Lok Sabha Question No. 905 (UNSTARRED), answered on 2025-12-04
Subject: Cashless Treatment For Road Accident Victims
Ministry: ROAD TRANSPORT AND HIGHWAYS
Asked by: Shri Daggumalla Prasada Rao, Shri G M Harish Balayogi

## GOVERNMENT OF INDIA MINISTRY OF ROAD TRANSPORT AND HIGHWAYS

## LOK SABHA UNSTARRED QUESTION NO. 905 ANSWERED ON 04.12.2025

## CASHLESS TREATMENT FOR ROAD ACCIDENT VICTIMS

905. Shri Daggumalla Prasada Rao: Shri G M Harish Balayogi:

Will the Minister of ROAD TRANSPORT AND HIGHWAYS

सड़क परिवहन औि िाजमार्ग मंत्री

be pleased to state:

- (a)  whether  the  scheme  for  providing  cashless  treatment  to  road  accident victims has been implemented across all States and Union Territories, if so, the details thereof; (b)  whether  all  State  Governments  have  issued  the  necessary  orders  for implementation and the criteria prescribed for the empanelment of hospitals, if so, the details thereof; (c)  the  number and the details of hospitals empanelled under this scheme, State-wise; (d) the number of beneficiaries treated since the inception of the scheme and the details of funds disbursed from the Motor Vehicle Accident Fund, Statewise; (e) the number and total value of claims raised by empanelled hospitals for cashless treatment and the extent of payments disbursed to them; and (f) whether insurance companies are involved in payment disbursal and if so, the details thereof including their role, the claims raised through them and
- the status of disbursal?

## ANSWER

## THE MINISTER OF ROAD TRANSPORT AND HIGHWAYS (SHRI NITIN JAIRAM GADKARI)

- (a) In accordance with the legal mandate under Section 162 of the Motor Vehicles  Act,  1988,  Cashless  Treatment  for  Road  Accident  Victims Scheme,  2025  has  been  notified  vide  S.O.  2015(E)  dated  05.05.2025. Furthermore,  comprehensive  guidelines  detailing  the  process  flow,  roles and responsibilities of  various  stakeholders,  and the  Standard  Operating Procedures (SOPs) for its implementation have been issued vide S.O. 2489 (E) dated 04.06.2025.

The victims are entitled to cashless treatment upto ₹1.5 lakh per victim per  accident  for  maximum  period  of  7  days  from  date  of  accident  and applicable  to  all  road  accidents  caused  by  use  of  motor  vehicle  on  any category of road.

- (b) -Hospital Empanelment Guidelines for the Cashless Treatment of Road Accident Victims‖ has been issued by National Health Authority (NHA) and attached as Annexure A. The scheme has been formulated under the legal mandate of the Motor Vehicle Act, 1988.
- (c)  As  per  the  Scheme  guidelines  notified  vide  S.O.  2489  (E)  dated  04 th June, 2025, designated hospitals under the Scheme-including empanelled hospitals under the Ayushman Bharat Pradhan Mantri Jan Arogya  Yojana (AB PM-JAY) that comply with the guidelines issued by the National Health Authority (NHA) for this scheme- shall be deemed designated hospitals for the purposes of the Scheme.

The number and the details of hospitals empanelled under National Health Authority, state-wise are as under

|   S.No | State/Uts                   |   No. of empanelled Hospitals |
|--------|-----------------------------|-------------------------------|
|      1 | ANDAMAN AND NICOBAR ISLANDS |                             7 |
|      2 | ANDHRA PRADESH              |                          2472 |
|      3 | ARUNACHAL PRADESH           |                            56 |
|      4 | ASSAM                       |                           356 |
|      5 | BIHAR                       |                          1098 |
|      6 | CHANDIGARH                  |                            33 |
|      7 | CHHATTISGARH                |                          1675 |

