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DRAFT MOU

(Please Type the MOU in Rs. 20/- Rs.50/- or Rs.100/- stamp paper, in duplicate, Fill in the Gaps with your hospital related details & mail both the copies to Anyuta Corporate Office at No: 31 / 18 Loyola Layout, Main Road, Ward – 111, Shanthala Town, Bangalore 56004.)

MEMORANDUM OF UNDERSTANDING

THIS MEMORANDUM OF UNDERSTANDING made at BANGALORE this _____ Day of _______________________ 2013, between

M/s ANYUTA TPA IN HEALTHCARE PVT LTD, (ATPAIHPL) a company duly registered under The Companies Act, 1956, and having its Registered Office at No 65, Lavelle Road, 4th Cross, Bangalore – 560 001 and the Corporate Office at No: 31 / 18 Loyola Layout, Main Road, Ward – 111, Shanthala Town, Bangalore 560047, represented by Dr. N. Ravindra Shetty as its Medical Director & Chief Executive Officer. Hereinafter, referred to as “Anyuta – TPA in Health Care” (Which expression shall unless be repugnant to the context or meaning thereof shall deem to mean and include its successors and assignees)

And

M / S____________ HOSPITAL, having its registered office at ………………., represented by its Medical Director / Director / Chief Executive Officer / Chief Operating Officer and/or Administrator Dr. / Mr. ______________________, Hereinafter referred to as MEDICAL PROVIDER (Which expression shall unless it is repugnant to the context or meaning thereof shall deem to mean and include its successors or assignees)

Whereas M/s ANYUTA TPA IN HEALTHCARE PVT LTD is a Licensed Third Party Administrator in Healthcare Services licensed by Insurance Regulatory & Development Authority of India (IRDA) (Vide IRDA License No. 17 dated 16th May 2002 renewed till 15/05/2014 (Renewed from 16/05/2011 to 15/05/2014 Certificate dated 19/11/2012, Hyderabad) under the IRDA (Third Party Administrators – Health Services) Regulations 2001.

Whereas the MEDICAL PROVIDER is a Registered, Licensed Hospital, with all the safety factors to treat the Policyholder / Insured, henceforth referred to as the BENIFICIERY. The above parties hereby agree to join hands to provide health care to the BENIFICIERY by way of this MOU, effective from the day it is signed by the parties and shall remain valid for a period of 3 years.

NOW THIS MOU Witnesses and it is agreed by and between the parties as follows:

The Medical Provider hereby agrees to,

1. Identify the Beneficiary, by way of his Medical Identification Card, Policy Number, New Pension Number, Policy Value, Validity, Bank details like Bank Name, Branch Name, Account Number, Branch Code, IFSC Code, MICR Number, etc., before treating the Policyholder.

2. Provide prompt, ethical, efficient, cost effective healthcare services, to the Beneficiary, as per the insurer`s policy conditions.

3. Intimate Anyuta – TPA in Health Care, before commencing the treatment, its intention to admit and treat the Beneficiary, by way of a Pre – authorization request letter, sent by E – mail, Fax, Courier or Post, within 12 hours of admission or prior to admission.

4. Send the Pre – authorization request letter containing the details of the Primary Physician / Surgeon in charge of the Patient, his Specialty, Qualification and Registration number, along with the need to admit and treat the Beneficiary, Provisional Diagnosis, Investigations needed, non - invasive or invasive procedures that will be carried out, the medicines that may be prescribed, number of hospitalization days, and the approximate cost of the entire treatment.

5. Explain to the patient, the ailment he is suffering with, the line of treatment offered, need for hospitalization, need for the type of investigation, need for the invasive or noninvasive procedures, type of medicines used, the course of the treatment, post hospitalization care and cost, rehabilitation process, etc.

6. Explain to the Beneficiary and his close relatives, the Pros and Cons of the line of treatment offered, cost involved and the payment module like, the part of the cost that the Insurer will pay and the part of the cost the Beneficiary will have to pay out of his pocket to the Hospital.

7. Hand over two files at the time of discharge, one containing the Original Claim Documents and another containing the Copies of the Original Claim Documents to the Beneficiary along a Covering Letter, listing all the Documents enclosed in it and stating that the Beneficiary is properly identified and treated taking all precautions needed for the safety and well-being of the patient and that the final bill issued, is for the entire treatment and the services rendered by it is as per the Medical and Professional ethics.

