1.
Can High end Radiological Diagnostic and High-end Histopathology taken with Surgical procedures as
an add on procedure as mentioned in Claim Adjudication Manual at page 20.
Answer: Please refer STG and HBP package for your state.
2. Is the LOS mentioned in STG fixed or indicative as lots of triggers are coming from NAFU for inadequate
LOS or exceeding the LOS? especially for medical packages
Answer: LOS mentioned in STG are only indicative.
3. Can we do same process “‘change of ward” in neonatal cases
Answer: Yes, you can use the same process of change of ward in neonatal cases.
4. With Regards to changing of wards for per day packages, Can the Medco make the changes at the time
of discharged or it has to be done during hospitalization?
Answer: MEDCO can make the changes during the hospitalisation and at the time of discharge.
5. If a patient was admitted for medical management for 4 days, and death occurred at 3am or 4am
(early morning hours) of the 5th day, how much claim amount be paid to the EHCP? Would the amount be
paid for 4 days or 5?
Answer: We need to pay for 5 days in such a scenario in medical case. If it is observed that the death was due
to negligence or mortality audit has significant findings suitable action shall be taken against the hospitals and
claim amount shall be withheld till explanation received and reviewed by experts.
Please refer claims adjudication manual for claim payment in special cases -section 8.
6. Can SHA download all the queries raised by the ISA at CPD/PPD level specially when multiple queries
are raised in a single case
Answer: You can see all the queries raised by CPD /PPD in TMS for an individual claim.
SHA can use the query dashboard which provides information on various types of query category used. It also
provides information on various other attributes like username, hospital, district etc where query is raised
7. Can the TAT be relaxed in dialysis?
Answer: Please refer section 10 of claims adjudication manual for NHA’s guidelines on turnaround time. Please
note these guidelines are for all types of claims including dialysis.
8. All the new guidelines for TAT will be implemented when? Whether it will give effect to old cases
pending in TMS Port from hospital side. Now we have to take follow up with hospital to close query in CPD
Answer: New guidelines for TAT are already implemented for private hospitals in many states who agreed for
immediate implementation. It will be rolled out for public hospitals very soon.
Though old cases are not affected, please follow up with EHCP to process these cases at the earliest. Overdue
claims dashboard is created to provide insights on pending claims from EHCP.
9. Can we download data wherein we can see the details of each enhancement including type of ward
and number of days?
Answer: You can see all the enhancement details by logging into CPD /PPD role in TMS for an individual claim.
10. Is it mandatory all day on bed images in ICU package or just consider as per attached documents?
Answer: It is always advised to take images as per NHA guidelines. This is done to ensure the genuineness of
claim.
11. Can we also see PMAM or MEDCO user productivity dashboard?
Answer: Hospitals can see PMAM or MEDCO activity. Productivity dashboard is created with the intent to
monitor the productivity of processing team from TPA/ISA/IC side. Hence it does not include the MEDCO and
PMAM.
12. How coronary angiography package is shown? is it given separately during hpb 1.0
Answer: In HBP 2.0 it is PTCA, inclusive of diagnostic angiogram. However please refer the approved state
specific packages for more details.
13. For all those packages that has a maximum limit, what happens if the hospital is a NABH, will the
settlement be Maximum amount + 15%? or just the maximum amount. The TMS has automatically calculates
the package cost + 15%.
Answer: Logics for all calculations are inbuilt in TMS for hospitals and packages as agreed in the respective
states.
14. In government hospital cases most of the time sign & stamp not available in investigation reports, how
to deal all such cases.
Answer: As per the guideline’s investigation reports must be signed by doctor/pathologist with registration
number. However, claim seems to be suspicious it needs to be investigated.
15. If hospital provide digital sign on investigation report, all such cases can be considered
Answer: As per the guideline’s investigation reports must be signed by doctor/pathologist with registration
number however if hospital has provided digital signature, it may be considered subject to verification of the
genuineness of the claim.
16. Is digital signature valid on ICPs and discharge paper?
Answer: As per the guideline’s ICP and discharge summary must be signed by doctor with registration number
however if hospital has provided digital signature, it may be considered subject to verification of the
genuineness of the claim.
17. Is PPD / CPD productivity report active in IMPACT portal
Answer: The dashboard with information on PPD/CPD productivity can be accessed through the impact portal
Productivity dashboard.
18. What is the TAT for preauthorization for portable cases?
Answer: It is 6 hours. For more information, please refer section 10 of claims adjudication manual for all
turnaround time.
19. Is there any MIS available for details of audited cases under Comprehensive Audit Module?
Answer: Yes, it will be made available.
20. There must be an Indicative point on claim processing page if the case got AUTO-APPROVED in PPD.
Answer: This is available in CPD / PPD login.
21. Can a POP cast application packages be blocked additionally along with Ortho surgical package? Many
of the hospital is blocking additional DJ Stenting package along with PCNL which I believe is part of PCNL
procedure. Similarly, lower ureter/upper ureter packages are clubbed with DJ stenting package.
