMENT
COMMITTEE
COMMITTEE
CGHS E Hospital / AMA
BSA
Name
Name
Designation
Designation
Signature
Signature
ANNEXURE I
Service Level Agreement – e-Adjudication Claims services
Objective
The objective of this Service Level Agreement is to ensure mutual understanding and consistency of
service levels required by OFAj and those provided by BSA and its allied partners.
Roles & Responsibilities Support Options
The service deliverables from BSA with the agreed timelines are as follows:
S. No.
1
Activities
Turn Around Time (TAT) for uploading Referral letter
online By OFAj Hospital. / One ink sign copy will be
handed over to individual.
Turn Around Time (TAT) for uploading Admission
letter online By CGHS empaneled Hospital. / One ink
sign copy will be attached to case file.
Turn Around Time (TAT) for upload of Estimate by
CGHS Hospital & hard copy to Individual.
Issue of By intimation by Email regarding Medical
Advance to CGHS Hospital.
Turn Around Time (TAT) for uploading of Final
claims by CGHS empanelled Hospitals.
Turn Around Time (TAT) for submission of Final
claims in physical form by CGHS empanelled
Hospitals to DFS OFAj.
Scrutiny of medical bill by BSA and submission to DFS
– OFAj
Time lines
4 hrs.
8
Payment by DFS through Bank to empanelled
hospitals.
9
Uploading of document by all modules as soon as it is
generated, printed, signed and scan.
15(Fifteen) working day of
receipt of approved claims
from OFAj Hospital / BSA.
As early as possible.
2
3
4
5
6
7
4 hrs.
As soon as possible on
admission
1 ( One) working days after
issue of estimate.
As soon as possible on
discharge
3( Three) working days of
discharge
07(seven ) working days
ANNEXURE II
1.
DEFINITIONS
1.1
The following terms and expressions shall have the following meanings for purposes of this
Agreement
1.1.1
“Agreement” shall mean this Agreement and all schedules/Annexure, supplements, appendices,
appendages and modifications thereof made in accordance with the terms of this Agreement.
1.1.2
“Beneficiary” shall mean a person who is eligible for coverage of OFMR and CS (MA) holds a
valid card at the time of admission. ( will be decided by factory)
1.1.3
“Benefit” shall mean the extent or degree of service the beneficiaries are entitled to receive as per
the rules/instructions on the subject.
1.1.4
“Bill” shall mean the demand raised by the ______ on _____ _______ for adjustment of the
provisional payment made to the empanelled hospital/ diagnostic centre by the ______.
1.1.5
Bill Scrutinize Agency / Scrutinize (BSA) shall mean M/s.________ the service provider while
performing this Agreement.
1.1.6
“Business Day” shall mean days on which Central Govt offices are open for business.
1.1.7
“Credit
facility”
means
the
service/treatment
provided
to
specific
categories
of
________beneficiaries by empanelled hospitals/diagnostic centre on credit and without any
payment of cash deposit in advance by the OFMR and CS (MA) beneficiary. This facility is
extended to employees of OFAj against estimates.
1.1.8
“Emergency” shall mean a serious medical condition or symptoms resulting from injury or
sickness which arises suddenly and requires immediate care and treatment, generally received
within 24 hours of the onset to avoid jeopardy to the life or serious damage to the health of the
beneficiaries until stabilization at which time this medical condition or symptom is not
considered an Emergency anymore.
1.1.9
“Party” shall mean either the OFAj or the BSA M/s.________ and parties shall mean both OFAj
and BSA M/s.________.
1.1.10
“Service Fees” shall mean the agreed fees payable by the OFAj to the BSA
from CGHS
empanelled Hospital bill for services rendered by it as detailed in the Agreement.
1.1.11
“Service Area” shall mean the area within which the OFAj has authorized the BSA to provide
services.
1.1.12
“DFS” shall mean distress relief fund scheme will facialate for cashless payment of Medical
expenses .
ANNEXURE III
Treatment in Emergency :
The following ailments may be treated as emergency which is illustrative only and not
exhaustive depending on the condition of the patient and discretion of CMO In-charge of
Ordnance Factory Hospital.
Acute Coronary Syndrome (Coronary Artery Bye - pass Graft / Percutaneous Transluminal
Coronary Angioplasty ) including Myocardial Infarction , Unstable Angina , Ventricular
Arrhythmias, Paroxysmal Supraventricular Tachycardia , Cardiac Tamponade , Acute Left
Ventricular Failure / Severe Congestive cardiac failure , Accelerated Hypertension , Complete
Heart Block and Stoke Adam Attack , Acute Aortic Dissection .
Acute Limb Ischemia, Rapture of Aneurysm , Medical and Surgical Shock and Peripheral
circulatory Failure .
Cerebro-Vascular attack – Stokes , Sudden unconsciousness , Head injury , Respiratory failure ,
Decompensated Lung Disease , Cerebro – Meningeal Infection , Convulsions , Acute Paralysis ,
Acute Visual Loss .
Acute Abdominal Pain.( any cause )
Road Traffic Accidents/ with injuries including fall , Severe.
Hemorrhage due to any cause .
Acute Poisoning
Acute Renal failure
Acute Abdominal pain in female including Acute Obstetrical and Gynecological Emergencies.
Electric Shock.
Any Other life threatening condition.
In emergency the hospital will not refuse admission or demand an advance payment from the
beneficiary or his family member and will provide credit facilities to the patient, on production
of valid ………… card and the hospital shall submit the bill accordingly .The refusal to provide
the treatment to bonafied Beneficiaries in emergency cases on credit basis without valid ground
would attract disqualification for continuation of empanelment .
The nature and appropriateness of the emergency is subject to verification ,which may be verified
, inspected or medically audited by the CMO In Charge on random basis at its own discretion .
The CGHS empanelled Hospital will intimate all instances of patients admitted as emergencies
without prior permission to the CMO In Charge within prescribed time.