8. Hand over the Original Claim Document File containing, the Certified copy of the Beneficiary’s Health Insurance Policy, Completed and Signed Claim Form, ID Card, Copy of the Bank Cheque leaf, Discharge Summary, Investigation Reports duly signed by the concerned Specialists, Final Single Split Bill under different heads, elaborating each of the expense incurred.

9. Allow Anyuta – TPA in Health Care, to inspect the Hospital to assess the Investigation, Treatment facilities, Operation Theater facilities, Medical record keeping, Billing, Hospital Registration Documents, etc. The hospital will also arrange at its cost, for Anyuta – TPA in Health Care to visit the Hospital and conduct case discussion with the concerned Doctors and the Patients in case of disputed Claims and provide all the documents needed free of cost.

10. Indemnify, Anyuta – TPA in Health Care, from any legal and financial implications / costs and liabilities that may arise out of its omission and commissions, in treating the patient or any other matter to that effect.

11. Treat the emergency cases on priority basis without waiting for the Authorization letter, but shall intimate the TPA and follow the procedures as listed above and as is done in the other cases.

12. Provide its Bank details like, Bank`s Name, Branch Code, Account Number, IFSC Code, MICR Code, or Scanned Copy of the Cheque leaf, PAN Number, Hospital Registration Number, Contact details, like, Telephone Landline Number, Mobile Number, Fax Number, E – Mail address, Website Address.

13. Check on the payments received and return the excess payment if done by Anyuta – TPA in Health Care in the course of Claim Settlement.

14. Pay the costs incurred by Anyuta – TPA in Health Care due to the wrong doings if any, by the MEDICAL PROVIDER.

15. Allow the Anyuta TPA empaneled / Patient`s choice of Specialists, to operate or treat the insured patient, after scrutinizing his / hers, competence and all the legal requirements to do so, like his Qualifications / Registration with Indian Medical Council / Local Medical Council / Medical Indemnity Insurance, etc.

Anyuta – TPA in Health Care - Process Cycle

Identification:

For the purpose of identification, Anyuta – TPA in Health Care shall provide each beneficiary with an Identity Card, bearing his / her recent photograph, name and date of birth or an Identity Card without photograph but bearing beneficiary’s signature. The beneficiary will produce this card at the time of admission for the purpose of identification.

Procedure for Admission:

1. The Beneficiary requesting for hospitalization and treatment under the Insurance Scheme, should provide the Copy of the Insurance policy copy, Specify the Cover value, used amount, the balance left for the year, ID copy, Address Proof, Telephone number, Mobile Number, Bank name, address, Account number, Branch code, IFCS Code, MICR Code, to establish his identity and to facilitate Electronic Claim Settlement by the TPA.

2. The MEDICAL PROVIDER should send a Pre – authorization request for hospitalization of the Beneficiary in Anyuta – TPA in Health Care format. On receipt of such request and after scrutiny, Anyuta – TPA in Health Care will issue the Pre Admission Authorization Letter (PAAL) specifying beneficiary’s entitlement of available benefits. The PAAL will be either faxed to the Medical Provider or hand delivered by the beneficiary and produced at the time of admission. The Provider will not admit any beneficiary without PAAL except in the case of Medical Emergency. All original reports/ Bills duly signed by the beneficiary should be sent to M/s Anyuta – TPA in Health Care and not handed over to the beneficiary.

3. The beneficiary should be explained by the Medical Provider in detail, in the language that he and his immediate relatives understand, about his Health (medical or surgical) conditions, the need for Specialists Care over Family Physicians Care, the need for Hospitalised Care over the Out – Patient or Domiciliary Care, the options of treatments available (conservative or surgical) with health and cost benefits, the best line of treatment in his case, the reason for adopting such line of treatment, the outcome of such treatment, the need for each of the laboratory investigation, invasive or non invasive procedures, the number of days of admission, the reason for each days admission, follow up procedures, costs incurred in each event in the hospital and after discharge, reason for such costs, payment module, Co – payment if any, the reason for such payments, the anticipated outcome of the treatment, the adjustments that he/she might have to do in his life style, the economical and social impact, impact on his family, etc.

