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WELCOME

AAROGYASRI HEALTH CARE TRUST


OPERATIONS WING
CASE PROCESSING
PRE-AUTHORISATION

CLAIMS

FOLLOW-UP CLAIMS

ENHANCEMENTS

ERRONEOUS CLAIMS

MISCELLANEOUS
Aarogyasri
Mithras

RAMCO

Treating Doctor
Executives

Team
Leaders

Panel/Trust
Doctors
Positive Purposeful Productive Association

Clear Transparent Polite Exchange of Communication
Pre-auth
Dept.
Net Work
Hospital
WORK INTERFACE
P
A
T
I
E
N
T
WORK FLOW
NWH
Elective Cases Emergency Cases
Emergency Telephonic Approval
Patient Registration
Medical Consultation
Updating OP/IP Status
Outpatient
Consultation &
prescription
Inpatient
Patient-on-bed
E-preauthorization
Preauth approval
Surgery/Therapy
Discharge
Follow-up
Claims
Beneficiaries approaches NWH from various sources

Aarogya Mithra examines the referral card / BPL card and facilitates the beneficiary to
undergo Preliminary Diagnosis and basic tests.

Network Hospital, basing on the Diagnosis, admits and sends Preauthorization
Request through E-Preauthorisation by RAMCO.

Pre-auth Executive(PEX) will verify homepage,WAP number, details of the Pt. and all
other non-medical documents like Pre-auth forms, consent, counseling, DTRS forms,
Health card/White card etc., and forward to the Panel doctor (Specialist) with remarks.

Panel doctor (Specialist) examines, verifies and approves if all the
conditions/Documents are as per AHCT guidelines or kept pending for want of
clarification on remarks from NWH.

After Panel doctor, The Trust doctor examines , verifies all documents and Approve /
Pending / Reject the case.

After Trust approval the NWH extends Cashless Treatment and provides Cashless
Surgery/Therapy.

PROCESS FLOW OF
PREAUTHORIZATION

Receive the patient

Verify the documents of the patients like health card/ration card/
beneficiary copy/Birth certificate/delivery certificate in case of child
etc.

Facilitates the Patient for consultation with concern specialist and
for admission.

Facilitates NWH to send proper pre-authorization as follows.

a) In patient Case registration and handovers the pt. to RAMCO

b) Preauth updation by RAMCO of NWH

Facilitates the approval and Treatment/Surgery
ROLE OF AAROGYA MITHRA
(Treating doctor/RAMCO/Aarogya mithra)
Telephonic Intimation-Initiated
(Aarogya Mithra)
Telephonic Intimation-Registered by Mithra
(RAMCO)
In-Patient Case Registered
Telephonic Intimation for
Medical/Surgical Emergency cases
Telephonic Intimation Initiated
Telephonic Intimation ID Cancelled
If IP registration
not done with in
72hrs.

Emergency Telephonic
Intimation Numbers :
1) 8333817471, 2) 8333817472
3) 8333817473, 4) 8333817475
Telephonic ID provided by Trust on NWH request


The Pre-auth executive(PEX) will verify Non technical
document details of Preauthorization .

Facilitate the Emergency Telephonic approval cases by
connecting the call conference to Trust doctors and enter the
details of surgery/ treatment and other data of the Pt and NWH
and provides telephonic intimation ID. (TID)

Monitoring on regular basis for clearance of pre-authorisations
in TAT( Turn Around Time) i.e. in 12 hours


ACTIVITY OF PREAUTH EXECUTIVE

After detailed examination and verification of the submitted
technical documents, the Panel doctor (Specialist) approves and
forward the case to the Trust Doctor for further process.

If the Documentary evidence is insufficient doctor will keep the
case pending for updating remarks.

If the pending updated by NWH is not satisfactory as per the
AHCT guidelines the case will be rejected.


Aarogya mithra / Executives quickly follow up the case with
RAMCO of the NWH to update the Case.

PREAUTH DOCTORS (PANEL & TRUST)

W A P Card (White Andhra Pradesh Card)
A A P Card (Annapoorna Andhra Pradesh Card)
Y A P Card (Anthyodaya Anna Yojana Card)
Health Card (Rajiv Aarogyasri Bheema Health Card)
Journalist Card (JPAP)
T A P Card (Temporary Andhra Pradesh Card)
RAP Card (Rachhabanda Andhra Pradesh Card)
CMCO letter

Pediatric Cases
Beneficiary Copy / Birth certificate / Delivery
certificate / Self declaration by parents.

ELIGIBILITY CRIETERIA
Health Card (Rajiv Aarogyasri Bheema Health Card)

District name
is mentioned
in the
Aarogyasri
health card

District is
also indicated
using color
code
WAP0483003B0052
District op Number
(B 2
nd
shop in that Mandal)
Mandal Cons. code
What exactly WAP number says?
WAP (WHITE ANDHRA PRADESH) CARD
Y A P Card (Anthyodaya Anna Yojana Card)
Barcode
A A P Card (Annapoorna Andhra Pradesh Card)
Barcode
Chief Minister Camp Office Referral letter (CMCO
Referral Card)
Rachhabanda Andhra Pradesh Card
Beneficiary
photo
BENEFICIARY COPY FOR TAP CARD (ELECTIVE CASES)
Temporary Andhra Pradesh Card
TAP01C401027105
District op Number

Mandal Cons. code
What exactly TAP number says?
Points to remember:

