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What is Pradhan Mantri Jan Arogya Yojana(PM-JAY)?

Pradhan Mantri Jan Arogya Yojana(PM-JAY) is a pioneering initiative of Prime Minister Modi to ensure that poor and vulnerable population is provided health cover. This initiative is part of the Government’s vision to ensure that its citizens – especially the poor and vulnerable groups have universal access to good quality hospital services without anyone having to face financial hardship as a consequence of using health services.

What benefits are available under PM-JAY?

PM-JAY provides an insurance cover upto Rs 5 lakh per family, per year for secondary and tertiary hospitalization. All pre-existing conditions are covered from day 1 of implementation of PM-JAY in respective States/UTs.

What health services are available under PM-JAY?

The health services covered under the programme include hospitalization expenses, day care surgeries, follow-up care, pre and post hospitalization expense benefits and new born child/children services. The comprehensive list of services is available on the website.

Who is eligible to avail benefits under PM-JAY?

PM-JAY covers more than 10 crore poor and vulnerable families across the country, identified as deprived rural families and occupational categories of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data. A list of eligible families has been shared with the respective state government as well as ANMs/BMO/BDOs of relevant area. Only families whose name is on the list are entitled for the benefits of PM-JAY. Additionally, any family that has an active RSBY card as of 28 February 2018 is covered. There is no capping on family size and age of members, which will ensure that all family members specifically girl child and senior citizens will get coverage.

Where can beneficiaries avail of services under PM-JAY?

Services under the scheme can be availed at all public hospitals and empaneled private health care facilities. Empanelment of the hospitals under PM-JAY will be conducted through an online portal by the state government. Information about empaneled hospitals will be made available at through different means such as government website, mobile app. Beneficiaries can also call the helpline number at 14555. Regular updates will also be provided through ASHAs, ANM and other specific touch points This information will be activated shortly.

Will beneficiaries have to pay anything to get covered under this scheme?

No. All eligible beneficiaries can avail free services for secondary and tertiary hospital care for identified packages under PM-JAY at public hospitals and empaneled private hospitals. Beneficiaries will have cashless and paperless access to health services under PM-JAY.

What is the enrolment process? Is there any time period for enrolment?

PM-JAY is an entitlement based mission. There is no enrolment process. Families who are identified by the government on the basis of deprivation and occupational criteria using the SECC database both in rural and urban areas are entitled for PM-JAY.

How are the beneficiaries identified?

The beneficiaries are identified based on the deprivation categories (D1, D2, D3, D4, D5, and D7) identified under the SECC (Socio-Economic Caste Census) database for rural areas and 11 occupational criteria for urban areas. In addition, RSBY beneficiaries in states where RSBY is active are also included.

Can those families whose names are not on the list avail the benefits under PM-JAY?

In this phase, no additional new families can be added under PM-JAY. However, names of additional family members can be added for those families whose names are already on the SECC list.

Will a card be given to the beneficiary?

A dedicated PM-JAY family identification number will be allotted to eligible families. Additionally, an e-card will also be given to beneficiary at the time of hospitalization.

If I am listed as a beneficiary and I need to be hospitalized, what documents do I need to bring to the hospital?

At the time of admission to the hospital, beneficiaries should carry ration card or any other government recognized photo identity document like Aadhaar etc.

What happens if I fall ill during my travel or when I am out of my district or state?

The scheme will have portability of benefits across the country. Beneficiary can avail services all across the implementing States/UTs. You can call helpline number 14555 for details.

How will this scheme effect previous schemes like RSBY, Senior Citizen Health Insurance Scheme or any other health insurance scheme implemented within a certain state?

The scheme will subsume the functional RSBY schemes – Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme (SCHIS).

What is the grievance redressal mechanism in case of any complaints or denial of service?

A well-defined three tier complaint and grievance redressal mechanism will be in place. This includes constitution of various committees, use of electronic, mobile platform, an All-India helpline number 14555 internet as well as social media. Robust safeguards to prevent misuse/fraud/abuse by providers and users will also be in place.

What was the need of HBP 2.0?

Packages were rationalized against the following aberrations found in the original HBP

  • Package rates offered for many packages were inadequate to cover the cost of procedures
  • Duplication of packages was observed both within a single specialty and across specialties
  • The terminology used for the nomenclature of packages was inconsistent
  • Few of the procedures were overlapping with the ongoing National Health Programs
  • Some of the high-end procedures / investigations / drugs are not covered in HBP 1.0
  • Due to the non-availability of certain treatments, a lot of procedures were being booked under Unspecified packages
What is the total package count of HBP 2.0?

HBP 2.0 has 867 packages split into 1573 procedures. By the new nomenclature, many packages are a group of procedures split primarily based on surgical approach or different types of treatment modalities available for a similar type of treatment. Through the first year of implementation of AB PM-JAY, it was felt that frequency of utilization of individual procedures is required for analysis. Hence, there was a need to capture the different procedures covered under single package separately and thus the concept was introduced.

How many specialties are covered in HBP 2.0?

HBP 2.0 covers 23 specialties (including ‘Unspecified’). All specialties from HBP 1.0 have been retained except for Pediatric Cancer that has been discontinued. All procedures of pediatric cancers have been split into medical / surgical oncology.

The specialty of pediatric cancer has been discontinued. How will these patients be treated?

All the procedures of Pediatric cancer have been included under the other three specialties of oncology viz. Surgical, Medical & Radiation Oncology. Hence Pediatric cancer specialty may not be visible under specialty list, but all the pediatric cancers are adequately covered.

How many procedures are covered under each specialty in HBP 2.0

The following is the break up of procedures by specialty in HBP 2.0

S. No Specialty HBP 1.0 Packages HBP 2.0 Packages HBP 2.0 Procedures
1 Burns Management 12 6 20
2 Cardiology 39 20 26
3 Cardio-thoracic & Vascular surgery 92 34 113
4 Emergency Room Packages 4 3 4
5 General Medicine 72 76 98
6 General Surgery 253 98 152
7 Interventional Neuroradiology 15 10 15
8 Medical Oncology 52 71 263
9 Mental Disorders Packages 17 10 10
10 Neo-natal care Packages 10 10 10
11 Neurosurgery 83 54 82
12 Obstetrics & Gynecology 79 59 77
13 Ophthalmology 42 40 53
14 Oral and Maxillofacial Surgery 9 7 9
15 Orthopedics 101 71 132
16 Otorhinolaryngology 94 35 78
17 Pediatric Medical Management 102 46 65
18 Pediatric Surgery 34 19 35
19 Plastic & Reconstructive Surgery 9 8 12
20 Polytrauma 12 10 21
21 Radiation Oncology 14 14 35
22 Surgical Oncology 48 76 120
23 Urology 161 94 143
24 Unspecified Surgical Package 1 1 1
Total 1,393 872 1,574
Have prices been reduced for some procedures in HBP 2.0?

