Notification and Final TPA Empanelment Criteira.v1 07-12-12[1] · Customer complaint / Grievance...

Empanelment Criteria for Third Party Administrators to service RSBY

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Notification

All Third Party Administrators (TPAs) desirous of working in Rashtriya Swasthya Bima Yojana (RSBY) will need to be empanelled by Quality Council of India. Any TPA who is at present working in RSBY will need to apply for the empanelment by 31st January 2013. Details about this are provided in the Document as below for this purpose. In case of any clarification please contact [email protected]


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QCI Empanelment Criteria for Third Party Administrators to service

RSBY


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INTRODUCTION This standard specifies requirements for Empanelment of Third Party Administrators (TPA) which: 1. need to demonstrate their ability to consistently provide services that meet the

requirements of the interested parties (for example Insurance companies, State Nodal Agencies, Ministry of Labour & Employment (MoLE), Hospitals, beneficiaries etc.) with a view to provide complete services related to effective implementation of RSBY scheme,

2. aims to enhance the interested party satisfaction through effective application

of an assessment process for continual improvement of the management system of the TPAs.

All requirements of this standard are generic in nature and are intended to be applicable to all Third Party Administrators. This standard is non-prescriptive in nature and the TPAs shall determine the extent of the prescriptions based on: 1. applicable statutory and regulatory requirements 2. applicable MoLE and Insurance companies requirements 3. IRDA policies, objectives and other requirements 4. resources required for effective implementation of the standard The scheme for Empanelment of Third Party Administrator (TPA) will help to assess the competence and credentials of TPAs. The assessment process will help the Insurance Companies in selecting and engaging a competent TPA through maintaining a Register of Empanelled TPAs. The Register will be maintained by Quality Council of India (QCI). The Assessment Process (in brief): Step 1: Document Review There will be a desk top review of documents pertaining to legal entity, background of the organization, manpower, experience, standard operating procedures, resources available etc. of the TPA that have applied for Empanelment. The review will be in line with QCI Empanelment criteria for Third Party Administrators to service RSBY. Any non-conformance(s) observed will be informed to the TPA. The TPA will take corrective actions and close the non-conformance(s) to the satisfaction of QCI assessor(s).


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Step 2: Office Assessment QCI will then conduct an office assessment of the TPA whose document review has been completed in Step 1. Generally the office assessment will be conducted at the central office. If found necessary, the regional office(s) may also be included in the office assessment. The office assessment will be essentially a verification of what has been stated in the document submitted by the concern TPA. This will include: a. Process of empanelment and de-empanelment/suspension of hospitals b. Customer complaint / Grievance handling process c. Claim settlement process d. Support services including helpline e. Processes that support the guidelines of RSBY schemes, liaison with Ministry

(MoLE), NIC, State Nodal Agencies, etc. f. Process of enrolment of beneficiaries on site, personalization and issuance of

Smart Cards by Smart Card Service Providers etc. g. Audit & Monitoring process during enrolment process to ensure quality delivery

of cards h. Data transfer to Server, maintenance of district servers, kiosks, etc. i. Data security process j. MIS report to all concerned stakeholders k. Deployment of competent personnel in various activities l. Fulfilment of all tasks laid down or agreed upon in the MOU/Contract between

the TPA and the Insurance Companies that they are working for. The above list is indicative and not exhaustive. All non-conformances observed during office assessment will be informed to the concerned TPA for taking necessary corrective actions. After the non-conformances are closed to the satisfaction of QCI assessor(s), a provisional empanelment will granted to the TPA. A certificate of provisional empanelment will be issued to the TPA. Step 3: Field Assessment Only provisionally empanelled TPA will be eligible for getting projects from insurance company. Once the TPA gets a project, it shall inform QCI about the same. QCI will then conduct a field verification and assessment of the operational processes of the TPA related to the project. Report of the same will be submitted to MoLE and the insurance company. Based on the report, QCI and MoLE jointly will take the decision on final empanelment of the TPA. Before the Final empanelment, the TPA has to submit, within3 months of receipt of first project work, a report or comments from Insurance Company (any two, if working for more than two) for whom the concerned TPA is providing service at the time of Empanelment. A certificate of final empanelment will be issued to the TPA. Note: The application for Final Empanelment will have to be submitted to QCI within 3 months of receipt of first project work from the Insurance Company alongwith the provisional certificate of empanelment.


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If the TPA is not able to submit the application for Final Empanelment within 3 months of receipt of first project work, then the TPA will be allowed to apply again for Provisional Empanelment only after a gap of 9 months, and they will not be allowed to take any new RSBY work during this period. In case the TPA fails to get final Empanelment even after applying for it due to an issue related to effective operation of the management system of the TPA or its performance, then the TPA will be allowed to apply again for Provisional Empanelment only after a gap of 9 months and they will not be allowed to take any new RSBY work during this period. All TPAs (New & Existing) will have to first get the Provisional Empanelment and then apply for the Final Empanelment in three months failing which they shall not be allowed to participate in RSBY process any further. The Ministry of Labour and Employment reserves the right to relax these conditions for reasons expressed in writing. Step 4: Empanelment The period of provisional empanelment will be for one year and final empanelment for three years. During the three years period the TPA will have to maintain all the requirements of the standard. After three years the TPA will have to submit an application for renewal of empanelment Step 5 Renewal of Empanelment The TPA will move an application for renewal of Empanelment three months before the completion of the final Empanelment, so that the renewal process is completed well in time. The renewal process will consist of provisional empanelment followed by final empanelment as mentioned in step 1 through step 4. Step 6 (if required): Cancellation / Suspension of Empanelment There will be a random sample evaluation or verification of any complaint against a TPA which shall be conducted by QCI, as and when advised by the MoLE during the three years period of final empanelment. If any gross violation of the requirements of the standard if found during such evaluation or verification, QCI in consultation with MoLE will suspend or cancel the empanelment of the TPA.


