Tender Document for Selection of Implementation Support Agency (TPA) For providing support services for the implementation of Health Scheme (PM-JAY, AAUY and SGHS) In the State of Uttarakhand August 2021 Volume II: About Health Schemes (AB-PMJAY, AAUY and SGHS) Schedule of Requirements, Specifications, Scope of work and Allied Technical Details Tender for Selection of Implementation Support Agency For providing support services for the implementation of Health Scheme (PM-JAY, AAUY and SGHS) In the State of Uttarakhand Table of Contents Abbreviations ................................................................................................................................................ 5 Definitions and Interpretations .................................................................................................................... 6 Disclaimer................................... ................................................................................................................ 11 1. Name of the Scheme ............................................................................................................................. 13 2. Objectives of the Scheme ...................................................................................................................... 13 3. Health Scheme Beneficiaries and Beneficiary Family Unit .................................................................... 13 4. Benefit Cover and Benefit Limit ............................................................................................................. 14 4.1 Benefit Cover and Benefit Limit ................................................................................................. 14 4.2 Health Scheme Benefit Limit on a Family Floater Basis............................................................. 15 5. Benefit Package: Health Scheme Cover ................................................................................................. 15 5.1 Benefits under Health Scheme Benefit Cover ............................................................................ 15 5.2 Exclusions under Health Scheme Benefit Cover ......................................................................... 16 5.3 Benefits Available only through Empanelled Health Care Providers ......................................... 16 6. Package Rates ........................................................................................................................................ 16 7. Special Provisions for State Government Employees and Pensioneres (GEP) Beneficiaries – IPD Treatment ..................................................................................................................................................18 8. Special Provisions for State Government Employees and Pensioneres (GEP) Beneficiaries –OPD Treatment...................................................................................................................................................19 9.Identification of Health Scheme Beneficiary Family Units ................. ………………………………………………….20 10. Empanelment of Health Care Providers ................................................................................................ 20 11. Agreement with Empanelled Health Care Providers ............................................................................. 21 12. De-empanelment of Health Care Providers .......................................................................................... 21 13. General Responsibilities and obligations of the EHCP…………………………………………………………….…….....21 14. Process for beneficiary identification, issuance of AB-PMJAY, AAUYand SGHS E-Card and transaction for service delivery………………………………………………………………………………………………………………………………..23 15. Scope of Services - IPD and Day Care……………………………………………………………………………………………...27 16. Monitoring and verification of EHCPs………………………………………………………………………………………………30 17. Implementation Support Contract(Service Level Agreement /Scope of work ...................................... 31 17.1 Term of the Implementation Support Contract (Service Level Agreement ) with the Implementation Support Agency ............................................................................................................ 31 17.2 Start of Benefit Cover Period ..................................................................................................... 31 17.3 Commencement of Benefit Cover Period in State ..................................................................... 31 17.4 Implementation Support Period ................................................................................................ 31 17.5 Renewal of Implementation SupportContract (Service Level Agreement ) ............................... 32 17.5.1 Benefit Cover Period for the Health Scheme Beneficiary Family Unit in the First Benefit Cover Period.....................................................................................................................................................32 17.6 Benefit Cover Period in the Renewal……………………………………………………………………………………..32 17.7 Payment of Fee to Implementation Support Agency……………………………………………………………..32 2 Tender Document Volume II: About AB-PMJAY, AAUYand SGHS State Health Authority , Government of Uttarakhand Tender for Selection of Implementation Support Agency For providing support services for the implementation of Health Scheme (PM-JAY, AAUY and SGHS) In the State of Uttarakhand 18. Cashless Access of Services ................................................................................................................... 33 19. Pre-authorisation of Procedures ........................................................................................................... 34 20. Portability of Benefits ............................................................................................................................ 36 21. Claims Management .............................................................................................................................. 36 22. Project Offices of the Implementation Support Agency ....................................................................... 37 22.1 Project Office at the State Level ................................................................................................ 37 22.2 Organizational Set up and Functions......................................................................................... 37 23. Capacity Building Interventions ............................................................................................................. 39 24. Management Information System......................................................................................................... 40 25. Commitments of the Implementation Support Agency ........................................................................ 41 26. Plan for Provision of Services in the Absence of Internet Connectivity ................................................ 42 27. Monitoring and Verification .................................................................................................................. 42 27.1 Scope of Monitoring .................................................................................................................. 42 27.2 Monitoring Activities to be undertaken by the Implementation Support Agency ..................... 43 27.3 Monitoring Activities to be undertaken by the State Health Authority ..................................... 44 27.4 Key Performance Indicators for the Implementation Support Agency ...................................... 46 27.5 Measuring Performance ............................................................................................................ 46 28. Fraud Control and Management ........................................................................................................... 47 29. Reporting Requirements ....................................................................................................................... 48 30. Events of Default of the Implementation Support Agency and Penalties ............................................. 48 30.1 Events of Default ....................................................................................................................... 48 30.2 Penalties .................................................................................................................................... 49 31. Coordination Committee ....................................................................................................................... 50 31.1 Constitution and Membership ................................................................................................... 50 31.2 Roles and Responsibilities .......................................................................................................... 50 32. Grievance Redressal .............................................................................................................................. 51 33. Renewal of the Implementation Support Contract(Service Level Agreement).....................................51 34. Termination of the Implementation Support Contract (Service Level Agreement) and Consequences ............................................................................................................................................51 35 . Force Majeure ……………………………………………………………………………………………………………………………….52 36. Confidentiality of Information and