| 8              | DELHI               | 180   |
|----------------|---------------------|-------|
| 9              | DNH AND DD          | 20    |
| 10             | GOA                 | 25    |
| 11             | GUJARAT             | 2076  |
| 12             | HARYANA             | 1361  |
| 13 HIMACHAL    | PRADESH             | 294   |
| 14 JAMMU AND   | KASHMIR 270         |       |
| 15             | JHARKHAND           | 555   |
| 16             | KARNATAKA           | 3607  |
| 17 KERALA      |                     | 607   |
| 18 LADAKH      |                     | 10    |
| 19 LAKSHADWEEP | 5                   |       |
| 20 MADHYA      | 1611                |       |
| 21             | PRADESH MAHARASHTRA | 1698  |
| 22 MANIPUR     | 70                  |       |
| 23 MEGHALAYA   |                     | 180   |
| 24 MIZORAM     |                     | 88    |
| 25 NAGALAND    |                     | 79    |
| 26 ODISHA      |                     | 787   |
| 27             | PUDUCHERRY          | 31    |
| 28 PUNJAB      |                     | 812   |
| 29             | RAJASTHAN           | 1905  |
| 30 SIKKIM      |                     | 19    |
| 31             | TAMIL NADU          | 2295  |
| 32             | TELANGANA           | 1526  |
| 33             | TRIPURA             | 142   |
| 34 UTTAR       | PRADESH             | 6140  |
| 35             | UTTARAKHAND         | 419   |
| 36             | WEST BENGAL         | 48    |
| Total          | Total               | 32557 |

- (d) Out of the total number of 6,833 treatment requests raised, 5,480 victims have  been  found  eligible.  The  remaining  cases  have  been  rejected  by  the Police. The total fund disbursed under the Motor Vehicle Accident Fund is Rs. 73,88,848/-.
- (e)  Out  of  the  2,644  claims raised by hospitals and approved by concerned State  Health  Agency,  payment  of  Rs.  73,88,848/-    has  been  disbursed  to hospitals.
- (f)  The  reimbursement  to  hospitals  is  being  done  through  Motor  Vehicle Accident Fund (MVAF) which is funded through contributions from General Insurance  companies  for  cases  where  the  Motor  Vehicle  involved  is

insured  and  through budgetary  support for other-than-insured  motor vehicle cases. Once the victim is discharged from the Scheme, the hospital will have to submit the claim along with required documents to State Health Agency (SHA). The claim will be verified and approved by the SHA. Once the claim is  approved, the payment will be made by General Insurance Council for insured cases and by the District Collector for other-than-insured cases.

ANNEXURE  REFERRED  TO  IN  REPLY  TO  PART  (b)  OF  THE  LOK  SABHA UNSTARRED  QUESTION  NO.  905  FOR  ANSWER  ON  04.12.2025  ASKED  BY SHRI  DAGGUMALLA  PRASADA  RAO  AND  SHRI  G  M  HARISH  BALAYOGI REGARDING CASHLESS TREATMENT OF ROAD ACCIDENT VICTIMS

Hospital Empanelment Guidelines for the Cashless Treatment of Road Accident Victims