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Contents

Subject Page No. 01. Section – 1: Definitions ....................................................................................1 02. Section – 2: Requirement for Empanelment ....................................................2 03. Section – 3: Assessment of the Organization ..................................................7 04. Section – 4: Empanelment fees .....................................................................10 05. Section – 5: Certificate of Empanelment and Register .................................11 06. Section – 6: Appeals, Complaints & Disciplinary Proceedings.......................12 07. Section – 7: Code of Conduct ........................................................................13 08. Section 8: Fee Structure ….............................................................................15 Application for Empanelment of TPA ..................................................................16 Appendix I: Service Level Agreement for TPA empanelment under RSBY……..17 Appendix II: Outsourcing Procedure ...................................................................23 Application format for Outsourcing activities …....................................................24 Appendix III: Procedure for Handling of Complaints ……....................................25


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Section – 1: Definitions

1. Third Party Administrator (TPA): TPA means a Third Party Administrator who, for the time being, is licensed by Insurance Regulatory and Development Authority (IRDA), and is engaged, for a fee or remuneration, by whatever name called as may be specified in the agreement with an insurance company, for the provision of health services;.

2. MoLE: Ministry of Labour and Employment

3. QCI: Quality Council of India

4. NBQP: National Board for Quality Promotion

5. Interested Party: Person or group having interest in the functioning and performance of the TPAs including the recipient of the services.

6. Management Systems: System to establish policy and objectives and to achieve those objectives

7. Quality: Quality is the degree of excellence and distinguishing nature of attributes of the services. Quality is the on-going process of building and sustaining relationships and fulfilling the stated and implied needs. Quality is the customers’ perception of the value of the suppliers’ work output

8. Empanelment Manual: Document specifying the management system of the TPA based on the requirements of the Empanelment standard.

9. Process: Set of interrelated on interacting activities which transforms inputs into outputs

10. Process Approach: Any activity or set of activities that uses resources to transform inputs to outputs can be considered as a process.

For organizations to function effectively, they have to identify and manage numerous interrelated and interacting processes. Often, the output from one process will directly from the input into the next process. The systematic identification and management of the processes employed within an organization and particularly the interactions between such processes is referred to as the “process approach”.

11. Document: Document is information and its supporting medium. Example: procedure, drawing, report, standard, record

12. Record: Record is a document stating results achieved or providing

evidence of activities performed.


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Section – 2: Requirement for Empanelment

1. Minimum Criteria: a) All TPA must have valid licences from Insurance Regulatory and Development

Authority (IRDA). The same should be submitted alongwith the application for provisional empanelment.

b) Turnover: For any of the districts, only TPAs with turnover of Rs. 5 Crores each year for the previous 3 financial years will be eligible

c) Claims Experience: For any of the districts, only TPAs who have handled a minimum of 25,000 claims in any one of the previous 3 financial years will be eligible.

d) Average Claim Settlement Time: The average claim settlement time should be 30 days.

2. Capability of service: SLAs as defined The TPA shall have full capability to deliver services as per the agreed SLA with the insurance company. The Service Level Agreements for TPA empanelment is placed at Appendix I. The same shall be complied with. 3. Legal Status a) The Third Party Administrators (TPA) desiring QCI Empanelment shall be a legal

entity. They have to hold valid license issued by IRDA and registered under Registration of Society Act etc. Evidence for the same shall be provided to QCI along with the application.

b) The TPA should also submit the Income Tax Statements for the previous three years in support of its application.

c) The TPA should have valid Service Tax Registration and a valid IRDA License d) The TPA should submit all the documents as prescribed by the MoLE in the

RSBY Tender document. The applicant should refer to the latest tender documents on the MoLE website.

e) The TPA should not be blacklisted to work for any of the state or central government schemes.

4. Governance The management of the TPA shall establish and maintain a formal documented system and continually improve its effectiveness in accordance with the requirements of this standard, insurance agency and MoLE. This should include the followings:


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a. Management Responsibility: i. The TPA shall document its organizational structure, defining roles,

responsibilities and authorities of personnel involved in providing services. The TPA shall identify the top management of the organization. The overall responsibility of compliance to the requirements of the Empanelment standard lies with the top management.

ii. The top management personnel shall be in permanent employment with the TPA.

iii. The TPA should have a well-established documented Quality Management System for taking up RSBY projects.

iv. TPA should have valid ISO 9001:2008 certification at the time of execution of the project.

In brief the TPA shall determine:

1. the processes needed for establishing the operating system and its application throughout the project.

2. ensure the operation, control and continual improvement of these processes so that these are effective in realizing the objectives of the scheme.

3. ensure the availability of resources necessary to support the operation and control of these processes.

4. monitor, measure and analyse these processes 5. implement actions necessary to achieve planned results and continual

improvement of these processes.

b. TPA should not normally outsource part of its operations to another agency. In case it outsources any process that effects the requirements of this standard, it shall ensure proper control over such processes. This shall be documented and proper agreements for the activity shall be maintained. The outsourced agency shall have to adhere with similar requirements as applicable to TPA. QCI will review the same for its effectiveness. The procedure for outsourcing and format has been provided in Appendix II

c. Empanelment Co-ordinator: Management shall appoint a senior staff member

who will coordinate with QCI for empanelment process. This senior staff member shall also be responsible for monitoring and effective implementation of all empanelment requirements.

d. Empanelment Manual:

The TPA shall develop an Empanelment manual describing: i. Background of the TPA ii. Organization structure / legal status iii. Linkages / recognitions iv. Profile of the senior management v. Facilities vi. Scope / regions of the services vii. All Standard Operating Procedures (SOPs) adopted for servicing RSBY viii. Internal assessment procedure


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ix. Performance evaluation to ensure adherence to quality parameters and guidelines of MoLE

