Written by Standards and Benchmarks for the Hospitals in the Provider Network – IRDAI Notification on Hospitals for Insurers and TPAs
IRDAI has released a notification on 20th July, 2022 with an advisory to Non Life Insurers and TPAs about on boarding Hospitals under Cashless Empanelment Scheme and the changes to the Standards and Benchmarks Criteria laid down for the Hospitals earlier.
This advisory calls for Insurers choosing their own empanelment criteria for Hospitals and updating the same in their respective websites for the benefit of industry and stakeholders , as updated from time to time.
IRDAI has suggested to Board of Insurers to consider the Minimum Resources and Infrastructure conditions that prevail in wide range of Hospitals across the country while empanelling the Hospitals. The insurers are now empowered to empanel the network providers that meet the standards and benchmarks criteria as specified by their respective boards. The board approved empanelment criteria shall be published in the website of the insurers from time to time.
This advisory enables Insurers to extend the scope of coverage of cashless scheme to wide range of healthcare facilities in the country. While empaneling network providers for cashless facility, insurers are also advised to focus on the delivery of quality healthcare services.
These instructions come into force with immediate effect.
Download the IRDAI Advisory here
Source – https://www.irdai.gov.in/ADMINCMS/cms/Circulars_Layout.aspx?page=PageNo4762
To understand the requirement of IRDAI advisory on Standards and Benchmarks for the Hospitals, please download the earlier advisories as shared below :
Master circular (ref. IRDAI/HLT/REG/CIR/193/07/2020 dated 22nd July, 2020). . Download here to read more about the Master Circular
Please read Chapter IV of the Master Circular shared above to understand the norms laid down under Standards and benchmarks for hospitals in the provider network. Reading the Master Circular of 2020 helps healthcare establishments understand the specification laid down earlier for Cashless Schemes and Reimbursement Claims .
What does the Chapter IV of the Master Circular says ?
Insurers and TPAs, wherever applicable, shall ensure that Network Providers or Hospitals which meet with the definition of ‘Hospital’ provided in Chapter I of these Guidelines shall meet with the following minimum requirements:
a. All the Network Providers as at 27th July, 2018 shall, comply with the following by 26th July, 2020:
i. Register with Registry of Hospitals in the Network of lnsurers (ROHlNl) maintained by lnsurance lnformation Bureau (llB). [https://rohini.iib.gov.in].
ii. Obtain either “NABH Entry Level Certification” (or higher level of certificate) issued by National Accreditation Board for Hospitals and Healthcare Providers (NABH) or State Level Certificate (or higher level of certificate) under National Quality Assurance Standards (NOAS), issued by National Health Systems Resources Centre (NHSRC).
iii. In respect of all the new entrants (after 27th July 2018), only those hospitals that are compliant with the requirements specified at Clause (a) (i) above shall be enlisted as network providers. These network providers shall comply with the requirements stipulated at Clause (a) (ii) above within one year from the date of enlisting as a Network Provider and this shall be one of the conditions of Health Services Agreement.
iv. lnsurers and TPAs may also endeavour to get hospitals (other than Network Providers) involved in reimbursement claims to meet the requirements stipulated at Clause (a) (i) and (a) (ii) above.
b. AYUSH Hospitals and AYUSH Day Care Centres which meet the definition of AYUSH Hospitals and AYUSH Day Care Centres defined under Chapter I of these Guidelines shall also obtain:
(i) Either “NABH Entry Level Certification” (or higher level of certificate) issued by National Accreditation Board for Hospitals and Healthcare Providers (NABH) or State Level Certificate (or higher level of certificate) under National Quality Assurance Standards (NQAS), issued by National Health Systems Resources Centre (NHSRC).
(ii) All the existing AYUSH Hospitals and AYUSH Day Care Centres shall comply with the requirements referred above within a period of twelve months from 26th November, 2019, if the said certificate
is not already obtained.
(Note: The above instructions at a and b are subject to the directions of the Hon’ble Delhi High Court in its order dated 29th May 2019 / 31st May 2019, in respect of W.P(C) 6237 of 2019, which needs to be complied with till further orders of the Hon’ble Court.)
c. The providers shall comply with the minimum standard clauses in the agreement amongst Insurers, Network Providers and TPAs applicable to providers listed in Annexure 22 of Master Circular Ref.
IRDAI/TPA/REG/CIR/130/06/2020 dated 03.06.2020 and as amended from time to time.
d. Providers shall be bound by the Provider Services—Cashless facility admission procedure laid down in Schedule A of Master Circular Ref. IRDAI/TPA/REG/CIR/130/06/2020 dated 03.06.2020 and as amended from time to time.
e. Providers shall be bound by the process of de-empanelment of providers laid down in Schedule B of Master Circular Ref. IRDAI/TPA/REG/CIR/130/06/2020 dated 03.06.2020 as amended from time to time.
f. Providers shall follow the standard discharge summary format prescribed under Schedule C of Master Circular Ref. IRDAI/TPA/REG/CIR/130/06/2020 dated 03.06.2020 and as amended from time to time.
g. Providers shall follow the standard format for provider bills prescribed under Schedule D of Master Circular Ref. IRDAI/TPA/REG/CIR/130/06/2020 dated 03.06.2020 and as amended from time to time.
h. Providers shall ensure that the standard claim form and form for request for cashless hospitalization for Health Insurance Policy provided for under Annexure 30 of Master Circular Ref.IRDAI/TPA/REG/CIR/130/06/2020 dated 03.06.2020 and as amended from time to time are adhered to in respect of all claims.