4. The beneficiary should be explained the reasons for listing the Procedure done under a single skin incision, in one anatomical area, under one anesthesia, as multiple Procedures and claiming fee for individual procedure separately.

5. The beneficiary will be treated as a credit patient on Anyuta – TPA in Health Care Account. The credit facility should be provided up to the amount specified in the PAAL as per the Healthcare Insurance Policy conditions. For expenses incurred over and above the amount specified in the Authorization Letter or the Insurance Policy conditions, the Medical Provider would collect such expenses directly from the beneficiary.  Expenses incurred by the beneficiary for non- – medical items such as special attendant charges, telephone, snacks, admission charges, registration charges, and that is outside the policy conditions, must be collected from the beneficiary.

6. In case of emergencies, the Provider shall start treatment first and then scrutinize the Identity. Anyuta – TPA in Health Care should be informed immediately and we would arrange to send the Authorization Letter to the Provider within 24 Hours. In the event of AMHTPAIHPL not issuing Authority Letter, the Provider will collect the full amount from the beneficiary directly.

7. The Medical Provider will arrange to supply all components of treatment like medicines; injections, surgical sundries, disposable items, implants, stents, valves and other items that may be required for treatment of the beneficiary and include them in the final bill, split item wise, stating the cost of each item separately.

8. After the beneficiary is discharged from the hospital, the Medical Provider shall submit the Claim File containing the original documents like the, Proof of Identification, Claim Form, Discharge Summary, Investigation Reports, Bills and the Covering Letter, listing the contents of the File to Anyuta – TPA in Health Care AMHTPAIHPL, directly in case of Cashless Services or give it to the Policyholder along with a Certified Copy in case of Reimbursement, as the complete care and cost documents.

Procedure for Claim Settlement

A. The Claim File, Should contain all the original Documents and Bills relevant to the treatment in the following order,

B. Claim Form duly signed

C. Covering Letter mentioning the Documents and Bills enclosed

D. Anyuta Check List

Doctor`s Certificate

1. Informed Medical Decision, Admission, Investigation, Treatment Regime, Procedures and Costs

2. Doctor`s Clarification Certificate

3. Informed Medical Decision, Admission, Investigation, Treatment Regime, Procedures and Costs

4. Patient Bill Details filled in the Anyuta Claim Detail Format

5. Copy of the Anyuta Authorization Letter received

6. Copy of Anyuta Pre – authorization Letter received

7. Policyholder`s Details (Name, Mobile or Land line No.)

8. Policy details (Name of the Insurer, Policy Cover, Continuity of the Policy, Unused amount)

9. Policyholder`s Bank Details ( Name, Account No., Branch code, IFSC Code, MICR Code)

FINAL BILLS

1. The bills should be prepared as per the policy limits and conditions for the individual healthcare product purchased by the individual policyholder. 

2. The Hospital Bill should contain, under separate heads, services rendered by it, services availed from Specialists who are not the hospital employee, laboratory and diagnostic center bills, which are not the part of the hospital.

3. The services provided by the outside sources should be billed separately and the Receipts should be issued by the individual service provider (Doctor/ Institution) accordingly.

4. The item wise bill should mention in detail, the charges payable for various medical services provided and also for the unit of each service, as per the agreed tariff. All original bills / Doctors bills should be counter signed by the Policyholder, (beneficiaries) hospital authority and enclosed with the claim form.

5. The final bill should not include charges for Attendant pass, Tonics, telephone, snacks, barber and other non-reimbursement items.

6. The Diagnostic reports should be signed by the concerned Specialist and not by the Technicians.

7. The Diagnostic and Pharmacy Bills should be accompanied by the Prescriptions signed by the Ordering Doctor, Reporting Specialist and the Dispensing Pharmacists carrying the registration number and the seal.

ORIGINAL DISCHARGE SUMMARY WITH ICD – 10 CODES

To bring in International standards in healthcare documentation, statistics, geographical disease mapping, and disease analysis, take preventive measures and formulate the treatment regime, the disease should be classified and coded as per the International Classification of Disease ICD – 10.

Transparent Medical Documentation & Accounting

A. The discharge summary should carry the Present history / Past history / Allergies / Pre-existing Disease / Differential diagnosis / Final diagnosis, events that lead to the injury /disease / complications in the order of priority. The treatment regime should be supported by the symptoms / diagnosis / investigations. The discharge summary should summarize symptoms with their duration, clinical findings, investigations, differential and final diagnosis, overall treatment, and follow-up treatment.