The manual shall describe all the processes and their interactions. It shall include or provide references to all documented procedures/procedure manual(s) and other applicable guidelines. 5. Control of Documents The TPA shall establish a documented procedure describing the arrangements for:

a) Preparing, reviewing and approving internal documents including their identification, revision and retention

b) Controlling external documents, including the relevant regulations that should be continuously kept updated.

c) Ensuring that relevant documents are available to all concerned within the organization and to the interested parties

6. Control of Records A documented procedure shall be established to define control of records providing for identification, indexing, storage, retention time and disposition. The records shall be regularly maintained. These records shall also be maintained in English for Empanelment purposes. The records may be in the form of any type of media such as hard copy or electronic media. These records shall be maintained for the full period of empanelment (i.e. till re-empanelment). These records shall be made available to the QCI as and when required. 7. Compliance to Statutory and Regulatory Requirements The TPA shall identify and comply with the applicable statutory and regulatory requirements specified by the MoLE, IRDA and other relevant bodies/government. The records for the above shall be maintained and made accessible for QCI Empanelment purposes and/or for assessment by the Insurance companies and/or for verification by the MOLE. 8. Human Resources TPA shall have adequate number of well qualified professionals (Staff, experts etc.), full time to support the scope of services being offered by it. Expertise may be classified as data collection, data verification, data analysis, printing, customer support, technical experts (for RSBY transaction), claim


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adjudicators, medical panel consisting of allopath doctors, provider & network executives (PNEs), analysts, investigators, etc. TPA shall provide adequate training to the staff to meet the Empanelment and other statutory & regulatory requirements. TPA shall maintain records of qualifications and experience, professional development activities of the staff 9. Infrastructure The TPA shall identify, provide and maintain the specific equipment and infrastructure to support RSBY projects. Regular maintenance of these should be carried out to ensure smooth operations. The TPA should have the capacity to provide services in the geographies it accepts contract for. The TPA shall define responsibilities and authorities for carrying out purchase, storage, safeguarding, installation, usage and maintenance activities for the projects. Infrastructure and equipments shall include as appropriate and as specified in functional and technical specifications for various activities and shall include but not be limited to the followings:

� Registered office � District Kiosks � Transaction system set up � Adequate computers � Adequate promotion facilities within the district � Proper MIS system � Certified software for enrolment / renewal & transactions � Central server of technical specifications to ensure seamless continuity � Business Continuity Plan

10. Confidentiality The TPA shall have adequate arrangements consistent with applicable laws to safeguard confidentiality of all information provided by the Ministry/ Insurance company/s / Hospitals collected through the field work or through any other sources related to the projects. These arrangements shall be extended to include organizations or individuals acting on its behalf and its representatives. Except as required, information about an organization shall not be disclosed to a third party without written consent of the organization. 11. Complaints and Appeals The TPA shall have documented procedures for handling and disposal of complaints within a reasonable time. The documented procedure shall include provision for required corrective and/or preventive actions to be taken as a result of any complaint or appeal. The procedures shall include the potential involvement of QCI in unresolved complaints or appeals.


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The TPA shall inform all stakeholders of the right to make a complaint or an appeal and shall provide written details of the process for doing so, on request. The TPA shall establish a documented procedure for complaint handling process. Various steps in the complaint handling process shall include but will not be limited to the following:

a) provide information regarding complaint handling process to all interested parties

b) acknowledgement of the complaint c) investigation for redressal of the complaint d) communication with the complainant for satisfactorily closure of the complaint

The TPA shall notify each complainant or appellant in writing of the result of the complaint or appeal and of the right to appeal against the result to QCI. The TPA shall maintain records of all complaints and appeals, of their resolution and the corrective & preventive actions taken. The procedure for handling complaints and appeals is mentioned in Appendix III. 12. Changes The TPA shall notify QCI of any changes that it makes in its organization structure, key manpower, infrastructure, Empanelment manual, documents, locations etc. QCI reserves the right to carry out assessment of changes before its approval. The expenses for this assessment shall be borne by the organization.


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Section – 3: Assessment of the Organization

1. Language All communications, documentation and records shall also be in English. 2. Assessment Process Step 1: Document Review There will be a desk top review of documents pertaining to legal entity, background of the organization, manpower, experience, standard operating procedures, resources available etc. of the TPA that have applied for Empanelment. The review will be in line with QCI Empanelment criteria for Third Party Administrators to service RSBY. Any non-conformance(s) observed will be informed to the TPA. The TPA will take corrective actions and close the non-conformance(s) to the satisfaction of QCI assessor(s). Step 2: Office Assessment QCI will then conduct an office assessment of the TPA whose document review has been completed in Step 1. Generally the office assessment will be conducted at the central office. If found necessary, the regional office(s) may also be included in the office assessment. The office assessment will be essentially a verification of what has been stated in the document submitted by the concern TPA. This will include: a. Process of empanelment and de-empanelment/suspension of hospitals b. Customer complaint / Grievance handling process c. Claim settlement process d. Support services including helpline e. Processes that support the guidelines of RSBY schemes, liaison with Ministry

(MoLE), NIC, State Nodal Agencies, etc. f. Process of enrolment of beneficiaries on site, personalization and issuance of

Smart Cards by Smart Card Service Providers etc. g. Audit & Monitoring process during enrolment process to ensure quality delivery

of cards h. Data transfer to Server, maintenance of district servers, kiosks, etc. i. Data security process j. MIS report to all concerned stakeholders k. Deployment of competent personnel in various activities l. Fulfilment of all tasks laid down or agreed upon in the MOU/Contract between

the TPA and the Insurance Companies that they are working for. The above list is indicative and not exhaustive. All non-conformances observed during office assessment will be informed to the concerned TPA for taking necessary corrective actions. After the non-conformances are closed to the satisfaction of QCI assessor(s), a provisional empanelment will granted to the TPA. A certificate of provisional empanelment will be issued to the TPA.