## Table of Contents

| 1.                                                                                             | INTRODUCTION..............................................................................3                                                                                                                                                     | INTRODUCTION..............................................................................3                                                                                                                                                     |
|------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 2.                                                                                             | PURPOSE AND SCOPE....................................................................4                                                                                                                                                          | PURPOSE AND SCOPE....................................................................4                                                                                                                                                          |
| 2.1                                                                                            | PURPOSE......................................................................................4                                                                                                                                                  | PURPOSE......................................................................................4                                                                                                                                                  |
| 2.2                                                                                            | SCOPE .......................................................................................4                                                                                                                                                  | SCOPE .......................................................................................4                                                                                                                                                  |
| 3.                                                                                             | EMPANELMENT OF HEALTHCARE PROVIDERS - APPROACH & CRITERIA.........................................................................................5                                                                                             | EMPANELMENT OF HEALTHCARE PROVIDERS - APPROACH & CRITERIA.........................................................................................5                                                                                             |
| 3.1                                                                                            | APPROACH FOR EMPANELMENT........................................................5                                                                                                                                                               | APPROACH FOR EMPANELMENT........................................................5                                                                                                                                                               |
| 3.2                                                                                            | CRITERIA FOR EMPANELMENT ..........................................................6                                                                                                                                                            | CRITERIA FOR EMPANELMENT ..........................................................6                                                                                                                                                            |
| 3.3                                                                                            | INFRASTRUCTURE REQUIREMENTS....................................................6                                                                                                                                                                | INFRASTRUCTURE REQUIREMENTS....................................................6                                                                                                                                                                |
| 3.4                                                                                            | SPECIALITIES REQUIRED FOR EMPANELMENT.......................................6                                                                                                                                                                   | SPECIALITIES REQUIRED FOR EMPANELMENT.......................................6                                                                                                                                                                   |
| 3.4.1 SPECIALTIES REQUIRED FOR EMPANELMENT....................................6                | 3.4.1 SPECIALTIES REQUIRED FOR EMPANELMENT....................................6                                                                                                                                                                 |                                                                                                                                                                                                                                                 |
| 3.4.2                                                                                          | 3.4.2                                                                                                                                                                                                                                           | CARE................................................6                                                                                                                                                                                           |
| 3.4.3 QUALIFIED MEDICAL PERSONNEL...................................................7          | 3.4.3 QUALIFIED MEDICAL PERSONNEL...................................................7                                                                                                                                                           |                                                                                                                                                                                                                                                 |
| 3.4.4 LICENSE AND ACCREDITATION.......................................................7        | 3.4.4 LICENSE AND ACCREDITATION.......................................................7                                                                                                                                                         |                                                                                                                                                                                                                                                 |
| 3.4.5 24X7SERVICE AND MONITORING ..................................................7           | 3.4.5 24X7SERVICE AND MONITORING ..................................................7                                                                                                                                                            |                                                                                                                                                                                                                                                 |
| 3.4.6 GEOGRAPHICAL LOCATION ...........................................................7       | 3.4.6 GEOGRAPHICAL LOCATION ...........................................................7                                                                                                                                                        |                                                                                                                                                                                                                                                 |
| 4.                                                                                             | ROLE AND RESPONSIBILITY FOR EMPANELMENT........................8                                                                                                                                                                                | ROLE AND RESPONSIBILITY FOR EMPANELMENT........................8                                                                                                                                                                                |
| 4.1                                                                                            | ROLE OF MORTH.......................................................................8                                                                                                                                                           | ROLE OF MORTH.......................................................................8                                                                                                                                                           |
| 4.2                                                                                            | ROLE OF STATE ROAD SAFETY COUNCIL (SRSC)...............................8                                                                                                                                                                        | ROLE OF STATE ROAD SAFETY COUNCIL (SRSC)...............................8                                                                                                                                                                        |
| 4.3                                                                                            | ROLE OF STATE HEALTH AGENCY (SHA)...........................................8                                                                                                                                                                   | ROLE OF STATE HEALTH AGENCY (SHA)...........................................8                                                                                                                                                                   |
| 4.4                                                                                            | ROLE OF NATIONAL HEALTH AUTHORITY (NHA).................................8                                                                                                                                                                       | ROLE OF NATIONAL HEALTH AUTHORITY (NHA).................................8                                                                                                                                                                       |
| 4.5                                                                                            | ROLE OF STATE EMPANELMENT COMMITTEE (SEC).............................9                                                                                                                                                                         | ROLE OF STATE EMPANELMENT COMMITTEE (SEC).............................9                                                                                                                                                                         |
|                                                                                                | 4.5.1 Structure of State Empanelment Committee (SEC) ............ 9                                                                                                                                                                             | 4.5.1 Structure of State Empanelment Committee (SEC) ............ 9                                                                                                                                                                             |
| 4.6 ROLE OF DISTRICT EMPANELMENT COMMITTEE (DEC).........................9                     | 4.6 ROLE OF DISTRICT EMPANELMENT COMMITTEE (DEC).........................9                                                                                                                                                                      |                                                                                                                                                                                                                                                 |
| 4.6.2 Structure of District Empanelment Committee (DEC) ......                                 | 4.6.2 Structure of District Empanelment Committee (DEC) ......                                                                                                                                                                                  | 10                                                                                                                                                                                                                                              |
| 4.7 ROLE OF THIRD-PARTY EMPANELMENT AGENCY (TPEA) ...................10                        | 4.7 ROLE OF THIRD-PARTY EMPANELMENT AGENCY (TPEA) ...................10                                                                                                                                                                         |                                                                                                                                                                                                                                                 |
| 5. PROCESS OF EMPANELMENT......................................................12              | 5. PROCESS OF EMPANELMENT......................................................12                                                                                                                                                               | 5. PROCESS OF EMPANELMENT......................................................12                                                                                                                                                               |
| 5.1 APPLICATION AND REGISTRATION ON THE PORTAL ............................12                  | 5.1 APPLICATION AND REGISTRATION ON THE PORTAL ............................12                                                                                                                                                                   | 5.1 APPLICATION AND REGISTRATION ON THE PORTAL ............................12                                                                                                                                                                   |
| 5.1.1 Option 1: Fast-Track Empanelment                                                         | 5.1.1 Option 1: Fast-Track Empanelment                                                                                                                                                                                                          | .................................. 12                                                                                                                                                                                                           |
| 5.1.2 Option 2: Desktop and Physical Verification                                              | 5.1.2 Option 2: Desktop and Physical Verification                                                                                                                                                                                               | 12                                                                                                                                                                                                                                              |
| .................... 5.1.3 Empanelment in Brownfield states................................... | .................... 5.1.3 Empanelment in Brownfield states...................................                                                                                                                                                  | 13                                                                                                                                                                                                                                              |
| 5.2 ON-BOARDING PROCESSES AFTER APPROVAL ...................................13                 | 5.2 ON-BOARDING PROCESSES AFTER APPROVAL ...................................13                                                                                                                                                                  |                                                                                                                                                                                                                                                 |
| 5.3                                                                                            | 5.3                                                                                                                                                                                                                                             |                                                                                                                                                                                                                                                 |
| 6.                                                                                             | AB PMJAY EMPANELLED HOSPITAL ......................................14 INCENTIVE STRUCTURE FOR EMPANELMENT............................15                                                                                                         | AB PMJAY EMPANELLED HOSPITAL ......................................14 INCENTIVE STRUCTURE FOR EMPANELMENT............................15                                                                                                         |
| 7.                                                                                             | DISCIPLINARY PROCEEDINGS AND DE-EMPANELMENT.............16                                                                                                                                                                                      | DISCIPLINARY PROCEEDINGS AND DE-EMPANELMENT.............16                                                                                                                                                                                      |
| 7.1                                                                                            | RATIONALE FOR DISCIPLINARY PROCEEDINGS ..................................16                                                                                                                                                                     | RATIONALE FOR DISCIPLINARY PROCEEDINGS ..................................16                                                                                                                                                                     |
| 7.2                                                                                            | PROCESS FOR DISCIPLINARY PROCEEDINGS .....................................16 7.2.1 Empanelment Disciplinary Committee (EDC) ................... 16 7.3 DE-EMPANELMENT .......................................................................19 | PROCESS FOR DISCIPLINARY PROCEEDINGS .....................................16 7.2.1 Empanelment Disciplinary Committee (EDC) ................... 16 7.3 DE-EMPANELMENT .......................................................................19 |