B. The discharge summary should be complete in all respects also should contain Hospital name, Hospital Bank Account Number, Hospital UPIN / MCI No, Policy ID, Policy No, Policy development officer / agent, Receipt No, Insurance office, Policyholders name / relationship to policyholder in case of group policy.

ICD – 10 CODE CERTIFICATION COURSE

We are authorised to Conduct ICD – 10 Code Certification Course and issue the Certificate. 

NOTE

Standardization of Medical Documentation, Treatment Regime, Healthcare Management and Delivery System is our aim. This will promote Internal as well as International Health Tourism and bring in better revenue to the participating Hospitals at the same time will make healthcare affordable to each and every person. We welcome your suggestions whole-heartedly for improvements, transparency and accountability.

CLAIM FORM

Should be duly signed by the patient / attendant / and submitted along with the relevant hospital documents as needed by the Insurer.

For speedy Claim Settlement

A. Send us the Claim Documents neatly Filed with a Covering letter mentioning the documents enclosed in order.

B. Claim Form, Discharge Summery, Bills and other Documents, duly signed by the Hospital Authority / Concerned Doctor / and the Patient (Policyholder) in the Anyuta Formats.

C. Audit the Pharmacy bills and include in your Final bill as a single figure.

D. Procedure done at a time in one anatomical area is considered as a single procedure and Settled as such.

E. To consider and settle the Claim for multiple procedures done under one Anesthesia, by one Surgeon, in one anatomical area, under one skin incision, the Surgeon should justify and issue a Certificate to that effect owning the responsibility.

CLAIM PROCESS

Transparent Medical Auditing

A. ATPAIHPL does the Medical and Financial Audits for the Insurance Companies and settle the claims by way of RTGS money transfer to the Hospital Bank account or the Policyholders Bank account. Hence the Hospital should attach a Scanned copy of the Policyholder`s Cheque leaf showing his Bank Account number, Branch code, IFCS Code, MICR Code, along with the request for Pre – authorization letter.

B. ATPAIHPL provide cashless facilities to the Policyholders through the provider network, wherever possible and the Claim settlement is by RTGS money transfer.

C. ATPAIHPL will process the claim documents submitted to it without prejudice. In the interest of the Healthcare financier, Healthcare recipient and the Healthcare provider, our doctors will scrutinize the Documents for quality care, ethical practice, economy, need for hospitalized care over outpatient care, need for the number of hospitalized days, need for all the investigation carried out, need for all the medications and its duration, the need for the invasive and non-invasive procedures ordered and conducted, need for referral to other medical discipline, need for surgery over conservative line of management, etc. based on the above factors the claim settlement amount will be arrived at and settled.

D. However, the Hospital / Primary Doctor in charge of the patient can appeal against the settled amount within 15 days of settlement by issuing a certificate justifying the Hospitalization/ Investigation / Treatment regime and the Billing pattern. In such case the claimed amount will be settled as per the policy guidelines holding the doctor liable for damages in the event of any Moral hazard discovered at a later date.

PAYMENTS:

A. ATPAIHPL shall make all payments as per the policy guidelines and conditions in respect of the Final Bills directly to the Provider in case of Cashless Services rendered to the Policyholder, or to the Policyholder by way of cheque / RTGS money transfer to the concerned account, within a period of 45 days from the date of receiving the Final Bill, along with all relevant documents as mentioned in clause 7 of the MOU. In case of the Service Provider collecting advance payment from the patient for treatment, this should be returned to the policyholder. The proof of such collection by the Service Provider as advance will have to be attached with the list of bills.

Claim settlement

1. ATPAIHPL will settle the claims by way of Cheque payment / NEFT / RTGS money transfer to the Hospital account and hence the Medical Provider should give his Hospital Bank Account number to facilitate the process.

Bank Details

1. For NEFT / RTGS Claim Settlement for Cashless facility offered by the Hospital, the Hospital should provide its Bank details and the details are,

Bank name: ………. Branch code: IFSC Code: …….. MICR Code: ……….