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Step 3: Field assessment Only provisionally empanelled TPA will be eligible for getting projects from insurance company. Once the TPA gets a project, it shall inform QCI about the same. QCI will then conduct a field verification and assessment of the operational processes of the TPA related to the project. Report of the same will be submitted to MoLE and the insurance company. Based on the report, QCI and MoLE jointly will take the decision on final empanelment of the TPA. Before the Final empanelment, the TPA has to submit, within months of receipt of first project work, a report or comments from Insurance Company (any two, if working for more than two) for whom the concerned TPA is providing service at the time of Empanelment. A certificate of final empanelment will be issued to the TPA by QCI. Note: The application for Final Empanelment will have to be submitted to QCI within 3 months of receipt of first project work from the Insurance Company alongwith the provisional certificate of empanelment. If the TPA is not able to submit the application for Final Empanelment within 3 months of receipt of first project work, then the TPA will be allowed to apply again for Provisional Empanelment only after a gap of 9 months, and they will not be allowed to take any new RSBY work during this period. In case the TPA fails to get final Empanelment even after applying for it due to an issue related to effective operation of the management system of the TPA or its performance, then the TPA will be allowed to apply again for Provisional Empanelment only after a gap of 9 months and they will not be allowed to take any new RSBY work during this period. All TPAs (New & Existing) will have to first get the Provisional Empanelment and then apply for the Final Empanelment in three months failing which they shall not be allowed to participate in RSBY process any further. The Ministry of Labour and Employment reserves the right to relax these conditions for reasons expressed in writing. Step 4: Empanelment The period of provisional empanelment will be for one year and final empanelment for three years. During the three years period the TPA will have to maintained all the requirements of the standard. After three years the TPA will have to submit an application for renewal of empanelment Step 5 Renewal of Empanelment The TPA will move an application for renewal of Empanelment three months before the completion of the final Empanelment, so that the renewal process is completed


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well in time. The renewal process will consist of provisional empanelment followed by final empanelment as mentioned in step 1 through step 4. Step 6 (if required): Cancellation / Suspension of Empanelment There will be a random sample evaluation or verification of any complaint against a TPA which shall be conducted by QCI, as and when advised by the MoLE during the three years period of final empanelment. If any gross violation of the requirements of the standard if found during such evaluation or verification, QCI in consultation with MoLE will suspend or cancel the empanelment of the TPA. Step 7: Suspension or Cancellation QCI may suspend or cancel an enrolment because of any of the following, but not limited to:

� non-compliance or violation of the MoLE and/or QCI requirements � providing insufficient or incorrect information to MoLE and/or QCI � improper use of QCI Empanelment mark � changes without MoLE and/or QCI approval � failure to report any major legal (mandatory compliance) changes � any other condition deemed appropriate by MoLE and/or QCI � non-payment of fees.


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Section – 4: Empanelment fees 1. Application and Provisional Empanelment Fee The application should be accompanied by the application fee, without which the application will not be processed. This fee covers the administrative costs for processing the application and carrying out necessary assessment for provisional empanelment which includes document assessment and office assessment. The fees will be as per the fee structure provided in Section 8. 2. Final Empanelment and Annual Fee Successful TPA organizations who will be granted final empanelment will be intimated for the remittance of annual fee. The applicants will be required to pay the annual fee every year. . The fees will be as per the fee structure provided in Section 8. 3. Re-application fees (for renewal) Re-assessment fees will be charged as per the fee structure provided in Section 8. Note: 1. In case of conduct of any on-site visits which will be required in connection with a

customer complaint, an assessment fees based on man-days spent will be charged as per the fee structure provided in Section 8. The travel, boarding and lodging arrangement will be made by the TPA.

All fees are to be paid vide a demand draft / at par cheque in favour of “Quality Council of India” payable at Delhi. All the fees are non-refundable.


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Section – 5: Certificate of Empanelment and Register

All successful TPA’s will be issued a certificate on meeting the Empanelment criteria and approval of the Empanelment Committee for Provisional and Final Empanelment. The Empanelment Committee will consist of representatives of QCI & MoLE. The certificate is the primary evidence of validity of empanelment and should be presented on commencement of a project and thereafter on demand as appropriate. The Register of Empanelled TPA’s will be hosted on the QCI web site/RSBY website. In case an empanelled TPA does not want to publish their details, an application may be sent to QCI for the same.


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Section – 6: Appeals, Complaints & Disciplinary Proceedings

QCI empanelled TPAs and applicants for Empanelment have the right to appeal against any decision taken by QCI. An appeal should be made in writing to the Board Chairman of National Board for Quality Promotion (NBQP), which is the implementing body of QCI for this scheme. He is authorized to either take a decision or appoint an Appeals Committee (out of the Board Members of NBQP or members of other QCI Boards) to resolve the issue. In case of non-acceptance of the decision of the Appeals Committee by the applicant, the appeal can be made to the Secretary General, QCI who will then appoint an arbitrator for the purpose. The arbitration shall be held in the city of Delhi and shall be in accordance with the Arbitration and Conciliation Act 1996. Similarly complaints made

� by an empanelled TPA against QCI � by an empanelled TPA against another empanelled TPA or � by an organization, certification body or a beneficiary against an empanelled

TPA. will be considered according to the procedures of QCI. QCI retains the right to undertake disciplinary proceedings against empanelled TPAs who are found to have acted contrary to the Code of Conduct. Options available include suspension of Empanelment and in instances of serious or sustained breach, withdrawal of Empanelment (as mentioned Step 6 and Step 7 of Section 3). QCI may suspend or cancel the QCI Empanelment based on one or more of the following but not limited to:

� non-compliance with the QCI code of conduct � providing insufficient or incorrect information to QCI � improper use of QCI Empanelment certificate or logo � failure to report any major complaint against the applicant � non-payment of fees � any other condition deemed appropriate by QCI

The Certificate would be cancelled and recalled by QCI. In case, there is any unresolved issue between QCI & TPA, the same shall be referred to Ministry of Labour & Employment (MoLE), who will examine the issue and take an appropriate decision. The same shall be informed to TPA.