| 7.3.1   | 7.3.1                                                                                          | Presentation of case to the SEC and De-empanelment ... 19                                      |                                                                                                |
|---------|------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------|
| 7.3.2   | 7.3.2                                                                                          | Actions to be taken after De-empanelment ..................... 20                              |                                                                                                |
| 7.4     | GRADATION OF OFFENCES.............................................................22           | GRADATION OF OFFENCES.............................................................22           | GRADATION OF OFFENCES.............................................................22           |
|         | 7.4.1 Penalties............................................................................ 23 | 7.4.1 Penalties............................................................................ 23 | 7.4.1 Penalties............................................................................ 23 |
| 8.      | GRIEVANCE MANAGEMENT.........................................................25                | GRIEVANCE MANAGEMENT.........................................................25                | GRIEVANCE MANAGEMENT.........................................................25                |
| 9.      | ANNEXURES.................................................................................26   | ANNEXURES.................................................................................26   | ANNEXURES.................................................................................26   |
| 9.1.1   | 9.1.1                                                                                          | Minimum Criteria ............................................................... 26            |                                                                                                |
| 9.1.2   | 9.1.2                                                                                          | Qualified Medical Personnel .............................................. 27                  |                                                                                                |

## 1. Introduction

The  National  Health  Authority  (NHA)  is  the  apex  body  responsible  for implementing India's flagship public health insurance scheme, the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY). It has also been entrusted with designing strategy, building technological infrastructure,  and  leading  the  implementation  of  the  Ayushman  Bharat Digital Mission to create  a  National  Digital  Health  Ecosystem.  NHA manages the integration of health insurance schemes across Central and State  governments,  ensuring  the  smooth  delivery  of  healthcare  services through a robust IT infrastructure and by empaneling hospitals nationwide. It collaborates with various ministries to standardize and enhance healthcare delivery across India.