No Photograph of the Beneficiaries

No Barcode Reader
Journalist (Working / Retired) Scheme Under CMRF
Journalist
Card no.
Barcode
Star Health and Allied Insurance Co. Ltd.
THE PATIENT SHOULD BE ALLOWED TO SUBMIT ANY OF THE 17
PHOTO IDENTITY PROOF LISTED BELOW ALONG WITH TAP/RAP
CARD FOR ANY EMERGENCY CASE
1.Election photo Id card
2.Job card issued under NREGP
3.Pension document
4.Pattadar Pass book
5. House site pattedar
6. SC/ST/BC Certificate
7. Certificate of Physical Handicap
8. Registration document containing the photograph
9. Student identity card issued by recognized educational Institution
10. Driving license
11.Pass book with photograph issued by public sector bank/post office
12. Freedom fighter ID card
13. ID card issued to BIDI workers by Min of Labour
14. PAN Card
15. ATM card with photograph
16. Passport
17. Aadhar Card
For Pediatric Emergency Case (Bedside Photo of Mother/Father
with New Born Baby + Birth Certificate issued by the Hospital)
Fathers
Health
card
On
bed
photo
On bed
Photo
with
parents
S.No Anomaly in cards
Nature of
Treatment
Requirement for benefit
1 No Rajiv Aarogyasri Health card - BPL card
2
No name but photo available in the
White card/health card and photograph
matches the patient
-
Patient self declaration is
enough
3
Name is there but photo is not available
on White card/Health card
-
Any photo ID card( Driving
license, College/ School ID
certificate from tahsildar
along with photograph etc.,)
to correlate the patient name
and photograph
4 Xerox copy of the card - Check the card details online
5 Loss of card due to a natural disaster -
Rice coupons- WAP number
Check card details online
ANOMALY IN CARDS
Fake-White Andhra Pradesh card (WAP-Card)
S.No. should
start with 2
Photos are
in different
directions

NET WORK HOSPITAL PREAUTHORIZATION DEPT
Pending Lack of proper documentation.
Documentary evidence submitted
insufficient to support the diagnosis and
treatment plan.

Rejections Inappropriate treatment plan. / Non
submission of required documents
Cancellations With out updating the pending remarks
applying cancellation and raising the
second Preauth.
Improper cancellation documents

Preauthorization Issues
Guidelines for Pediatrics age group patient
NWH has to provide cashless treatment to any patient admitted under pediatric
age can be treated under Aarogyasri without his/her name in any card
likeWAP/RAP/TAP/ etc on fulfillment any of following documents.
Date of birth certificate or
Letter issued by tahsildar or
Delivery certificate or
Beneficiary certificate issued by District Collector or
Declaration by the parent
Due to non availability of laparoscopic surgeons the Trust has allowed to Govt.
hospitals to perform by open method and the package for open procedure is as per
the annexure.
For other NWH if they are unable to continue to perform lap. Technique,
same open package amount will be approved as per the explanation given by
the NWH.
Category Code Name of the
Procedure
Package
amount
Proposed
package
amount.
General Surgery S1.3.2.1 Lap.
Appendicectomy
18000 17500
Pediatric
Surgeries
S8.8.7 Lap.
Appendicectomy

25000 17500
Surgical
Gastroenterology
S6.7.4 Lap.
Cholecystectomy
30000 17500
Gynecology &
Obstetrics
S4.2.1 LAVH 20000 17500
ENHANCEMENT CASES
Enhancement of Package may be considered in certain cases where hospitals
have to attend :-
1) Associated diseases not packaged under Aarogyasri scheme.
2) For the same patient extended surgeries in certain situations.
3) Extended stay on account of unrelated complications.
In order to facilitate the hospitals to continue to provide cashless treatment
under the scheme.

ENHANCEMENT CASES GUIDELINES

CASES ELIGIBLE FOR CONSIDERATION OF ENHANCEMENT

MEDICAL TECHNICAL COMMITTEE COMPRISING OF SENIOR OFFICIALS WILL PROCESS THE FLOW

1. HIV, HbsAg or HCV positive cases 5000/- for additional expenditure

2. For Additional surgical procedure/Treatment, which is not covered under Aarogyasri scheme in
addition to the Treatment approved under the scheme .

3. Extension of Procedure due to underlying (Anatomical, Pathological etc.,) variances .

4. Complications totally unrelated to the surgical procedure and due to underlying associated conditions such as
a. Diabetes
b. Hypertension
c. Immunosuppressive status etc .

5. Medical/Surgical Complications for which packages are available but totally unrelated to the approved
Surgery/Therapy for which the hospital cannot be empanelled due to infrastructure requirements. (In all such
cases enhancement amount shall be equal to the approved package amount under the scheme).

6. For associated injuries in poly-trauma for which no package is available in the scheme .

7. Complications in cases of Medical / Conservative Management for which packages are not available under
the scheme leading to extended hospital stay .

8. Approval of Enhancement shall be with in the package limit of Two Lakhs per Family per Year.
ENHANCEMENT CASES FOR REJECTION
a) Subsequent requests for the enhancement after being approved once.
b) Early submission of request before indicative period
c) Submission of request after discharge.
d) Mere presumption of case may get into complications in advance due to
high risk will not be considered
e) Common post operative complications directly attributed to primary
ailment for which pre-authorization was obtained. The hospital shall
extend cash less treatment to this complications under the same package.
The hospital shall extend the cashless treatment and services to the
Aarogyasri patients under the approved package irrespective of the status of
the enhancement.
When ever there is wrong uploading of documents by NWH like patient on bed
home page photo, WAP card Number, Gender, Age, OT details etc
The NWH is permitted to raise the request for change of wrong document to clear
the claim.
In case of preauthorization they can cancel the Preauth and can raise fresh
Preauth with correct documents
Change Management System (CMS)
CHANGE MANAGEMENT SYSTEM (CMS)
CREATING REQUEST FOR CMS