Prices have been reduced for 57 procedures in HBP 2.0 as compared to HBP 1.0.

Have prices been increased for some procedures in HBP 2.0?

Prices have been increased for 270 procedures in HBP 2.0 as compared to HBP 1.0.

What was the rationale for discontinuing packages from HBP 1.0?

554 existing packages were discontinued in HBP 2.0. Four primary principles were followed for discontinuation of packages between HBP 1.0 to HBP 2.0

  • Removal of duplicate packages
  • Exclusion of procedures which were covered under other packages
  • Obsolete procedures
  • Packages that were redefined / included elsewhere

The National Health Authority, through revision of packages ensured that no therapeutic area, initially covered under AB PM-JAY is left uncovered in HBP 2.0

With 554 discontinued packages, has the treatment coverage reduced in AB PM-JAY?

No. The National Health Authority, through revision of packages made a conscious effort to ensure that no therapeutic area, initially covered within AB PM-JAY is not left uncovered in HBP 2.0. The discontinued packages have been redistributed into other multiple procedures that are included in PM-JAY.

Will the unspecified package still be available in HBP 2.0?

Yes. While it has been the aim of package revision to include most commonly used treatment modalities within HBP 2.0, some state specific, or uncommon conditions may still have been overlooked. So, while it is expected that booking of procedures under the unspecified category would be reduced, the category has still been maintained in new revised package list.

Is Cataract still available under AB PM-JAY

Yes, It is available

What was the rationale for adopting new packages in HBP 2.0?

237 new packages have been introduced in HBP 2.0. The following packages were introduced as new packages

  • Packages that were booked frequently as unspecified packages
  • Therapeutic areas that were earlier not covered
  • Follow up packages
  • Packages recommended by the expert groups
What is the new concept of Packages and Procedures?

By the new nomenclature, many packages are a group of procedures split primarily based on surgical approach or different types of treatment modalities available for a similar type of treatment. Through the first year of implementation of AB PM-JAY, it was felt that frequency of utilization of individual procedures is required for analysis. Hence, there was a need to capture the different procedures covered under single package separately and thus the concept was introduced.

Can the same package be booked under multiple specialties?

There are many procedures which fall under the purview of more than one specialty. In HBP 1.0, the practice was to repeat the same package under every concerned specialty with individual package codes and independent terminology, resulting in unnecessary repetition / duplication. Now such procedures have been consolidated under a single specialty and marked as ‘Cross specialty procedures’, so that they can be used by other relevant specialties as well.

What is stratification of procedures?

In HBP 2.0, certain procedures have been identified that involve different treatment modalities for same or similar procedures e.g. type of anesthesia, surgical approach, unilateral / bilateral, etiology etc. Although the difference appears minor between the multiple stratifications of a procedure, there is a clear financial impact of the same. Such procedures have been classified as stratified procedures wherein an additional layer of stratification has been added to account for additional effort / cost.

Are implants / High end consumables included in surgical packages?

Yes, the price of both these entities, wherever used, are included in the final procedure price. In many packages, the final total cost (including procedure and implant / consumable) is given. In other packages, costs of procedure and implant / consumable is given separately. In such cases, these two costs are entered in the system already and reflected in the form of a final cost in the Transaction Management System (TMS). Thus, it is possible that for the same package, different rates may be seen for certain procedures based on the type of implant / consumable selected in such cases. (Also refer to answers for Q. 17 to 20)

Can more than one implant be booked for a procedure?

HBP 2.0 provisions for use of multiple implants within a procedure and independently accounts for the price of each implant used. However, for most procedures, there is a cap on the maximum number of implants that will be reimbursed in a procedure.

Will the hospitals be getting reimbursed separately for the implants?

No. Price of implant will be included in the price of the selected procedure. The price of the implant will be added to the procedure price at the back-end by the TMS and will be reflected in the final reimbursement. Some procedures may require details of the number / type of implant used from a selection dropdown to calculate the total price of implants used.

What is Static & Dynamic pricing of procedures?

A concept of static and dynamic pricing has been introduced in HBP 2.0 to account for variations in prices that are now possible in HBP 2.0 based on number / types of implants used. Procedures with no implants, or pre-defined included implants will follow a static price with no variations. On the other hand, in case of procedures where multiple implants are permitted, or in case there is an available choice in type of implant, the TMS would prompt for details of the number / type of implant used from a selection dropdown to calculate the total price of implants used.

How is the final procedure rate calculated in the TMS?

For final calculation of procedure rate, Final Procedure Price = Procedure price + Stratification rate (if any) + Incentive (if applicable) + Implant(s) rate (if any).

Is there any change in the incentives offered on the package rates under AB PM-JAY?

There is no change in the NHA policy for incentives. However, the percentage of incentive will no longer be applicable to the price of the implant. Incentive will only be calculated on the procedure rate. Indicative incentive mechanisms are as below, (this is a voluntary exercise at the States’ discretion, with prior intimation to the NHA).

S. No Criteria Incentive
(Over and above base procedure rate)
1 Entry level NABH / NQAS certification 10%
2 Full NABH accreditation 15%
3 Situated in Delhi or some other Metro 10%
4 Aspirational district 10%
5 Running PG / DNB course in the empanelled specialty 10%

These percentage incentives are added by compounding rather than in simple way. Thus, for a package costing Rs. 10,000 otherwise, the payment made for a hospital with full NABH accreditation in an aspirational district will be ₹10,000 x 1.15 x 1.10 = ₹12,650. It will not be calculated as ₹10,000 x 1.25 = ₹12,500

What are the Aspirational districts?

117 Aspirational districts have been identified by NITI Aayog based upon composite indicators from Health & Nutrition, Education, Agriculture & Water Resources, Financial Inclusion and Skill Development and Basic Infrastructure which have an impact on Human Development Index.

What are the Metros?

The Metros include Delhi (UA) (including Faridabad, Ghaziabad, NOIDA and Gurugram), Greater Mumbai (UA), Kolkata (UA), Chennai (UA), Bangalore / Bengaluru (UA), Ahmedabad (UA), Hyderabad (UA) and Pune (UA).