The Ministry of Road Transport and Highways (MoRTH) has recognized the importance of hour when immediate care can save lives. MoRTH on 5 th  May 2025 has notified the scheme offering cashless treatment for road accident victims. The scheme provides free treatment of up to Rs

- 1.5 lakhs per accident per person for a maximum period of 7 days.

The Ministry of Road Transport and Highways shall be the nodal authority in the Central Government for notification of the guidelines and addressing issues related to the Scheme. The implementation of the Scheme in each State or Union Territory shall be monitored by the respective State Road Safety Council. The implementation of the Scheme in each district shall be monitored  by  the  District  Road  Safety  Committee  constituted  under  subsection (3) of section 215 of the Act.

For the empanelment under the scheme, SHA shall be responsible in their respective  States/UTs.  The  treatment  will  be  provided  through  hospitals already empanelled under PM- JAY which have the facility  to  provide  the treatment for road traffic accidents victims.

## 2. Purpose and Scope

## 2.1 Purpose

The primary purpose of these empanelment guidelines is to ensure smooth onboarding  and  participation  of  hospitals  which  are  equipped  to  provide cashless  medical  treatment  to  road  accident  victims  under  the  Scheme launched  by  the  Ministry  of  Road  Transport  and  Highways  (MoRTH).  This applies  to  hospitals  across  India  that  wish  to  participate  in  MoRTH's accident care scheme. These  guidelines  aim  to  ensure  that  only  hospitals  with  the  necessary infrastructure, skilled personnel, and capacity to deliver high-quality, timely emergency care, especially during the golden hour, are empaneled. The  ultimate objective is to reduce fatalities and improve recovery outcomes for road accident victims.

## 2.2 Scope

The scope of these guidelines outlines the key areas to ensure comprehensive  and  transparent  process  for  empanelling  hospitals  for providing cashless treatment to road accident victims under the scheme

## 2.2.1 Empanelment of Healthcare Providers: Approach, Criteria, and Incentives

The  guidelines detail the approach  for selecting hospitals  based  on infrastructure, medical specialties, and experience in trauma and polytrauma care. Specific criteria and an incentive structure will be outlined to encourage hospitals to join the network and maintain high standards of care for road accident victims.

## 2.2.2 Institutional Setup and Oversight

A detailed framework for institutional roles at the national and State levels is provided. The roles of the National Health Authority (NHA), State Health Authorities  (SHA),  as  well  as  State-  Specific  committees  like  the  State Empanelment Committee (SEC) and District Empanelment Committee (DEC),

is described. Additionally, the function of Third-Party Empanelment Agencies (TPEAs) in evaluating hospitals is also included.

## 2.2.3 Process of Empanelment and Disciplinary Actions

This guideline covers the application and approval process for hospitals to be empanelled, including registration steps and post-empanelment procedures.  Processes  for  handling  non-  compliance,  disciplinary  actions, and de-empanelment is also clearly outlined to ensure that hospitals adhere to the required standards for trauma, polytrauma and emergency care.

## 3. Empanelment of Healthcare Providers - Approach & Criteria

## 3.1 Approach for Empanelment

The guidelines for empanelment of hospitals for cashless treatment of Road  Accident  Victims  (CTRAV)  ensures  that  hospitals  capable  of providing trauma and polytrauma care are empaneled. Hospitals should be located not only in high-risk areas identified by MoRTH as accident hotspots but also in other places (National Highways, State Highways, municipal Roads, etc) to make sure accident victims can get quick and easy access to care in all regions. The following approach outlines the key steps for empaneling hospitals:

##  Deemed Empanelment for AB PMJAY Hospitals:

The empanelled hospitals identified by their respective states which are equipped with trauma and polytrauma care support for treatment of road traffic accident victims will be deemed empanelled and notified. These provisions  are  made  for  immediate  onboarding  of  hospitals  to  provide critical  trauma  care  services  to  the  road  traffic  accident  victims.  Any new hospital empanelled under AB PMJAY which is capable of providing Trauma  and  polytrauma  services  to  the  Road  Traffic  Accident  (RTA) Victim will also be deemed empaneled.