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Section – 7: Code of Conduct

All TPA’s are obliged to rigorously observe the following Code of Conduct. Failure to do so may result in suspension or withdrawal of Empanelment. 1. An empanelled TPA shall as far as possible act in the best professional

manner without any fear or favour

2. In particular and without prejudice to the provisions contained in the above sections, it shall be duty of every TPA its chief executive / chief administrator officer or its employees or representatives to: (a) establish its or his or their identity to the public and the

insured/policyholder and that of the insurance company with which it has entered into an agreement.

(b) disclose its licence/Empanelment to the insured/policyholder/prospect. (c) disclose the details of the services it is authorised to render in respect

of health insurance products under an agreement with an insurance company;

(d) bring to the notice of the insurance company with whom it has an agreement, any adverse report or inconsistencies or any material fact that is relevant for the insurance company’s business;

(e) obtain all the requisite documents pertaining to the examination of an insurance claim arising out of insurance contract concluded by the insurance company with the insured/policyholder;

(f) render necessary assistance specified under the agreement and advice to policyholders or claimants or beneficiaries in complying with the requirements for settlement of claims with the insurance company;

(g) conduct itself /himself in a courteous and professional manner; (h) refrain from acting in a manner, which may influence directly or

indirectly insured/policyholder of a particular insurance company to shift the insurance portfolio from the existing insurance company to another insurance company;

(i) refrain from trading on information and the records of its business; (j) maintain the confidentiality of the data collected by it in the course of its

agreement; (k) refrain from resorting to advertisements of its business or the services

carried out by it on behalf of a particular insurance company, without the prior written approval by the insurance company;

(l) refrain from inducing an insured/policyholder to omit any material information, or submit wrong information;

(m) refrain from demanding or receiving a share of the proceeds or indemnity from the claimant under an insurance contract;

(n) follow the guidelines/directions that may be issued down by the Authority from time to time.


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3. The TPA shall not act in a manner detrimental to the reputation of any of the stakeholders including QCI and the client.

4. The TPA shall co-operate fully in any formal enquiry procedure of QCI as per appeals procedure

5. The TPA shall Comply with all regulatory and statutory requirements applicable to service provider organizations legal entity


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Section 8: Fee Structure

Sl. No Fee Details Fees (in Rs.) Current

Service Tax 1 Application and Provisional

Empanelment Fee 50,000 12.36%

2 Final Empanelment and Annual Fee (Annual fee to be paid every year)

40,000 12.36%

3 Re-application (for renewal) 3a Application and Provisional

Empanelment Fee 50,000 12.36%

3b Final Empanelment and Annual Fee (Annual fee to be paid every year)

40,000 12.36%

4 Onsite Assessment (Manday rate) (if required beyond provisional empanelment)

10,000 12.36%

General Information on Payment of Fee for TPA organization Empanelment 1. The fee is to be paid by a Demand Draft at Delhi or a At Par Cheque of Delhi in

favour of “Quality Council of India”. 2. Only the Application fee is to be sent along with the application. Applications

not accompanied by the application fee will not be considered. 3. The Annual fee is to be sent only after the receipt of confirmation from QCI.

Certificate will be sent after receipt of full fees and expenses. 4. Annual fee is to be paid in advance before the beginning of the next year of

certification. 5. Expenses on local travel, outstation travel, boarding and lodging etc. of

Assessors will be arranged by TPA in case of any need for conducting investigation/assessment connected with complaint handling.

6. Fees for man-days will be raised after assessment and has to be paid within 15-20 days of the receipt of the bill/invoice.

7. All fees are non-refundable Please submit your application to: Mr. Avik Mitra Advisor, National Board for Quality Promotion Quality Council of India 2nd Floor, Institution of Engineers Building Bahadur Shah Zafar Marg New Delhi - 110002 , India Tel + 91 11 2337 9321, 2337 0567 email: [email protected]; [email protected] For any query, the above may be contacted.


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Application for Empanelment of TPA 1. Name of the Applicant (Organization name) ..................................................................................................................... 2. Address...................................................................................................................... ....................................................................................................................................... Tel no ................................. (std code) (no.) Fax no. ................................. (std code) (no.) Email ........................................................ (The addresses of other branch offices should also be given. It can be attached as a separate sheet, with this application.) 3. The following documents are enclosed (two copies): a) Empanelment Manual for the service provider organization including:

I. All supporting procedure and administrative manuals, SOPs, instructions, etc.

II. All mandatory certificates like companies registration, IRDA licence, ITRs, service tax / sales tax, ISO 9001:2008 etc.

III. Employees and experts details with their resumes IV. All applicable and relevant self-declaration

b) Corporate Organization Brochure with a copy of legal identity c) Any other documents to demonstrate capability of service delivery. 4. Please find enclosed the Demand Draft / Cheque (At Par) no. ___________for Rs. _____________ dated __________ drawn on ____________ in favor of Quality Council of India, payable at New Delhi towards the application fee. We have carefully read all QCI guidelines for Empanelment of TPA. We confirm that the information in support of the application is correct to the best of our knowledge. We agree to abide by the code of conduct and terms & conditions of QCI as applicable from time to time. We authorize QCI to make any enquiry as deemed fit as part of the reviewing process. We understand that in case any information is found to be incorrect, it may result in rejection of this application and/or disqualification. We authorize QCI to utilize the information provided in this application for legal, research, training, sharing of best practices as may be deemed fit by QCI. If empanelled, we commit to notify QCI immediately of any changes in the status where information regarding such changes, if declared may affect the consideration for Empanelment of the organization. Authorized Signatory: Name .................................................................................................................... Designation.................................................................................................................... Signature ....................................................................... Date ....................................