[Cities classified as “X” in Ministry of Finance’s OM No. 2/5/2014-E.II(B) dated 21.07.2015]

What is an Add-on Procedure?

Certain packages which can be booked with a primary package at a 100% reimbursement contrary to the existing principle of 50% reimbursement of the second package. These packages are defined as Add-on Packages.

What are Stand-Alone Procedures?

For Fraud prevention and control, some packages have been identified that cannot be booked in combination with any other package / procedure. These are termed as stand-alone packages in the HBP 2.0

What are Sequential Procedures?

Some procedures in HBP 2.0 have been identified to follow a logical sequence in patient management. Any break in the sequence would trigger an investigation at the NHA who may seek justification for the same.

Is there a provision for Follow-Up procedures?

Procedures have been identified that require prolonged follow ups beyond the limit of 15 days as included in the coverage of the scheme. These follow ups may need medical intervention with utilization of consumables and consultations with the treating doctor. These have been sorted as follow up packages and are aligned to their specific primary packages. In addition, these packages can only be booked only upon submission of satisfactory documentary proof that the primary procedure was conducted on the patient, whether within or outside of the purview of AB PM-JAY.

Are there defined Day Care procedures in HBP 2.0?

All standard HBP guidelines are applicable across all packages in HBP 2.0. There is no relaxation in protocols for any procedures that are booked on Day Care or Inpatient basis / in Public or Private Hospitals / in Elective or Emergency conditions.

Are examples of procedures available for the new concepts introduced in HBP 2.0?

Examples for all new concepts introduced in HBP 2.0 are included as Annexure -1 with this document.

Have any Fraud control measures been built into the procedures of HBP 2.0?

Many Anti Fraud measures have been built into the procedures of HBP 2.0. A few of them are as under

  • Procedures within HBP 2.0 have been identified to be fraud prone and would be under scrutiny by the National Anti Fraud unit (NAFU) at the NHA. Utilization of these packages may trigger show-cause response from the NHA.
  • Prices of some procedures have been consciously kept at a bare minimum to avoid temptation of hospitals to abuse the same.
  • In cases where the patient undergoes multiple rounds of treatment, the minimum interval between two consecutive treatment interventions has been configured in the IT system, wherever applicable e.g. Appendicectomy, Hysterectomy, Cataract etc.
  • The maximum number of times a procedure can be booked for an individual patient has been integrated in the IT system, wherever applicable
  • Implants / High End Consumables usage has been defined at the procedure level where both the type of Implants / High End Consumables and their maximum permissible limit of usage has been detailed out
How are the new package codes different from HBP 1.0?

A unique alpha - numeric code comprising of five characters is assigned to each package. The first two alphabets of the package code denote the primary specialty and the three numbers denote the serial number of packages under the primary specialty. The sequence of packages is aligned according to their organ systems or the type of treatment modality involved.

Is there a standardized nomenclature of procedures in HBP 2.0?

In collaboration with World Health Organization (WHO), the NHA has initiated the process of aligning HBP 2.0 with International Classification of Health Interventions (ICHI) and International Classification of Diseases (ICD) coding of the WHO.

Are there any guidelines with respect to reservation of packages for Public Hospitals?

It is the discretion of the States to reserve packages for public hospitals based on their local conditions and infrastructure availability. However, as with HBP 1.0, certain procedures such as Hysterectomy, High Risk Delivery and Mental health packages have been recommended by the National Health Authority to be reserved for Public Hospitals. The same will continue to be reserved for Public Hospitals for HBP 2.0

Can states still add state specific packages to supplement HBP 2.0?

Yes. States are still at liberty to add state specific packages. However, prior approval from the NHA is mandatory that would ensure that the requested packages do not fall in the exclusion criteria of the scheme, or that the packages do not prior exist in the national master.

What is the process for States to add their own state specific packages to supplement HBP 2.0?

In collaboration with World Health Organization (WHO), the NHA has initiated the process of aligning HBP 2.0 with International Classification of Health Interventions (ICHI) and International Classification of Diseases (ICD) coding of the WHO. The same mapping will need to be adopted by the states before submitting their proposed list to the NHA for approval. The NHA would scan the list to cull out any duplicate procedures with the National list, as well as procedures that fall within the exception criteria of the scheme. States will also be required to send in their proposal with a reasonable justification for inclusion of their packages to the satisfaction of the NHA medical panel.

Do States have the flexibility to alter package rates?

Package / Procedure rates recommended by the NHA in HBP 2.0 have been arrived to through a scientific and rigorous process of costing exercises and committee recommendations. However, it is also accepted that costs and prices of services may vary between states. To account for the same, the states have the flexibility of increase the recommended rates anywhere within 10% for their specific state / UT. However, the states have the liberty to reduce the rates to any limits owing to conditions specific to their state.

What is the Minimum Document Protocol for HBP 2.0?

A set of mandatory documents have been defined for each package / procedure within the HBP 2.0. These documents would need to be mandatorily uploaded at the time of raising a pre-auth, or for raising a claim. These documents comprise the MDP / ‘Minimum document Protocol’ for HBP 2.0. These are available in the Transaction management System

Is there a defined Average Length of Stay (ALOS) for procedures booked under HBP 2.0?

No. There is no minimum / maximum length of stay defined for any procedure under HBP 2.0. Any defined ALOS published for patient care under HBP 2.0 is purely indicative and is not expected to be restrictive to patient care in any way.

What is the effective date of implementation of HBP 2.0?

The effective date of implementation, of HBP 2.0 will be state specific i.e. each state is expected to adopt the same as soon as possible subject to administrative feasibility.

How do States prepare for HBP 2.0? Are there any IT related expectations?

For all states using the NHA TMS, the transition to HBP 2.0 would be automated from the back-end and would require no preparations at the State level. For states using their own Transaction Management Systems, there would be preparations required that would be facilitated by the IT teams at NHA. Beyond IT, the States would be expected to facilitate and ensure trainings of all stakeholders involved as the system transitions to the newer version.

What if patient produces PMJAY card late and wants to get treatment under PMJAY at the time of discharge? e.g. patient party has produced card after 4 days post admission.

The hospital must develop a mechanism to identify PMJAY beneficiaries at the time of registration itself. However, a provision is made in the TMS to register the patient, back dated, up to 5 days maximum. Hence, treatment can be facilitated to patients who have produced the card before discharge and hospital should ensure no extra money is collected from the beneficiary.

What is the process to be followed if the hospital books a wrong package?