##  New hospital empanelment exclusively for CTRAV Scheme

Under  AB  PM-JAY,  fast-Track  Empanelment  is  available  for  NABHaccredited/AB-PMJAY quality accreditation or CGHS empanelled hospitals which are equipped with trauma and polytrauma care support for treatment of road traffic accident victims.

For  hospitals  that  are  not  eligible  for  fast-track  empanelment,  the  existing verification process as used under AB PM-JAY shall be conducted

As  per  the  scheme  guideline,  in  case  an  accident  victim  reaches  a hospital which is not empanelled either under AB PM-JAY or MoRTH, the hospital shall be still be required to provide initial treatment (stabilization)  to  the  accident  victim  and  subsequently  shall  refer him/her to nearby empanelled hospital.

##  Targeted Approach for Empanelment

The  approach  for  empanelment  is  designed  to  strategically  enhance  the healthcare network, with a focus on:

- Geographic Areas:  Special consideration must be given to  hospitals  with  trauma  and  polytrauma  facilities  in accident-prone  areas  as  highlighted  by  MoRTH  from time to time. This ensures that trauma care is accessible to accident victims in areas where medical facilities may currently be limited.
- Accredited Hospitals: States are encouraged to prioritise hospitals with trauma and polytrauma facilities that are accredited by the

NABH, NQAS and AB PMJAY quality accreditation, to ensure high standards of care and service delivery.

- Use  of  Alternate  Hospital  Databases:  Additional efforts  should  focus  on  hospitals  from  alternate hospital databases to further broaden the network, ensuring  adequate  trauma  care  availability  across the country.
- Empanelment managed by States and Union Territories SHA's  SHA  of  AB  PMJAY  implementing  States  and Union Territories are responsible for empanelling healthcare providers within their respective regions.

## 3.2 Criteria for Empanelment

The empanelment criteria for hospitals under the CTRAV Scheme for  providing  cashless  treatment  of  Road Accident  Victims,  must follow  established  guidelines  to  ensure  that  hospitals  meet  the required  standards  for  providing  trauma  and  emergency  care  to accident victims.

## 3.3 Infrastructure Requirements:

- The hospital should have a dedicated emergency department equipped to handle trauma cases.
- Availability of a 24/7 emergency care facility and adequate trauma care infrastructure, including
- ○
- Fully equipped Intensive Care Unit (ICU)
- Operation theatres with facilities for emergency surgery
- IPD services
- Imaging facilities (e.g., X-ray, CT scan, Ultrasound, MRI, etc)
- Blood bank or blood storage facilities
- Ambulance services with Basic Life support (BLS) /
- Advanced Life Support (ALS) systems.

## 3.4 Specialities required for empanelment

## 3.4.1 Specialties Required for Empanelment:

- Emergency Medicine / General Medicine
- General Surgery
- Orthopedic Surgery / Polytrauma

## 3.4.2 Specialties for Enhanced Care

- Burns Management
- Cardiothoracic and Vascular Surgery (CTVS)
- Cardiology
- Ear, Nose and Throat (ENT)
- Neurosurgery
- Obstetrics & Gynaecology
- Ophthalmology
- Oral & Maxillofacial Surgery
- Paediatric Medical Management
- Paediatric Surgery
- Plastic & Reconstructive Surgery
- Urology

## 3.4.3 Qualified Medical Personnel

Please refer to Annexure 1

## 3.4.4 License and Accreditation:

- The Private hospital must be registered with the local health authorities and meet any statespecific regulatory requirements.
- National  accreditation  e.g.,  NABH,  NQAS  and  AB PMJAY quality accreditation will be preferred.
- Hospitals  must  have  a  valid  licence  for  operation  under various medical and legal provisions, including licences for imaging and surgical equipment, and waste management.

## 3.4.5 24x7 Service and Monitoring:

- Availability of round-the-clock diagnostic services, including  pathology  and  radiology,  will  be  preferred  for empanelment.

## 3.4.6 Geographical Location:

- Hospital empanelment  must  be  prioritised in the accident hotspots as identified by MoRTH from time to time.

## 4. Role and Responsibility for Empanelment

## 4.1 Role of MoRTH

- MoRTH  should  identify  the  hotspots  for  empanelment  of Hospitals along accident prone areas, which are critical in providing  cashless  treatment  to  victims  of  road  accidents under the scheme, which should be informed from time  to time by MoRTH.

