Rashtriya Swasthya Bima Yojna: 2010 Guidebook - Health Systems ...

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RSBY Utilisation of Benefits Process FlowEntitlement Holders /BeneficiariesBeneficiary visits networkhospital with smart cardEmpanelled HospitalHospital verifies: Smart card Available benefit balanceOn discharge: Hospital bills TPA throughSmart cardThird Party AdministratorTPA pays claims to hospitalProvides Claims Fund to TPASubmits ClaimsPayment Status andSeeks Claims FundGovernment of DelhiDepartment of Labour& Mission ConvergenceBenefit utilisation dataInsurance CompanyPage 182010 RSBY Guidebook
Glossary of Terms• Beneficiary/Insured – a person who is covered to receive benefits under ahealth insurance policy• Benefit limit/Amount – amount payable by an insurer to a beneficiaryunder a health insurance policy• Benefit Limits – the maximum amount of benefits payable under a healthinsurance policy• Cashless Treatment/Service – means that the patient will not have tospend any amount (subject to the available limit of coverage) for takingtreatment or hospitalisation. The expenses incurred on the hospitalisationshall be claimed by the hospital from the insurance company• Congenital external disease – is an abnormality of the structure of a bodypart by birth• Coverage – benefits provided by a health insurance policy for which abeneficiary is covered• Covered Charges – expenses eligible for payment for medical care orsupplies, when incurred by a beneficiary under the health insurancepolicy• Covered Person – any beneficiary eligible for benefits under a healthinsurance policy• Day care Surgery – procedures that require surgical intervention that canbe performed on a beneficiary on a out-patient care basis• District Kiosk – facilitation centres established by the third partyadministrator (TPA) to assist covered beneficiaries after smart card hasbeen issued. Assistance provided by a district kiosk pertains tomodification in the existing cards, splitting of cards and issue of new cardsin lieu of lost or damaged cards• Eligibility – provisions of the health insurance policy, upon satisfying ofwhich, beneficiaries become eligible to avail benefits under the policy• Eligibility Date – the date from which the beneficiaries under a healthinsurance policy stand covered for availing the benefits covered under it2010 RSBY Guidebook Page 19
Page 1 and 2: Rashtriya SwasthyaBima Yojna2010 Gu
Page 3 and 4: Table of ContentsThe Concept of Hea
Page 5 and 6: The Concept of Health InsuranceHeal
Page 7 and 8: Rashtriya Swasthya Bima YojnaHouseh
Page 9 and 10: RSBY COVERAGEWho is eligible?• BP
Page 11 and 12: EXPENSES NOT COVERED UNDER RSBY•
Page 13 and 14: RSBY ProcessesENROLLMENTEnrollment
Page 15 and 16: USE OF SMART CARD• The smart card
Page 17 and 18: ROLE OF TPA’S DISTRICT KIOSKSDist
Page 19 and 20: UTILISATION OF BENEFITSHospitalisat
Page 21: WHO TO CALL WHEN THERE IS A QUESTIO
Page 25 and 26: • Out-patient Diagnostic - labora
Page 27 and 28: Annex I: Indicative List of Package
Page 29 and 30: Annex II: Indicative List of Day Ca
Page 31 and 32: Annex III: List of Empanelled Hospi
Page 33 and 34: 89Sai Nursing Home &Charitable Disp
Page 35 and 36: 9 Sant HospitalMain Burari Road, Sa
Page 37 and 38: List of Empanelled Hospitals - Sout
Page 39 and 40: List of Empanelled Hospitals - West
Page 41 and 42: 16Rao Raghubir Hospital &Maternity
Page 43 and 44: Annex IV: Important Contact Informa
Page 45 and 46: Annex V: List & Contact information
Page 47 and 48: Annex VI: References1. Fundamentals
Page 49: Annex VII: Photo Credits1. Page 1 -

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