The hospital can cancel the package booked with wrong package code applied earlier and raise a
new pre-auth/claim with right package code before discharge.

Who is MEDCO? What is the role of MEDCO?

MEDCO is the medical coordinator at the hospital, designated to look after clinical activities related to PMJAY beneficiary. His/her role is mainly to facilitate in ascertaining Diagnosis and blocking right package, Pre-auth initiation, Discharge & Claim Initiation etc. All these activities are done by MEDCO in coordination with treating doctor and PMAM.

PMAM is not medically oriented, how should they block the right package in the TMS?

The treating doctor must write appropriate package code as per the treatment decided and intimate to MEDCO. Also, MEDCO in the hospital should help PMAM in blocking the right package. Incase there is no MEDCO is available PMAM can take help from treating doctor.

If the patient is admitted for medical case and requires a surgery, how should the case be tackled?

Medical and Surgical packages cannot be booked together. All surgical packages include expenditure related to pre and post-operative care. Hence, the hospital shall cancel the pre-auth and generate a new pre-auth request for required surgery. Surgical package under the scheme covers 3 days pre and 15 days post hospitalization expenses.

What is the minimum duration of hospitalization that qualifies to be blocked under medical packages?

Minimum of 24 hours stay is required and the rationale for hospitalization should be provided by the hospital through clinical documents. The diagnosis needs to match the listed packages under PMJAY.

Who is PPD and what is his/her role?

Pre-auth Panel Doctor is part of pre-auth processing team (ISA/IC/TPA/SHA), his/her role is Approval/Rejection/Raising Queries of pre-auth request.

What is pre-auth auto approval?
  • Package Level Auto approval: Many packages which do not need approval of Pre-auth Panel Doctor (PPD) will be automatically approved in the TMS without going to PPD bucket instantly.
  • Forced Auto approval: Incase no action is taken by PPD within 6 working hours (from 11 AM to 6 PM) of pre-auth initiation for the packages where pre-auth is mandatory, the case will be auto approved in the TMS.
What is the pre-auth auto approval TAT?

For packages which need to be approved by PPD, the Turn Around Time (TAT) is 6 working hours. Incase if the case is not approved within the defined time, pre-auth will get auto approved. The working hours in TMS is defined as 11:00 AM to 6 PM for Auto-Approval of the Pre-Auths

  • TMS system calculates time by running schedulers on the data and schedulers shall be running between 11:00 AM and 6:00 PM with a frequency of 2 minutes.
  • For example, if a Pre-Auth is raised at 5:00 PM in the evening and no action is taken on the same till 11:00 AM, the Pre-Auth will be auto-approved at 11:00 AM. Scheduler start time is 11:00 AM because pre-auth approval team is given 2 hours’ time in the morning (assuming working hours start at 9:00 AM) for processing all previous day cases.
What shall be done in case of a medical package being auto approved and diagnosed with changes, later?

The hospital should cancel the case and block the right package with appropriate rationale, otherwise the claim may be rejected by the CPD.

What shall be done if pre auth is approved but audit findings reveal that pre-auth approval was not justified?

The decision and outcome of the investigation may be taken into consideration at the time of claim adjudication and if the claim is found to be fraudulent it shall be rejected, and disciplinary action should be initiated. However, if pre-auth was approved by TPA/IC erroneously same should be considered and paid to the hospital.

What is meant by pre-auth enhancement in medical cases?

For medical cases the first day would be on auto approved mode. In case extension of stay is required, the PMAM/MEDCO need to seek enhancement through the TMS. Enhancement request may be approved maximum up to 5 days at a time and the same process may be repeated, if required.

What should be done if hospital treats patient before getting pre-auth approval?

The hospital must develop a mechanism to identify PMJAY beneficiaries at the time of registration itself.

  • For Packages requiring pre-auth, mandatory pre-Authorization need to be sought before initiating treatment.
  • In case of emergency, telephonic pre-Authorization can be sought, and treatment can be initiated. However, all the required documentation needs to be uploaded within 24 hours.
When pre-auth is already initiated and later found that an additional surgery needs to be done. What should be done in this case?

The pre-auth raised earlier needs to be cancelled and same should be intimated to PPD. After intimation new package can be blocked.

Is uploading of mandatory document compulsory while raising pre-auth?

While initiating the Pre-Auth, uploading of all mandatory documents for the selected package is compulsory. If the patient is registered without Bio-metric Authorization, patient’s photograph is also required.

What is the definition of pre-hospitalization expenses under PMJAY?

This is the expenditure incurred by the beneficiary of the scheme up to 3 days before getting admitted in the hospital (Applicable only to the expenses made in same hospital where treatment under PMJAY is initiated). The expenditure may be related to diagnostics, consultation and medications etc. and inclusive in the package.

How to implement 3-day pre-hospitalization cashless benefit?

The hospital can register the beneficiary in the TMS when he visits hospital for the treatment. If the beneficiary needs admission, pre-auth can be raised and expenses incurred by the beneficiary till then (up to 3 days) shall be considered inclusive in the package. Incase if he does not need hospitalization or daycare procedure as under PMJAY scheme, then pre-hospitalization expenses will be borne by the patient.

What is the definition of post-hospitalization expenses under PMJAY?

It is the expenses incurred by the patient from the date of discharge up to 15 days for consultation, medicines & diagnostics and post-operative care. It is covered under the package and patient should not be charged additionally.

Also in case of surgery, any post-operative complication and re-admission, linked to the treatment, is to be covered under the earlier package cost.

How to implement 15 days post-hospitalization cashless benefit?

Hospital must procure required medications and provide to the beneficiary. In case if diagnostic evaluation and follow-up visits are needed within 15 days post discharge, it should be done free of cost by the hospital.

Which brand of implants or chemotherapy drugs are to be used?

It is up to the hospital to choose the brand meeting the specifications laid down by concerned authorities and patient should be ensured free and good quality treatment. The patient should not be charged any additional money for drugs or implants on the pretext of better quality.

What shall be done if the hospital doesn’t have diagnostic facility? Or the investigations are being done outside the hospital?

As per NHA guidelines the hospital cannot be empaneled without in-house diagnostic facility or without a tie up with nearest diagnostic facility for the PMJAY beneficiaries. The hospital should ensure cashless treatment to the beneficiaries of PMJAY.

Even if the investigations are done outside the hospital in a facility with which hospital has signed an MoU, the patient shall not be asked to pay for any services for the diagnostics if it is linked with the hospitalization in the hospital under PM-JAY.

Is booking of multiple medical packages allowed?