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Appendix I

Service Level Agreement for TPA Empanelment under RSBY

1. Project Office and Provider Network Executive a. The TPA shall establish within 15 days from the date of Contract with the

Insurance Company, a Project Office for better coordination with the Government at State Capital. In addition, the TPA should establish district offices in all districts that it is servicing. The following should be the strength of such State and District Project Offices:

i. At State Level: 1. One State Coordinator 2. One Experienced Claim Manager and two claim analysts per 3

lakh enrolled beneficiaries ii. At District Level: One District Coordinator, One Kiosk Manager having

technical experience and One Qualified Medical Practitioner per 2 lakh enrolled beneficiaries

b. There should minimum 1 Provider Network Executive (PNE) for every 25 Hospitals empanelled on an average. However, based on the size of the district and number of hospitals empanelled this condition can be revised before signing of the MoU between Insurance Company and TPA.

c. The role of PNE would be i. Provide support in the empanelment process ii. To create awareness within empanelled hospitals on claims settlement

process, billing process, essential medical documents and other relevant guidelines for hassle free treatment of beneficiaries.

iii. To supervise, monitor the treatment of the patient during hospitalization iv. To audit via patient home visits post discharge regarding transportation

allowance and post discharge medication.

d. For every 10 such PNE, there should be minimum 1 Medical auditor who should be minimum MBBS.

e. These resources should be on full-time contract/employment of TPA.

2. Empanelment of Heath Care Service Providers or Hospitals

a. The TPA will be responsible for carrying out an empanelment process of health care service providers (following the guidelines laid down) to provide the agreed Benefits under the scheme

b. The TPA will have to empanel health care service providers before the enrolment starts and ensure that the list of empanelled hospitals be provided to each enrolled family at the time of enrolment

c. All such elligible hospitals as were empanelled in the previous round of RSBY policy will have to be empanelled again for the new round, except for the hospitals which were either de-empanelled during previous year or


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are under suspension or the cases have been referred to District Grievance Redressal Committee (DGRC) or National Grievance Redressal Committee (NGRC) for judgement. In case the TPA wants to remove any earlier empanelled hospital then it has to follow process of de-empanelment.

d. The TPA with approval of Insurance Company can de-list/de-empanel/suspend a Network Hospital in their district from the RSBY network (following the guidelines for de-empanelment) if, it is found that guidelines of the Scheme are not followed by them and services offered are not satisfactory as per laid down standards

e. Suspension/ TID Blocking of Hospitals should not exceed 30 days and

decision on de-empanelment/ re-empanelment should be taken within 30 days. Prescribed protocol/ process on de-empanelment issued by MoLE should be strictly adhered to.

f. The transaction software to be installed in the hospitals shall be as per the guidelines issued by MoLE including the transaction software and its subsequent variants.

3. Enrolment Related Activities under RSBY:

a. The TPA will arrange its own (if it has been certified by QCI for RSBY) or utilise the services of a QCI accredited smart card provider for supply of smart cards in conformity to the specifications as per the guidelines of the scheme

b. Enrolment of beneficiaries under RSBY is carried out by Smart Card Service Providers who are separately accredited by QCI, but the primary responsibility of adherence of guidelines laid down under RSBY for enrolment will be of TPA. Responsibility of actions or performance of engaged SCSPs lies with the TPA who has engaged them

c. TPA shall ensure deployment of number of enrolment kits and trained enrolment team in the field as per the standard guidelines laid down under RSBY or as per specific guidelines of tender document published by respective state Govt. laid down under RSBY irrespective of SCSP being its own or outsourced.

d. The TPA shall ensure proper IEC activities, as agreed with the Insurance Company and SNA, before enrolment camps are set up

e. The TPA shall ensure proper audit & monitoring process during enrolment process to ensure quality delivery of cards

4. Setting up of Call Centre:

a. TPA shall arrange to set up a toll free help line/ call centre per state to address the queries/ problems/ requests of the Government and beneficiary


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families, Insurance Company as well as all other users of the scheme. The call centre shall be operational 24 X 7 throughout the policy period.

b. The data of the calls to call centre shall be shared with the SNA/Insurance Company on a monthly basis.

c. There should be a functional Customer complaint/Grievance handling process in place

5. Setting up of District Kiosk: a. TPA will set up and operationalize district kiosk and district server according

to the guidelines provided by MoLE, within 15 days of signing of the contract with the Insurer. District server will store all the enrollment and transaction data of a particular district. The District kiosk shall be operational throughout the policy period including extension and auto-renewal periods.

6. Settlement of claims a. The TPA shall ensure that all the Beneficiaries are provided with adequate

facilities so that they do not have to pay any deposits at the commencement of the treatment or at the end of treatment to the extent as the Services are covered under RSBY so that the treatment is purely cashless.

b. The TPA shall ensure that all claims received from the Hospitals in their own network as well from Hospitals outside their network for their own beneficiaries have to be settled within a month of the receipt of claims.

c. The claim is believed to be settled when the money has actually been transferred. So, the money transfer to the hospital has to happen within this one month. There shall be no relaxation of this requirement of 1 month time owing to any holiday or whichever account. Even rejection on any account, be it before investigation or post investigation, has to be communicated to the concerned hospital within this 1 month time frame.

d. A 24 hour Pre-authorization service for procedures not listed in the standard RSBY lists shall be established by the TPA. Separate Manpower may be deployed at State Level for pre-authorization process to avoid inconvenience to the beneficiaries.

e. All manual claims have to be digitized by the TPA within 7 days of receipt of the claims. This responsibility of digitization shall be only of the TPA and not the hospital.

f. Business Continuity Plan for interruption of services due to technological glitches shall be put in place as per the scheme guidelines.

g. In case the claim settlement exceeds 30 days, such cases should be brought to the notice of the State Nodal Agency/Insurance Company by the TPA along with proper explanation.


