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t^sm^ f^m^vw ^ w w ^ ^mfw/Hmw ^wr^ w h f^ ^m m # sm em i/^mw^ ^ mdmO Format for Pavmeait to Hespitais qpder U-He«itb Smart Card (Form 2) 1 1) Employesc/Pensioner ID No (as provided by Treasury) 2) Name 3) Father's/Husband's name 4) Post held 5) Disease /Procedure 6) Name of the Hospital II (I) Wc...... certify that Shri/SmtAun...... F«ih«/Motber/Spousc/Son/Daughtw Shri ...... department...... Grade ...... URN No ...... who is/was sulftrfaic from the ...... disoate and was under ihe supervision ...... in ...... hospital as an indoor patiem from dated...... fo ...... wWiiwt n lm i Ml ffif sfwrmrof milgWiiylfeiil 2 (a) It is cenifled that Shri/Smt/Km...... who was suffcrinf flrom...... disease and he/she was needed emergency medkal treatment/treatment outside Uttaraldumd and was under the sopervinon ...... in ...... hospital as an indoor patient from dated...... lO (a) Expenses on tnedicine Expenses on ptAoiogicai teat t . (c) Expenses on radiological test T . (d) Expenses on special test f . (c) Bxp«iscs on Padcago/Surtery T . (f) Room Rent ^ , (g) Other Expenses (with details) 7. Total f 2 (b)' Medictne &. euuninaticHi preecribed/done by them, which is according to the voucher attached, was necessary for the patienfs better cure. No medicines are iaehided in which cheap noalertais having Thcrapittic affects is present, even die mtterial which is primarily used for food products, toiletries and disinfectants is of Standard Quality. The bills For t ...... (in words also)...... Checked A found corroct for payment CO hospitals. Ill* Original file to be lubmittad alter d«ly coaaterstgBcd by the detigaated aattarity:- (a) Requisition for autboriaatiae ieOer (RAL with bencfictafy signature) (b) Authorisation letter to Hospital by Second Party (TPA) (c) Photocopy of Smart Card. (d) Undertaking letter fiM* dependent of the U-Heaith Smart Card Holder. (e) Prescription, Investigation Rcfiort with Diagnosis (f) Medical ft Hospitalization IKlb (g) Pinal Discharge Slip (h) Original certificate to be attac^ied expenses incurred during treatment NOTK; - Overwriting A. pute not alkninsd in Ori|^ul BilU Sl Voudiers if done to be oountarsipwd be the designated authodty.

~~IV- (A) Amottat dae for reinabaraemeiit to Hoapital...... (B) Past Payment details: a) Current Hospitalization (Period...... ) T.. b) Previous Hospitalization ( I ^ o d ...... ) T..~~

MD India State Project Head MD India Medical Offfcar (MBBS) (Name Qualification with Seal) (Naaae QvaHfkatiea witli Seal) F or Offlce Use Q alv Cftliatf rftaw d OfmtfT I certify that Shri/Smt/Km...... has taken treatment in ...... hospital and necessary prescribe/given medical fiksility y n s minimum and according to the G.O for U-lwaltfa smart card and the reimbursement rates for the hosfHtais wUch has been certified are according to the rules and are actual. Tbetefoie the above bills amounting to f ...... checked and found as per CGHS rates as mentioned in MOU and may be reiminirsed to the above hospiul.

Finaaee Controller flaaaea Officer/A.. A. Officer Stata Nodal Offlcar Accoaets Maoager D.C.M.H & F.W D.G.M.H & F.W U-HaaMi V U-Haalth Moathlv InfomiatkMi System (MIS> (Form 3) Format for UHealth- Audit (Form 4) (A) Audit by Financa Pwartment (Internal Audit)

~~Once in a year of U-Health Cell & Second Party.~~

~~(B) Aadit by the U-Health Cell -~~

~~5-10% of the claims raised for payment.~~

~~I - As and when the following triggering poiate are seen: -~~

1 Frequent use of a particular hospital 2 Frequent admissioDs by the same URN number 3 Frequent admissions for conservative treatment 4 Frequent use of emergency clause 5 Doing of more than one procedure repeatedly 6 Maiic^et feedback 7 Over use of costly medicines 8 Any other after studying and analysis of MIS 9 Frequent use o f Co Morbidity fiactor 10 R eflated overstay 11 Frequent use of complication clause in case of surgical cases

~~[I - Post Hospitalization~~

~~5-10% beneficiary check (50% of which would be telephonicaUy and 50% would be physical verification) as per the format attachol~~

~~( O A u d it by the Second Party-~~

It would ratgage one trained profes^nal preferably medical person with the degree of MBSS and one hospital coordinator eadb in GarhWal MaadiU & Knmaon Mandai prefendiib' residing in that region (US Nagwr, Nainital for K um aon & D ehndns, BLarldwar for Garhwal)

I- (1) Periodic Visit to the Hospital (Every Empanelled H<^ital has to be visited once in a month). The hospital to be visitsd as per format designed and attached. (2) lOC^ validation of claims. II- Post Hospitalization

~~10% Visit to the beneficiary for verification o f treatment taken. (50% of which would be telqpbonically and 50% would be fdiysical verification) as per the format attached.~~

~~7/1 Empaneiled Hospital Audit (Form 5)~~

~~Name of the Spot Audit team leader: Date of visit to the Hospital.' Time of field visit; Location Name of tilie Hospital; Type of the Hospital (Public or Private) Number of Beds Address:~~

SJS. Question Response Cateeories Yes No 1- b there any signboard outside hospital showing that it is empanelled in U-Health? 2- Is there a U-Health help aie o f Submission of Bilb (viH) Final Discharge Slip (ix) Date of payment of bills 6- Is there any U-Health patient admitted in the ho^ital at the time of the visit? (i) Did you pay at any step? (ii) Are you satisfibd with tiie scheme? (iii) If Ko/Yes, Reascxi 7- Total no of cases till date ? U-Health Beneficiary Verification Report ( F o r m - 6 )

~~Name of the Spot Audit team leader;- Date of visit/call to the beneficaiary:- Time:- Location:- Name of the Hospital where treatment taken:- Type of the Hospital (Public or Private):- Address:-~~

S.N. Question Response Categories 1 Yes No 1 Was theax any U-Hcahh poster/ advertisement in the hospital ? 2 Did you have to wait for authori ration /treatment? 3 Did you pay at any step? 4 Are you satisfied with the scheme? 5 If No/Yes, Reason 6 Any suggestion?

~~K IJBdeitakiBg for Cerlificit^ (Fonn 7)~~

~~I certify that Slari/Snrti'Km ...... is my Father/Mcrther/Spouso^Son/I^Bighter/otiicr and is my dqjendmt as declared in the Consent Fonn (Form-1).~~

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