Booking of multiple medical packages is not allowed under PMJAY.

Is booking of multiple surgical packages allowed?

Yes, booking of multiple surgical packages is allowed. However, PPD and CPDs shall perform the due diligence while approving and processing such claims.

For multiple surgical packages how much amount will hospital get?

For multiple packages, rule of 100%-50%-25% (i.e. Costliest 100%, 2nd costliest – 50% then 25% each) shall be applied.

Is the rule of 100%-50%-25% applicable for all claims with multiple packages blocked by the hospital?

This payout ratio is applicable only for multiple surgical package selection. However, for add-on implant related packages like additional stent, additional coil etc. 100% payouts will be applicable.

What is maximum number of surgical packages which can be booked together?

It will depend upon the condition of the patient. In case of planned surgeries this number normally does not go beyond 2 or 3. However, in certain conditions e.g. poly trauma, more number of packages may need to be booked. There is no upper limit prescribed from the policy side.

How will rule of 100-50-25 apply if more than 3 surgical packages are booked together?

It is envisaged that it will be a rare occurrence that more than 3 surgical packages have to be booked simultaneously. However, in case more than 3 packages are booked then all the packages beyond second package will be reimbursed at 25% level.

Can hospitals book medical package & surgical package together?

No, hospitals are not allowed to book medical and surgical packages together.

What shall be done in case of surgical package where ICU care is required?

ICU care, if required, is a part of surgical packages.

How to flag a case in the TMS?

Flagging concept enable user to raise a flag against cases which are suspicious. Flagging can be done by Trust/Insurance users. Once the case is flagged, it will be removed from work list and will be visible in Flagging Committee login for further investigation.

  • Step 1: Log-in as any Trust/Insurance user. Open a case and click on the Flag tab.
  • Step 2: Select the nature of Flag and click on “flag” button.
  • Step 3: Once the user clicks on Flag button, System will throw a confirmation message and select yes. Case will appear in flagging committee log.
Can hospital book unspecified and specified package together?

No. It is not allowed to book unspecified and specified package together.

What kind of treatments cannot be booked under unspecified surgical code?

Any medical treatment, standalone diagnostics, medications, government reserved packages, treatments under exclusion policy of PMJAY and any specified package that has a listed price under PMJAY cannot be booked under unspecified package code. Unspecified packages should not be used to bypass the laid down guidelines for different packages. Refer to the guidelines on use of unspecified package.

Is any alert system exist in the TMS-hospital login to remind on pending query?

In the left side menu of the TMS, there is a tab which shows number of queries pending. Same can be referred by the PMAM/MEDCO to find out pending queries.

How to de-flag a case in TMS?
  • Step 1: In the flagging committee login, user must select the file which has to be removed from the list and use ‘de-flag’ button
  • Step 2: A prompt dialogue box will appear to confirm de-flagging
  • Step 3: After confirmation, the case will be de-flagged.
Is Family claim History available to PPD & CPD?

Yes, it is available in PPD and CPD tab(past history), if filled by MEDCO/PMAM.

Are reasons for rejection against rejected claims available to Hospitals?

Yes, it is available in 'Case Details Report'

Is package master available to states and hospital?

Yes, it is available in MIS tab of PMAM and SHA logins

Can TMS work offline?

For the places/Hospitals where there is no internet connectivity, the system will have a single user named as OFFLINE-MEDCO at SHA through offline TMS login. The user would be able to drive the entire process on behalf of hospital(for more details refer to TMS user manual). The hospitals should submit the required documents, case wise, to MEDCO who was mapped with particular hospital for uploading on TMS. MEDCO can register the case on back date basis up to 30 days.

What is meant by Query in TMS?

Whenever PPD/CPD/SHA wants to seek extra information/document for making any decision on a specific case, they will raise a query and the same will be visible to the hospital for its compliance on information/documents. Once, the relevant information/documents are attached by the hospital, the case comes back to the query initiator. There is separate button in the TMS where PPD/CPD can raise query.

When a case is assigned to PPD/CPD, where the case will appear?

Pre-Auth Updation/Claim Updation tab of the TMS.

What is the TAT for query updation (pre-authorization and claim) for hospitals?

As per Claims Adjudication manual, the suggestive TAT for responding to pre-Authorization and claim query by the hospital is 24 hours.

What is idle time out in TMS?

The idle time out in TMS is 15 mins

What shall be done if money is collected from the patient by the hospital over and above package rates?

Charging of extra money over and above package amount by hospital from the beneficiary is strictly prohibited and full refund and penalty up to 5 times the amount charged, is to be paid to the SHA by the hospital within 7 days of the receipt of Notice. SHA shall there after transfer money to the beneficiary, charged in actual, within 7 days and retain the balance punitive penalty.

What action shall be taken if fraud is confirmed for a paid claim?

In such cases, the claim amount must be recovered by SHA from the hospital and the SHA must initiate disciplinary action as per the guidelines.

What is the minimum qualification required to process the claims?

IC/ISA/TPA/SHA should hire the trained & qualified staff. State specific MOU with IC/ISA may be referred for exact qualification and number.

What % of claim amount will be given in case of LAMA/DAMA?

Leave Against Medical Advice or Discharge Against Medical Advice the % of claim amount is as below:

Surgical Cases:
  • LAMA/DAMA before surgery: No payment will be done to the hospital by the SHA/Insurer in such cases. This will be applicable in both cases whether pre-operative investigations have been done or pre-operative investigations have not been done.
  • LAMA/DAMA After Surgery: Payment for 75% of the package rate will be done to the hospital by SHA/Insurer in such cases. Daily case sheets and surgical notes along with indemnity consent note will need to be submitted by the hospital for auditing purposes to quality for payment.
Medical Cases:
Payment for 100% of the daily package rate for the full number of days when patient was admitted will be paid after other details satisfactorily checked. Required documentation (clinical notes) for each full day along with indemnity consent will need to be submitted for payment to be considered.
Can flexibility or relaxation be given to public hospitals with regards to uploading mandatory documents?

As per NHA guidelines Public & Private hospitals should be treated at par, however, SHA may take a considered view on case to case basis.

What shall be done if the hospital refuses or fails to provide any of the listed mandatory documents?

The claim can be justifiably repudiated and specific guidelines issued by the state authorities may be followed.

Is there any minimum stipulated time for Claim processing team to raise query on claim submitted by the hospital?

As per NHA guidelines the claim should be settled within 15 days of submission of claim by hospital, so it is expected that queries, if any, should be raised at the earliest.