## 4.2

## Role of State Road Safety Council (SRSC )

- Coordinate with National Health Authority for adoption and utilisation of the portal for onboarding of designated hospitals 1 .
- Coordinate with State Health Agency to designate hospitals  under  the  Scheme  for  providing  treatment,  in addition to the hospitals empanelled under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, as specified by the National Health Authority;
- Coordinate with State Health Agency to implement measures  required  for  the  detection  and  prevention  of fraud or misuse of the Scheme or its benefits;

## 4.3

## Role of State Health Agency (SHA)

- The SHA will identify and empanel hospitals with trauma and  poly  trauma  care  facilities  that  are  essential  for managing road accidents.
- The SHA is required  to  take  necessary  action  in  cases  of irregularities, such as fraud, and to proceed in accordance with the existing  guidelines for  disciplinary  action  against hospitals,  as  outlined  by  the  National  Health  Authority (NHA).
- The SHA is tasked with raising awareness among healthcare service providers regarding  the  scheme  to ensure maximum participation from eligible providers. This may involve conducting Information, Education and Communication (IEC) campaigns or sensitization workshops  at  various  levels  district,  sub  district,  taluka and block etc.

- SHA will maintain a list of empaneled hospitals and ensure compliance with the set standards/ guidelines
- SHA  will  ensure  creation  of  relevant  application  logins through  the  system  after  onboarding  the  hospital  in  the
- scheme.

## 4.4

## Role of National Health Authority (NHA)

- The  National Health Authority (NHA) will continue to support State Health Agencies (SHAs) in the empanelment process by developing comprehensive guidelines that establish  systems  and  processes  to  ensure  the  quality  of services and maximise the empanelment of healthcare

1   Designated  Hospitals  refer  to  hospitals  or  clinical  establishments onboarded by the State  Government  or  State  Health  Agency  (SHA)  for providing cashless treatment to victims of road accidents arising from the use of motor vehicles. This includes: Hospitals empanelled under AB PM-JAY that are capable of providing trauma and polytrauma services, and Hospitals specifically empanelled for the CTRAV scheme.

## providers, especially in critical areas.

- NHA recognizes the need to consider state-specific contexts and provides SHAs with the flexibility to adapt and implement these guidelines as per local needs.

## 4.5

## Role of State Empanelment Committee (SEC)

- SEC  will  play  a  key  role  in  the  approval  flow  for  the submitted applications. The final decision to approve/reject the  application  of  the  healthcare  service  provider  will  rest with the SEC. The decision on relaxation to be given to any healthcare service provider based on the recommendation of the  District  Empanelment  Committee  (DEC)  will  also  rest with  SHA.  SHA  to  ensure  that  the  quality  of  medical  care rendered to the patient is not compromised by this relaxation.
- Additionally, SHA will be responsible for providing supportive supervision  to  DEC  and  ensuring  timebound  empanelment process throughout its lifecycle.
- SHAs shall take necessary action to empanel the hospitals located near the accident hotspots identified by MoRTH.
- It  will  be  the  responsibility  of  the  SHA/SEC  to  monitor that  the  hospital  maintains  the  capacity  of  delivering quality  services  to  the  road  accident  victims  in  this scheme from time to time. It  may  also  include  periodic physical verification.

## 4.5.1 Structure of State Empanelment Committee (SEC)

The  State/SHA  may  continue  with  existing  institutions under the AB PMJAY schemes with the vested powers and responsibilities of SEC as per the guidelines.

## 4.6 Role of District Empanelment Committee (DEC)

The District Empanelment Committee (DEC) will play a critical support role  by  assisting the State Empanelment Committee (SEC) and State Health  Agency  (SHA)  at  the  district  level.  The  DEC  will  ensure  that

healthcare  providers  meet  the  required  standards  for  empanelment and handles disciplinary proceedings when necessary.

## 4.6.1 Role of DEC in Empanelment

## Document Validation and Scrutiny

- Validation  at  Empanelment:  At  the  time  of  empanelment, the  DEC  will  be  responsible  for  validating  and  scrutinising the documents uploaded by hospitals. This includes verifying  the  completeness  and  accuracy  of  documents such as hospital registration, staffing details, infrastructure, and compliance with necessary standards.
- Ongoing  Monitoring:  The  DEC  performs  regular  checks  to ensure that hospitals maintain compliance with empanelment requirements even after approval.