Optional

1. The Medical Provider agrees to give 15% discount including Drugs & Disposable from the prevailing tariff on the final bill submitted to ATPAIHPL on IPD & OPD services and 20% discount on all Executive Health Check-Ups. AMHTPAIHPL will pay the net amount by cheque to the Medical Provider after deduction of applicable discount.

Note:

Please note that Anyuta TPA is not benefitted by the discount you offer, the Insurer and the Insured are the beneficiaries. The insurance company will reimburse the TPA, the exact amount paid by ATPAIHPL to the hospital/ policyholder, on submitting the processed Claim Settlement documents along with the payment details to them and hence this exercise of requesting discount from the hospitals is a cost cutting measure only.

This discount is only a request from us and is optional.

GENERAL

1. The Medical Provider shall be responsible for any errors / omissions related to the Healthcare & other services rendered by them to the beneficiaries and shall keep ATPAIHPL indemnified.

2. The Medical Provider shall furnish to ATPAIHPL detailed Schedule of charges for various services and keep AMHTPAIHPL informed and take its consent on any revision in the charges, which may take place from time to time

3. The Medical Provider will have no objection for using its name as an empanelled Hospital only on advertisements, promotional literature, brochure, website, etc., sponsored by ATPAIHPL

4. The beneficiary will be provided treatment by the panel of consultants attached to the provider hospital according to the practice parameters and clinical protocols established by the Provider.

5. ATPAIHPL will not interfere in the treatment provided to its beneficiaries.

6. ATPAIHPL will not be in any way held responsible for the outcome of treatment or quality of care provided by the Medical Provider.

7. ATPAIHPL Medical team may visit the hospital as the part of its Managed health care programme, to liaison with the beneficiary and the Consultant in charge of the beneficiary. The Medical Provider agrees to extend necessary co-operation during such visits and hand over all the Claim and other related documents that may be asked for, free of costs .

8. The Provider will not disclose any information about beneficiaries or ATPAIHPL business activities and will not share such information with outsiders or agencies involved in similar business.

9. ATPAIHPL will also not disclose any information whatsoever relating to the Provider without its specific written consent.

10. ATPAIHPL reserves the right to appoint other Medical Providers also for extending medical care to the beneficiaries and the concerned medical provider shall have no objection.

11. Any dispute arising out of this MOU is subject to arbitration according to the relevant legal framework applicable. The place of arbitration shall be Bangalore only.

12. Any changes / amendments to this MOU shall be done / or effected only after obtaining written approval from both the parties.

13. In the event the Medical Provider has furnished wrong information or false information and in the event the information turns out to be false ATPAIHPL is entitled to de-empanel the Medical Provider / Hospital from its list of Network Hospitals.

14. The Medical Provider is solely responsible if he had treated a patient who is actually not the Beneficiary and AMHTPAIHPL, will not settle the claim in such cases.

15. TPAs have to deduct the Service tax at the rate of 10 % at source before making payments to hospitals, as per the Tax guidelines.

Anyuta Request

A. Please treat all the emergency cases and Critical Care patients without waiting for the Authorization letter from us; we will reimburse them, as per the Policy Conditions.

B. Please send us the Pre – authorization request letter in advance for planned admission and treatment

C. Please send us the Doctor`s and Ethical Certificate signed by the Primary Care Doctor for keeping the patient more than a day in case of planned Chemotherapy regime and other Day Care Procedures.

Jurisdiction

The Jurisdiction for any dispute arising out of this agreement shall be settled by the Courts of Bangalore City only.

Address

Address for Correspondence shall be Anyuta – TPA at No: 31 / 18 Loyola Layout, Main Road, Ward – 111, Shanthala Town, Bangalore 560047. Land line: T: 080 41128311. 25364766. Mobile: 98450 10136. E – Mail: ravi@anyuta.co cashless@ anyuta.co

IN WITNESS THEREOF THIS AGREEMENT WAS EXECUTED BY OR ON BEHALF OF THE PARTIES Signed and delivered by the within named 

(Type your HOSPITAL name,)   

  

Dr. / Mr. _________________________   

 

FOR & ON BEHALF OF M/S. ANYUTA TPA IN HEALTHCARE PVT LTD  

 

Dr. N. Ravindra Shetty 

|Witness 1) | |Witness 2) | |

|Name:         | |Name:         | |

|Address:         | |Address:         | |

|Signature | |Signature | |

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