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h. In case of rejections, the reasons of rejection (claim wise) have to be communicated to the concerned hospitals along with the name and contact details (e-mail id and telephone number wherever available as these details will also be available on the website) of the District level Conveners of the Grievance Committee. The Hospitals have to be informed that in case they are aggrieved with the decision of the Insurance Company, they can appeal against the decision.

i. The Hospitals will have a right to appeal against the decision of the TPA within 30 days of the intimation.

j. Inter Insurance Company claims within a State originating from own network of hospitals of the TPA will be shared amongst all Insurance Companies in a Meeting convened at the SNA every Month (preferably in the first week). These claims will have to be settled within the next 30 days from such sharing and thus by the next Meeting all claims will be settled.

k. Similarly Inter Insurance Company Claims outside the State will be shared amongst all Insurance Companies in the NaNO Meetings convened at the MoLE every Month. These claims should be settled further within the next 30 days from such sharing and thus by the next NaNO Meeting all claims will be settled.

7. IEC and BCC activities

a. The TPA in consultation with Insurance Company/State Nodal Agency will

prepare and implement a communication strategy for launching/ implementing the RSBY within 15 days of signing of the contract with the Insurance Company. The objective of these interventions will be to inform the beneficiaries regarding enrolment and benefits of the scheme.

b. Primary responsibility of adherence of guidelines laid down under RSBY for IEC/BCC will be of TPAs. Responsibility of actions or performance of engaged vendors shall lie with the TPA who has engaged them

8. Capacity Building Interventions

a. TPA shall design training/ workshop / orientation programme for Health Care

Providers, Members of the Hospital Management Societies, District Programme Managers, Doctors, GP members, Intermediary, Field Agents etc. and implement the same with support of Nodal Agency/ other agencies.

b. Atleast the following trainings shall be implemented by the TPA: i. Enrollment Team Training – To be done for each enrollment team

during the enrollment period. Enrolment team comprise of ASHA, ANM, FKOs, DKMA or other functionaries of State Govt. as well as Field Enrolment teams of engaged SCSP and IEC Teams

ii. Hospital Training – At least once a year for all the empanelled hospital in each district separately for Public and Private providers. One such training shall be at the inception of the policy cover.


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iii. State and District Officers of the Insurance Company – At least once a year for these officers for each of the district

c. The standardized training packages as provided by MoLE shall be utilized or

shall be jointly developed by the Nodal Agency and the Insurance Company.

d. Workshop schedule as suggested by the guidelines of the scheme shall be followed

e. State Coordinators/ District Coordinators shall attend meetings convened by Insurance Company/ District Authority/ SNA on weekly/ monthly or on requirement basis.

9. Fraud Mitigation Mechanism

a. The TPA shall conduct regular/periodical data analysis and trend watch on utilization of Hospital process

b. The trigger list as suggested by MoLE shall be used to throw suspicious claims though a system enabled process. Additions to the list may be made as deemed feasible

c. A Physical verification and Investigation of at least 10% claim picked on predefined alerts and trend watch has to be done by the TPA

d. Regular surprise checks and Audit shall be done by the TPA on the empanelled Hospitals and the treated beneficiaries to check frauds and induce fraud avoidance behaviour amongst providers

e. All such findings and analysis shall be shared by the TPA on periodical basis with the concerned Insurance Company

10. Data Submission and MIS reports

a. The TPA shall follow guidelines of enrolment and transactions data submission to the Insurance Company/SNA/MoLE as laid down by MoLE.

b. The TPA will provide exclusive synchronization with its system/server to Insurance Company/ SNA to review enrolment and claims related data.

c. The pre-enrollment data, Post Enrollment Data and transaction data along with other such documents in physical or electronic format shall be handled with utmost care and shall be classified, and stored for at least 5 years which may be used for dissemination to Government, Regulators, Concerned Insurance Company and other authorized users as and when needed. Since such data contains classified information about the beneficiaries and Insurance Company, the utmost care and privacy of data should be maintained.


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d. The TPA shall be responsible for preparation, maintenance and

management of MIS reports pertaining to the Policy in the prescribed format or the formats as required by Insurance Company/State Nodal Agency. These reports will be circulated on a weekly basis / monthly/ or on requirement to the Insurer and to the Government.

11. Service Period

a. The TPA shall provide the services to the policy until it expires including

extension and auto-renewal policy periods.

b. The rate of contract between TPA and Insurance Company for providing the services shall be valid for the entire policy period including auto-renewal period without change.

12. Any other activity as outlined in the Contract with the Insurance Company or in the Tender document


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Appendix II:

Outsourcing Procedure The TPA shall have a process in which it describes the conditions under which outsourcing (which is subcontracting to another organization to provide part of its activities on behalf of the TPA) may take place. The TPA shall have a legally enforceable agreement covering the arrangements, including confidentiality and conflict of interests, with each body or a person that provides outsourced services. This can include outsourcing to Smart Card Service Providers/Manpower agencies/any other organization, use of administrative and technical experts under contract. The TPA shall require the outsourced external agency or external administrative and technical experts to have a written agreement by which they commit themselves to comply with applicable policies and procedures as defined by the TPA in line with the requirements of the IRDA, QCI and MoLE. The agreement shall address aspects relating to confidentiality and to independence from commercial and other interests, and shall require the external staff to notify the TPA of any existing or prior association with any person/organization they may be assigned to work with. The TPA shall maintain up-to-date personnel records, including relevant qualifications of all outsourced experts. The TPA:

� shall take responsibility for all activities outsourced to another body, � shall ensure that the outsourced body that provides services, and the

individuals that it uses, conform to requirements of the TPA and also to the applicable requirements of IRDA, QCI and MoLE including competence, impartiality and confidentiality, and

� shall ensure that the outsourced body that provides services, and the individuals that it uses, is not involved, either directly or through any other employer, with an organization, in such a way that impartiality could be compromised.

The TPA shall have documented procedures for the qualification and monitoring of all bodies that provide outsourced services used for these activities, and shall ensure that records of the competence of administrative and technical experts are maintained.