How should a claim be processed for which investigation results suggest adverse findings?
  • The CPD shall reject the case and intimate the reason of rejection to the hospital.
  • SHA would initiate action as per the applicability of gradation of offences.
Who is CPD and what is the role?

Claim Panel Doctor is a part of claim processing team. CPD role is adjudication of claims i.e. Approval/Rejection/Raising Queries.

Who is CEX and what is the role?

Claim Executive is a part of claim processing team and his/her roles are verification of Nontechnical information like Documents, reports, dates etc. and to forward the case to Claim doctor with Inputs.

What is the TAT for claim settlement?

As per NHA guidelines, claim needs to be adjudicated and paid within 15 days of claim submission by hospitals. For portability cases it should be paid within 30 days.

How the claim settlement TAT will be calculated if any query is raised?

The TAT for claim adjudication and payment is 15 days and incase of portability cases it is 30 days, inclusive of claim queries, if any.

Is there any provision in the TMS to reopen a rejected pre-auth & claim if as per the hospital rejection is not justified?

The system will allow the SHA to revoke cases where preauthorization or claim request has been previously rejected or approved. For more details please refer to TMS user manual for approvers.

If two surgeries for same treatment is being carried out with 2 different packages, how should we go ahead with it? (e.g. In some cases where herniorrhaphy & hernioplasty both booked together for treatment of hernia)

The CPDs shall review the claim on merit and hospital shall be paid only for the surgery performed.

Is there any specific report/readings to be verified by the processing team while approving a claim?

Every package has defined set of documents which the hospital needs to upload while submitting the claim. These reports shall be verified by the CPD while processing claim and for taking informed decision.

How to decide the amount for a procedure booked under 'unspecified surgical package'?

For deciding on the approval amount, the PPD may consider the rate of closest match of the requested surgery, in listed PM-JAY packages. It should be noted that the amount approved by the PPD would be sacrosanct and the CPD would not be able to deduct any amount or approve partial payment for that claim. Unspecified package above 1 lakh: For any State/UT to utilize the unspecified package above 1 lakh, it is to be ensured that the same is approved only in (a) exceptional circumstances and/or (b) for life saving conditions. For detailed process please refer guidelines on unspecified packages.

In case of death of patient before surgery what percentage of claim amount shall be approved?

If surgery has not been done, then no payment will be made to the hospital. This will be applicable in both cases whether pre-operative investigations have been done or not.

In case of death of patient on OT table what percentage of claim amount shall be approved?

If death happens during the surgery, then 75 % of the total package rate will be paid. Daily case sheets and surgical notes will need to be submitted by the hospital for auditing purposes to qualify for payment.

In case of death of patient after surgery what percentage of claim amount shall be approved?

If death happens after the surgery/ post-operative stay has been performed, then 100% of package rate will be paid to the hospital after detailed medical audit. 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

Why mandatory documents are required to be uploaded for all cases?

Mandatory documents are required to be uploaded by the hospitals for all claims to enable the PPD and CPD to make right and informed decision on pre-auth request/claim.

Can the cases be assigned to a specific PPD or CPD for process in TMS?
  • The PPD & CPD will be auto-assigned the case on First in First Out basis.
  • However, after FIFO, the case can be assigned to particular PPD/CPD based on the requirement of the case.
Patient from State A is taking treatment in State B, which state treatment package rate is applicable in this case?

Package list and package rates as applicable in the State where the treatment takes place will be applicable i.e. State B in this case. However, if there are any packages reserved for government hospitals in the beneficiary home state, those packages cannot be treated outside state private hospital.

Treatment package in State A is reserved to Government Hospitals, can patient take treatment from empaneled private hospital of State B?

No. If the package is reserved for government hospitals in State A, the treatment can’t be taken in State B private hospitals.

Who will settle the claims of other state beneficiaries? e.g. If beneficiary from State A takes treatment in State B, who will pay the claims to hospital.

The payment of claims to the hospital will be made by Trust/Insurance Company implementing PMJAY in the home State where the beneficiary belongs to i.e State A in this example.

What is the TAT for settlement of portability claims?

TAT for portability cases is 30 days.

What is CGRMS? What is its purpose?

CGRMS (Central Grievance Redressal Management System) is an online portal used to address the complaints registered from different stakeholders under AB-PMJAY. Through this mechanism any one can lodge a complaint or grievance on the portal which will be addressed within a defined time frame

Who can register a grievance?

A complaint can be registered by the beneficiaries, their family members, empaneled 
hospitals, insurance companies, ISA, TPA or SHA and any other stakeholder who is relate
to implementation of PMJAY. 

How do I lodge a complaint or grievance?

Through online grievance redressal portal - CGRMS of AB PMJAY ( Offline Mode

  • AB PMJAY Call center helpline operated by the State/ NHA.
  • Through letter, telephone, e-mail, and fax to the official addresses of the SHA or the NHA
  • Directly with the DGNO of the district where such stakeholder is located or where such grievance has arisen
  • DGNO shall enter the particulars of grievances received via offline mode in the portal.
Should I have to login to register grievance?

No login required. Grievance can be registered directly by filling the form online.

What happens when I lodge a grievance?

A Unique Grievance Number will be generated against each grievance case. The case will appear in the concerned officer login for necessary action.

How do I track my Grievance?

Grievance can be tracked on the AB PMJAY Grievance portal (CGRMS), using your Unique Grievance Number - (UGN)

What type of grievance can be lodged by beneficiary?

Grievances can be against various stakeholders when there is lack of service or poor quality 
service. Ex. Denial of treatment by hospital, Money sought by hospital, misconduct of 
PMAM, PMAM not providing correct information, Poor facility in the hospital etc. For more 
details drop down in the grievance form can be referred.

What will happen to the grievances?

Grievance will be sent to concerned authorities for investigation and resolution

After redress can the grievance be escalated if complainant is not satisfied?

Yes, if complainant is not satisfied with the decision then grievance can be escalated to the higher authority by reopening the case.

What is the Turn Around Time (TAT) to resolve the grievances?

As per guidelines if the grievance is emergency in nature it shall be resolved by DGNO within 48 hours. In non-emergency cases it will be 15 days. However, if the case is escalated to DGRC, 30 days will be the TAT.

Can the hospitals break the treatment packages?

As a part of hospital empanelment process, hospitals must agree to the pre-fixed package rates, and it cannot be changed during the contract period.

How will a patient traveling to another state get to know whether the hospital provides a relevant package?

