All the claims processing shall be carried out electronically through the Dr.YSR Aarogyasri portal. Payments to all the NWHs shall be made through electronic clearance facility of the Dr.YSR Aarogyasri.
The claim intimation, collection of claim documents, scrutiny of claim documents shall all be done through the Dr.YSR Aarogyasri portal.
The Dr.YSR Aarogyasri shall follow the claim control number generated by the Dr.YSR Aarogyasri portal for further reference.
The grant of pre-authorization by the Dr.YSR Aarogyasri shall constitute the prima-facie evidence for any claim. Admission of a claim rests solely on three conditions viz., grant of pre-authorization for the listed therapy including changes in listed therapy necessitated by the exigencies of the case during management and intimated to the Dr.YSR Aarogyasri within the shortest possible time, claim amount being limited to pre-auth amount, and evidence of performance of a listed therapy. An intra operative photograph or a scar photo or a case sheet is sufficient evidence for settlement of a claim. Decision of Dr.YSR Aarogyasri on any claim settlement shall be final.
As soon as the claim lands with the Dr.YSR Aarogyasri, the following verification alone needs to be performed.
- Verification of identity of the patient
- Verification whether the claim amount is limited to pre-authorized amount.
- Verification of case management as per the pre-authorization.
- Verification of evidence of treatment.
- Upon the performance of a listed therapy the NWH initiates a claim. The claim will consist of the identity of patient, pre-authorized listed therapy and pre-authorized amount with enhancement if any, and evidence of performance of listed therapy in the form of an intra-operative photograph or a scar photograph linking the identity of the patient with the therapy or case sheet.
- The Dr.YSR Aarogyasri upon receipt of the claim shall verify the identity, listed therapy, amount of the claim and evidence.
- Upon confirmation by means of a photograph or a medical record such as a case sheet that the listed therapy has been performed, the claim shall be settled and payment made to the NWH within 7 days.
- If the Dr.YSR Aarogyasri is unable to establish the performance of the listed therapy in the first round of claims scrutiny, the Dr.YSR Aarogyasri will be allowed to return the claim requesting for specific information from the NWH. Any such request or clarification by the Dr.YSR Aarogyasri shall not result in additional investigations or diagnostic reports to be performed afresh by the NWH.
- The Dr.YSR Aarogyasri shall be allowed to send a claim back to NWH for any clarifications only once before final settlement. All remarks relating to the claim ranging from non-medical to medical queries shall be consolidated before being sent back to the NWH.
- An additional time of 7 days will be allowed in case of claim is sent back to the NWH for clarification.
- The Dr.YSR Aarogyasri issues guidelines from time to time for pre-authorization and claims settlement which shall be followed scrupulously.
Claim Reduction and Repudiation
- Reduction: The settlement of a claim shall be to the full extent of the package price or pre-authorization amount whichever is lower. No dis-allowance can be made to a claim unless approved by the scheme technical committee of the Dr.YSR Aarogyasri.
- Repudiation: The Dr.YSR Aarogyasri may repudiate a claim for reason of not being covered by the policy under intimation to Scheme Technical Committee.
- An appeal lies to the Appellate Committee either against repudiation (rejection) as defined in Term 12.4 (ii) or reduction of claim as defined in Term 12.4 (i) under Term 12.5 within 3 months from date of repudiation advice or settlement of claim.
- The NWH shall have a right of appeal to approach the appellate committee consisting of the Chief Medical Auditor, a member selected by the Dr.YSR Aarogyasri from out of the panel of specialist doctors not related to the NWH and provided by the NWH, under the chairmanship of CEO. The quorum for this committee shall be three members present and voting, and majority opinion shall prevail. The decision of this appellate committee shall be final and binding on the Dr.YSR Aarogyasri and the NWH. This right of appeal shall be mentioned by the Dr.YSR Aarogyasri in every repudiation advice given as per Term 12.4.
- The Appellate Committee shall have the power to re-open a claim if properly supported by documentary evidence.
- The Appellate Committee shall have the right to reopen a settled claim and direct the Dr.YSR Aarogyasri to settle for an appropriate amount within a period of 3 months of settlement of the claim. The Dr.YSR Aarogyasri further agrees to provide access to the Appellate Committee their records for this purpose. All the claims settled by the Dr.YSR Aarogyasri to the network hospitals based on the bills received from the hospitals in conformity with the package price arrived at and also based on the pre-authorization given by the Dr.YSR Aarogyasri shall be reckoned as final and not subject to any reopening by any authority except Appellate Committee.
Claim Float and Bank Account
The Dr.YSR Aarogyasri will have a separate bank account to pay the NWH making a valid claim and all payments will be electronically cleared on the Dr.YSR Aarogyasri portal. Detailed reports will be made available online on a real-time basis.