In the first step towards registering the hospitals under the Centre’s flagship Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), the Department of Health & Family Welfare in Delhi has formed a state empanelment committee. The committee will enrol healthcare service providers, including government and private hospitals. Along with this, seven other committees have been formed to smoothly conduct the hospital empanelment process, said officials. Delhi is 35th on the list of states and union territories to implement the Centre’s health insurance scheme, which provides free and cashless treatment for 1,961 medical procedures across 27 specialties. It covers the costs of medicines, diagnostic services, hospitalisation, ICU care, and surgeries, among other aspects. The state empanelment committee, headed by the AB-PMJAY CEO, will monitor the overall empanelment process and undertake disciplinary proceedings against errant health service providers in the state. It will also verify the hospitals registering for the scheme. Here are the details on seven other committees: District empanelment committee: The committee will ensure the timely empanelment of healthcare service providers, as well as handle matters about rejection or pendency of hospital applications at the level of the State Health Agency. These panels will be formed in all 11 districts of the city, with an additional district magistrate heading the committee. The DEC, at the district level, will assist the State Health Agency in disciplinary proceedings linked to healthcare providers, including validation and scrutiny of the uploaded documents; conducting field and desktop-based verification during empanelment and in case of any complaints related to infrastructure; submission of the verification reports to the State Health Agency through the online empanelment portal with a recommended decision to approve or reject with clear reasons for rejection; and recommending any relaxation in empanelment criteria, if needed (with justification). District implementation committee: These committees, headed by the local MLA and district magistrate, will also be formed across 11 districts of the city. The committee will execute the creation of Ayushman card; support in empanelment of hospitals; ensure active participation of empaneled hospitals under the scheme; address grievances raised by beneficiaries or hospitals; support in conducting beneficiary awareness campaigns; capacity development of various stakeholders and Pradhan Mantri Arogya Mitras frontline health workers; effective engagement with the empaneled hospitals; and on-ground coordination related to anti-fraud initiative. State grievance redressal committee (SGRC): Headed by the ABPMJAY CEO, the redressal committee will handle and resolve grievances received either directly or escalated through the district grievance redressal committee. When the beneficiary is one of the parties, the decision of the SGRC will be final. Along with this, the District Grievance Redressal Committee will monitor the grievance database to ensure that all grievances are resolved within 30 days or earlier, as per the provisions. State anti-fraud cell: The committee will develop, review, and update the state anti-fraud framework and guidelines based on emerging trends for service utilisation and monitoring data. State claim review committee (CRC): The committee will review all claims that are rejected and appealed by the provider. It will also randomly audit at least 2% of the pre-authorisations and 3% of the claims of each provider each quarter. State medical committee: The committee will examine the Unspecified Surgical Package (USP) claims submitted by empaneled hospitals and provide inputs to the competent authority to approve or reject the claims. The AB-PMJAY CEOwill recommend every case of USP for approval or rejection after taking inputs from the State Medical Committee, with details of treatment and pricing that are duly negotiated with the provider. State appellate authority: The authority will handle and resolve all grievances related to Ayushman Bharat PMJAY in Delhi, received or escalated through the state grievance redressal committee (SGRC).