The patient may contact the toll-free helpline number 14555 for support or reach out to the Ayushman Mitra in the hospital. 

What to do when there is no connectivity with the system

Treatment may be provided as per the guideline issued by NHA on usage of TMS in intermittent / poor connectivity locations

Who will pay for the treatment cost in case of portability?

The home state where the benficiary originate from will pay for the treatment expenses

Which package rate will be applicable in case of portability?

The packages rate applicable in the State where the hospital is situated will be applicable in case of portability

Government should provide tenders for insurance companies all over India

Government has stopped its policy for posting an all India partner

Is there a standard definition of HDU/ICUs?

Need to set up a standard definition on HDU/ICU for effective settlement of claims

What about tendering process of smaller states? is state grouping allowed?

States can explore the option of group tendering.

What would the situation be if the Insurance company decides to back out?

The state will work in trust mode until new Insurance company is on board for, the scheme.

What will happen in cases where medical and surgical procedures are done together?

Such a case will require enhancement in TMS

Can we use the golden card to search for patients for TMS?

Yes, we can use the QR code, or we can use the HHID

Can the same registration be used for OP and IP?

No, IP and OP will have different registration number.

What if a new doctor is recruited and his name is not listed in TMS

The new Doctor's information should be informed to ISA/IC in writing immediately after joining. If there is technical delay in updating the Doctor's information in TMS, "others" option may be selected from the doctor list in TMS. But it should only be used as a contingency option.

Can a hospital provide treatment for specialties which are not specified at the time of empanelment?

No. Only those specialties specified in the hospital empanelment module will be visible in the Transaction Management Software

What is the process for updating specialties in case of a hospital facility upgrade?

The information will need to be informed to the SHA in writing. The hospital will either be permitted to update the information through HEM portal or will be updated in backend by the SHA/ISA/TPA

If the patient is admitted for a 5-day package and the patient dies on 2nd day, what do we do in this case?

Patient mortality details may be updated in the TMS application and discharged. Payment for the services provided will be determined by the ISA/TPA after verifying the documents.

In MedicoLegal, we can have two cases: 1. Police has brought, 2. Patient comes self

When Medico legal case is added as Yes, the police station number is mandatory but legal case number is optional. Both should not be mandatory

What if the patient leaves the hospital against the medical advice (LAMA)?

Patient should be discharged in TMS and relevant information may be updated in the discharge summary

Possibility that after discharge a patient comes to know that he is NHPM beneficiary. Will he receive the benefit?

Patient will not be able to receive the benefits; However, he can utilize the same for next visit.

Is there a provision for re-consideration if the claim panel doctor gives a wrong rejection?

Yes. The hospital can challenge the decision in writing to the ISA/TPA. If the issues are not resolved, the same may be brought to the attention of grievance redressal committee.

What are the criteria for enhancement in TMS?

Need to codify enhancements- Days, Surgery+Surgery, Medical+Surgery

What services are excluded under PMJAY?

Any outpatient care, drug rehabilitation, cosmetic treatments, organ transplants and fertility treatment are not covered.

What happens if the disease is not in the package?

Any surgery that is not in the package will need to be pre-authorized after which the price will be negotiated between the hospital and SHA/IC and then the procedures can be planned. This is capped to an amount of Rs 1 lakh. This option is available for surgical procedures only.

I am a diabetic since years, will I now also get treatment?

Yes. PMJAY benefits will be available from Day 1 of the roll out of the scheme for inpatient hospital care. Any inpatient hospital care for pre-existing diseases will be covered. However, OPD will not be covered.

Do I need to pay for medicines I receive under this scheme?

No. Under PMJAY, medicines will be included in the package for the duration of treatment, including up to 15 days after discharge from hospital, as needed.

Are maternity benefits covered under JSY a part of AB-NHPM?

Normal Labour and delivery, including high risk deliveries, C-sections and associated treatments are covered under PMJAY. But JSY and another voucher scheme benefit are not given under PMJAY

If there are five members in a family who have already availed benefit under PMJAY, will a new-born be covered?

Yes. There is no limit of family size. The neonate will be provided care provided the benefit is not exhausted

Is there any provision for payment of transportation charges?

There is no provision of payment of transportation charges under the scheme.

What if an empanelled government/ private hospital is refusing to treat a beneficiary?

A dedicated Grievance Redressal Committee will be appointed at district, state and national level and all grievance will be addressed within a period of 30 days.

Any escalation matrix in case customer is unhappy with Arogya Mitra’s response or assistance?

Yes – Grievances against the Arogya Mitra can be escalated to the District Grievance Nodal Officer.

What if the hospital, after admitting a beneficiary, conducts the investigation and finding nothing worthy of a -surgery?

This will be handled on a case to case basis and the required process will be escalated for resolution within the grievance framework.

Can a hospital provide treatment for specialties which are not specified at the time of empanelment?

No. Only those specialties specified in the hospital empanelment module will be visible in the TMS.

Can a MEDCO share the information / record of patient to anyone?

The hospital is required to maintain complete confidentiality of patient information and must not be shared to unauthorized persons. For further details please refer to detailed guidelines

Can the hospital claim for treatment in event that the patient dies during the process of treatment?

Yes, the hospital can claim if the patient has undergone treatment but does not survive. The same would be subject to verification / approval of the CPD.

Can the MEDCO use the same login ID for HEM application in TMS application?

As of now MEDCO cannot. Currently, TMS application and HEM application have separate login IDs.

Under TMS, does IP and OP have same registration numbers?

No, IP and OP cases will have different registration numbers.

Does a beneficiary need to pay for getting medicines for the treatment received under this scheme?

No. Under PMJAY, medicines will be included in the package for the duration of treatment

Does the scheme only entitle beneficiary for admission to general ward?

Yes. If beneficiary wants an upgrade in room the all expenses for treatment will not be covered under PMJAY scheme. Admission to ICU for specified packages is allowed

How can MEDCO convert OP registered cases as IP or vice versa?

This provision is currently not built in TMS. The beneficiary can be re-registered correctly after discharging or cancelling registration in TMS.

How will a beneficiary get registered for treatment in a hospital?

The beneficiary has to provide NHPM-ID / Ration Card / Mobile Number / Aadhaar / Other Valid Identity Proof to the Medco or AM. The details of the beneficiary if available in the BIS will be retrieved in TMS for case registration.

If a beneficiary comes to know that he / she is an NHPM beneficiary, can such benefit be claimed later after treatment is complete or discharged?

In such cases, beneficiary will not be able to claim the benefits retrospectively.