Answer: Please refer STG & packages.
22. For neonatal cases - capping is there. But in few states, it is instructed by SHA to pay it as if neonates
require prolonged admission. So, in such cases, is it payable?
Answer: Yes, it is subjected to SHA approvals
23. Hospital has asking query for B/L inguinal hernia or hydrocele, but we have only unilateral package.
so, is it worth to raise 2 pre auth separately ?? pls clarify
Answer: If the procedures are done during the same admission, 2 separate pre-authorisations are incorrect.
For claim payment eligibility please refer section 8 of claims adjudication manual.
In case this type of procedure is common, SHA may consider creating a specific package in their state specific
package master taking NHA into consideration.
24. How to handle the audit of claim where trigger has given as inadequate LOS and while auditing it is
found that the beneficiary’s insurance amount is exhausted, and hospital submit the discharge card as
"Discharge from portal" but patient stayed for longer duration
Answer: Such a claim should be paid only up to available sum insured amount with a due remarks for extended
LOS.
25. I am CPD, questionary ask me ...post op x-ray submitted? when I select NO... then I am asked to
mention reason...Reason is known to hospital...how I can give reason.
Answer: Documents mentioned are mandatory as per STG. In case of lack of documents, please raise the query
to the hospital. In case hospital is unable to submit the mandatory document, a valid justification should be
sought and captured in TMS after selection of “No” by CPD/ PPD.
26. Clinical notes attached not having date and time
Answer: As per the guideline’s clinical notes must have date and time. If claim seems to be suspicious, it needs
to be investigated.
27. Clinical photos attached with dressing on
Answer: As per claims adjudication guidelines, it is mandatory to have post-operative scar photo with face of
patient in same frame (with consent of patient) i.e. the face of the person and site of surgery shall be visible
in the same frame. If claim seems to be suspicious, it needs to be investigated.
28. From which date, changes will be get activated for queries standardized, reason for rejection etc.
Answer: This feature is already deployed on production and can be accessed by logging in from the CPD/PPD
login id.
29. Kindly make some provision for seeing the Patient's Wallet Amount. like How much Amount was
present in the card before treatment and what is the balance amount on Card after treatment.
Answer: It is available in TMS “Insurance Wallet Amount”
30. For the conservative management of cholecystitis or appendicitis cases, most of the hospital has
initiated claim under Acute gastro enteritis package, can we consider it or not
Answer: It is hospital duty to select correct code, if hospital has committed the mistake CPD / PPD should reject
the claim and new claim should be generated by MEDCO / PMAM with correct code.
31. In surgical package hospital not following LOS as per package guideline, in all such cases how to deal
with. (Hospitals are not following LOS as define in HBP 2.0 please confirm what should be the course of action)
Answer: Payment would always be as per package rate in surgical procedures irrespective of LOS however it
is mandatory to check proper pre and post op care is provided to the beneficiary.
32. If excess amount is approved during preauth, what is the ideal method of rectifying this & bringing it
to the notice of Claims team?
Answer: If excess amount approved is discovered at the time of claim adjudication by CPD, kindly deduct and
pay appropriate amount.
33. Are STGs available for SHA TMS?
Answer: STG’s are available in TMS for MEDCO, CPD / PPD role. This is available in all greenfield states.
34. Combination of codes in cardiology; Some of network hospitals ask for arrhythmia, heart failure,
respiratory distress codes in addition to Emergency PTCA codes for one or two vessels. At times they ask for
ventilatory support code too just prior to PTCA quoting Cardiogenic shock.
My views: All these are taken care of by doing PTCA. If CHB is there needing TPI, then that can be allowed
(50%) Hence no need to approve these. For Streptokinase administration we are giving 50% when combined
with PTCA.
Answer: Please refer STG & package guidelines for processing of claim.
35. At times, in Cancer cases, ---pt. is admitted for some other complaint--viz pain abdomen. (under
medical code) and Investigated. --CT, MRI....Discharged. Readmitted the same day for specific treatment of
Cancer. In such cases mandatory investigations are done in the first admission to establish diagnosis. In such
cases, I feel only 50% charges should be paid for first admission. Your guidance needed.
Answer: Please refer STG & package guidelines for processing of claim.
36. We can have an option at CPD level to flag LAMA/DAMA/Death in additional to EHCP’s where hospital
not flagged the same.
Answer: We request you to raise IT support ticket for appropriate action.
37. In cases where SAFU has terminated fraud case, if we open that case ID, and if we check past history,
we are not able to see past history of those cases, please guide
Answer: We request you to raise IT support ticket for appropriate action.
38. Can we download their ports of different SAFU-AFO users wherein we can see the action taken by
them along with their remark for monitoring and evaluation purpose?
Answer: We understand that a download option is needed for cases done by different AFO users to monitor
the action taken along with remarks. Currently the data needs to be taken from TMS IT/ data team. However,
for a download option in TMS please raise the IT support ticket.