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Application format for Outsourcing activities Particulars Remarks 1 Name of Firm 2 Registered office address

Telephone number Fax number Email

3 Organization Structure with details of branch offices and administrative and technical staff employed (full time and empanelled for the purpose)

4 Details of the Contact Person (name, designation, address) Telephone number Fax number E-mail

5 Legal status and Certificate of Incorporation 6 Valid IRDA license, ISO Certification, Service Tax

Registration, Sales Tax Registration (Please enclose copies of Documents)

7 Annual turnover details (Kindly attach details for last three Years audited Balance Sheet)

8 Valid SCOSTA certificate from NIC if planning to do on field enrollment directly(may be of the relevant Card provider in which case undertaking should be given that only Valid SCOSTA cards would be used)

9 ISO 9001: 2008 certified 10 Bank Guarantee Details 11 Undertaking that company is not blacklisted by any

State /Central Government

12 Signing of the confidentiality clause with the TPA Remarks


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Appendix III : Procedure for Handling of Complaints

TPA is open to receiving complaints from any sources including any stakeholders/beneficiaries. The complaints can be against the quality of service provided by them. The complaint can also be against personnel involved in issuance of Smart Card, adjudication of claims, empanelment of providers, investigation etc. The complaint must be made in writing with complete details of complainant (name, address, organization etc.). If the complaint has no details of the complainant or the description is not adequate, the Insurance Company/MoLE will reserve the right of dealing with the complaint as deemed fit. Insurance Company/MoLE can investigate the reports appearing in media, if relevant. Once the complaint is received at TPA, the authorized personnel (herein to be referred as the Complaints and Appeals Officer) shall mark the complaint to the Insurance Company/MoLE immediately on its receipt. The same shall be acknowledged with the assurance of thorough investigation. The Complaints and Appeals officer shall maintain a record for the complaints that are received by TPA. The important dates viz. date of receipt of complaint, date of acknowledgement and date of final closure shall be recorded in Complaint File. Initial scrutiny of the complaint is done by the Complaints and Appeals officer. This is to determine that the complaint falls within the ambit of TPA activities and whether the complaint is valid. If it is found that the complaint does not fall within the ambit of TPA, the complaint is considered closed and the complainant and Insurance Company is informed accordingly. If the complaint falls within the ambit of TPA and the initial information provided in the complaint is sufficient the complaint is investigated further. 1 Investigation of Complaints 1.1 Procedure for dealing with complaints by TPA

� On receipt of complaint against TPA, Complaints and Appeals officer shall discuss and seek clarification with the concerned officer within 15 days.

� If the response to the complaint is not found satisfactory, the Complaints and Appeal Officer would depute an expert to investigate the matter.

� The expert would place the findings of the investigation with his/ her recommendation on action to be taken against the concerned officer.

� The outcome will be communicated to the Complainant and the Insurance company.

� In case the Complainant is not satisfied with the outcome, the complaint will be referred to the Insurance company for resolution.


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1.2 Procedure for dealing with complaints against TPA by Insurance Company

� The Insurance Company may file a complaint based on the Newspaper reports or based on any other evidence collected by it during the course of its operations with the TPA.

� On receipt of complaint against TPA, Insurance company will seek clarification from TPA for the same.

� In case the Insurance Company is not satisfied with the reply, the Complaints and Appeals officer of the Insurance Company shall investigate the complaint and if it is necessary, an independent expert can be sent to the TPA.

� If the complaint is found valid, the TPA would be warned for his action. If the complaint is of serious nature, the TPA may also be deleted from the empanelled database of TPA of the IRDA/QCI/MoLE.

� The Complainant shall be informed about the action taken by the Insurance Body.

� The Ministry and QCI shall be kept informed of the above actions.

PROCEDURE FOR HANDLING OF APPEALS 1.3 Receipt of Appeals

� Insurance Company shall receive appeals from TPA against adverse decisions taken by the Insurance Company.

� Complaints and Appeals officer of Insurance Company shall acknowledge the receipt of appeals from the TPA. A record pertaining to all appeals including important details like date of receipt, name and address of the TPA, details of appeals and outcome of appeals shall be maintained in the ‘Appeals File’.

� The appeals shall be examined by Appeals Committee of the Insurance Company and it will make recommendations.

1.4 Deliberation of Appeals Committee and Recommendations 1.4.1 Appeals Committee takes up the appeal for consideration. Representative

from Insurance Company involved in the decision appealed against, may provide technical inputs. He/ she shall not be involved in the formulation of recommendations of the Appeals Committee.

1.4.2 After examination of the appeal, the Committee shall seek clarification from all

appropriate sources. The Committee, if found necessary, can depute an expert to investigate the matter.

1.4.3 The Appeals Committee may recommend a fresh assessment/review of TPA.

On the basis of fresh assessment, the relevant Empanelment committee shall give an independent view on the status of TPA quality management system and technical competence as well as the subject matter of the appeal.


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1.4.4 Based on the data gathered through any of the above means, the Appeals Committee shall form its recommendations. The detailed report by the Committee shall be submitted to the Ministry and QCI within a reasonable time for his decision.

1.5 Financing the Complaint and Appeal Process: If the resolution of complaint/

appeal is done without undertaking any travel or additional assessment, no financing will be needed for such resolutions. If the resolution calls for undertaking travel and assessment, the cost will be borne by the TPA/Insurance Company.

1.6 Records Complaints and Appeals officer from TPA and Insurance Body shall maintain Complaints file and Appeals file. The file has the following:

� unique registration number given to each complaint/ appeal � date of receipt of complaint/ appeal � name & address of the complainant/ appellant � date of acknowledging of the compliant/ appeal � details of action/ investigation � date of closure

The complaints & appeals file is maintained by Complaints and Appeals officer. All correspondence in respect to complaints/ appeals, investigation reports and decisions are filed in order.

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