If the patient is admitted for a 5-day package and the patient dies on 2nd day, what do we do in this case?

Patient mortality details may be updated in the TMS application and discharged. Payment for the services provided will be determined by the ISA/TPA after verifying the documents.

If there are five members in a family who have already availed benefit under PMJAY, will a new-born be covered?

Yes. There is no limit of family size. The neonate will be provided care provided the benefit limit is not exhausted and the neonate is added to a family with at least one PMJAY verified beneficiary

In which languages is the TMS application available?

The TMS application is only available in English

What are the various types of Users in TMS?

The Hospital TMS has the following types of Users:

  • Hospital User - Pradhan Mantri Arogya Mitra or Medical Coordinator (MEDCO)
  • Preauthorization Panel Doctor (PPD)
  • Claim Executive (CEX)
  • Claim Panel Doctor (CPD)
  • State Health Agency (SHA)
Is it mandatory to upload Preauthorization Request Form (PRF)?

PRF was earlier a mandatory upload. However, since 23 Oct 2018, PRF has been removed

Is post-hospitalization expense covered in PMJAY?

Post-hospitalization expense is part of the package amount for the treatment. No expenditure is to be done by the patient or beneficiary post-discharge. Prior to discharge, the hospital has to provide a follow-up date for such treatment

Is the cost of diagnosis or investigation included?

The package amount includes the cost of diagnosis / investigation as needed after the patient has been registered.

Is the TMS application available for general public?

TMS application has not been made public for the general public

The primary diagnosis list does not populate even after entering 4 characters (minimum required). Why?

Please check that you have entered the word correctly as per the list of words available in primary diagnosis drop down menu. Therefore, enter valid characters only.

What do the beneficiaries have to pay to get be covered under this scheme?

All eligible beneficiaries can avail free services for secondary and tertiary inpatient hospital care as per identified packages under PMJAY at all public/government hospitals and empanelled private hospitals. Beneficiaries will have cashless and paperless access to inpatient hospital care under PMJAY.

What if there is an emergency treatment has to be done?

In case of an emergency, when a surgery needs to be done immediately (emergency cases) telephonic approval is taken from concerned Approvers and a Telephonic ID is generated. Later the Arogya Mitra / Medco will need to register the case into TMS as per process.

What is auto-approved pre-authorization?

Certain procedures do not require pre-authorization approval from PPD. In such case, approval is done immediately by TMS after initiation by Medco and the treatment can be started immediately. There 914 such procedures in the National Package. Certain other procedures are pre-approved for only the 1st day of admission. For any extension of treatment, approval has to be taken by Medco from PPD after every 5 days' interval. There are 164 such procedures in the National Package.

What is meant by packages?

A package includes end to end treatment for the entire episode of care required. i.e. Diagnosis, doctor and nursing charges, pre-hospitalization investigation, bed charges, consumables, medicines, food for the patient and post-surgery investigations and medicines.

What is the criteria for enhancement of package in TMS?

Enhancement is allowed only for surgery cases for another surgery. Enhancement to surgery is not allowed for Medical cases.

What is the process to be followed in empanelled hospitals?

Please refer to the detailed process flow.

What to do if I forgot the login ID or password?

In such cases please reach out to your SHA

What to do in case stay of patient in the hospital needs to be extended?

As per guidelines, extension of stay is not applicable for medical cases which are paid in packages. Extension would be required only for packages which are paid on ward basis. The same can be done through Pre-authorization within the existing case.

What to do when there is no internet connectivity at hospital during transaction?

Hospital will call Central Helpline and using IVRS enter AB-NHPM ID or Aadhaar number of the patient. IVRS will speak out the details of all beneficiaries in the family and hospital will choose the beneficiary who has come for treatment. It will also inform the verification status of the beneficiary - If eligible and verified then beneficiary will be registered for getting treatment by sending an OTP on the mobile number of the beneficiary. In case beneficiary is eligible but not verified then she/he can be verified using Aadhaar OTP authentication and can get registered for getting cashless treatment.

Hospitals with poor connectivity must always keep a print out of the authorized package list including the package code names and rates.

NHA has issued guidelines for usage of software when there is intermittent connectivity or no connectivity. This has to be followed in such hospitals / scenarios.

What will happen in cases where medical and surgical procedures are done together?

Such cases will require enhancement to be preauthorized in TMS.

When can a hospital initiate the claim for the treatment?

A hospital can initiate claim after the procedure has been completed and patient has been either discharged or marked as dead in TMS.

Which are the types of treatment available for a beneficiary?

More than 1350 procedures including Medical and Surgical are available under PMJAY in the National Package list.

Why am I getting an error while trying to upload a file in TMS?

Please check the file type allowed. Only JPG or PDF file are allowed. The file size should not exceed 500 KB

Why am I unable to register a patient?

If a beneficiary is already registered in another hospital and has not been discharged, then such beneficiary cannot be registered

Why am I unable to view the case status though I have registered the beneficiary in TMS?

In registered patient view, registered patients will be displayed. After that primary diagnosis will be done by the MEDCO and then either the patient will be converted as IP or OP. Case Status is available for IP cases only.

Why does a hospital not able to select certain / any procedure?

This happens if the specialties have not been provided in HEM application. Procedures would appear in TMS only for specialties which have been approved in HEM application. Specialties must be updated in HEM application.

Why does an error pop up while uploading document in TMS?

TMS application does not allow file to be uploaded if a file with same name has been uploaded earlier for a patient.

Is cancer treated under PM-JAY?

Yes, however the type and duration of treatment is different for all cancers. Cancer care treatments need to undergo a whole treatment plan approval similar to a ‘tumor board concept’ on the best course of patient management. A clinical treatment approval process is mandated for cancer care, since it involves a multi-modal approach covering surgical, chemotherapy and radiation treatments and appropriate supportive care that could assess to determine the best course of patient management for such conditions. Pre-authorization is mandatory for all packages involving cancer treatment. There would be 2-step approach for Pre-auth Pre-auth for the complete course of treatment mentioning the various stages of treatment and the detailed Oncology Treatment Plan Approval form has to be filled, signed & uploaded (Annexure 1) as part of Pre-auth Pre-auth has to be sought at each pre-defined stage / selecting package

Under which category are the Cancer packages listed?

Packages have been enlisted under Medical, Radiation and Surgical oncology. In the case of Surgical packages, they are not exhaustive – since there are significant overlaps with packages under other specialty domains. Such packages may be used as deemed necessary.