## Field and Desktop-Based Verification

- Physical  Inspections:  In  addition  to  desktop-based  audits, the DEC will conduct field verifications by visiting hospitals to assess  their infrastructure, equipment, and staffing capabilities,  ensuring  that  they  meet  the  empanelment criteria.
- Desktop-Based  Audits:  Can  be  initiated  only  in  exigency cases where physical inspection is not possible. The DEC will carry  out  desktop-based  verification  by  reviewing  hospital records and other submitted information to verify compliance remotely.

## Submission of Verification Reports

- Online Empanelment Portal: After completing verifications, the DEC submits its reports to the SEC through the online empanelment portal. The reports include detailed findings and  a  recommended  decision  to  either  approve  or  reject the hospital's empanelment application.
- Justification for Rejection: If the DEC recommends rejection,  it  must  provide  clear  reasons  for  rejection, ensuring transparency in the decision- making process.

## Pre-Empanelment Orientation for Hospitals

- Orientation Sessions: The DEC, in collaboration with SEC/SHA, can organise preempanelment orientation workshops  at  the  district  level.  These  sessions  aim  to educate hospital administrators on the empanelment process, the required documentation, and the standards they must meet.
- Guidance on Compliance: During these orientations, hospitals shall be guided on all the parameters for compliance including infrastructure, human  resources,  and digital  integration  before  getting  empanelled  under  the scheme.

## 4.6.2 Structure of District Empanelment Committee (DEC) -

The State may continue with existing DEC institutions under the AB PMJAY schemes with the vested powers and responsibilities of DEC  as  per  the  guidelines.  In  case  of  Third  Party  Empanelment Agency (TPEA) being in use, a member of TPEA will assist the DEC in its activities.

## 4.7 Role of Third-Party Empanelment Agency (TPEA) -

- If  additional  assistance  is  required  for  the  empanelment process, SHA may hire a third- party empanelment agency which  is either empaneled  by  NHA  or  hired  by  SHA separately.  The  TPEA  will  be  responsible  for  facilitating verification  of  healthcare  providers  (both  physical  as  well as  desk-top  verification).  However,  the  following  must  be ensured while hiring TPEA:
- The third-party empanelment agency engaged for this purpose  shall not be the current implementation support agency operating within the state or any other agency that may create a conflict of interest or lead to collusion. It is important that the physical verification process remains transparent and impartial.

- The  TPEA  should  not  be  the  same  agency  currently engaged by the SHA for any other purpose
- Any agency that has previously worked as a TPA for insurance companies  must  observe a cooling-off period  of  at  least  six  months  before  applying  to become a TPEA.
- The TPEA must ensure that a physical verification of healthcare service led by DEC
- The SHA, will conduct a sample physical audit of 10% of the facilities verified by the TPEA

## 5. Process of Empanelment

## 5.1 Application and Registration on the Portal

- It  is  mandatory  that the  hospitals  willing  to  get empanelled under  the  scheme  are  registered  in  the  -Health  Facility registry‖ under Ayushman Bharat Digital Mission. The hospital can get themselves registered using the web based portal (https://nhpr.abdm.gov.in/hfrAdmin/login)
- Hospital will register through User Management Portal (UMP) portal  (at  URL  : https://ump.pmjay.gov.in)  for  creation  of Hospital Engagement Module (HEM) and create logins of HEM Portal to initiate registration.
- Further,  using  the  credentials  created  using  UMP  for  HEM module, Hospital will  login  to  the  HEM  Module  and  initiate the registration process. URL for HEM portal (https://hem.nha.gov.in)
- Once the healthcare provider  has  filled  the  application,  the verification  and  approval  process will  be  undertaken  by  the SHA/SEC. Only those healthcare providers will be allowed to get empaneled under the scheme who have been registered as an establishment under the relevant central or state acts
- (if applicable).

## 5.1.1

## Option 1: Fast-Track Empanelment

- Hospitals holding NABH accreditation / AB PM-JAY certification  for  relevant  specialty  may  be  fast-tracked  for empanelment without physical verification.

## 5.1.2 Option 2: Desktop and Physical Verification

The entire process of desktop and physical verification for hospital empanelment must be completed within 30 days. First, the DEC or TPEA conducts a desktop verification, verifying documents uploaded by the hospital. If discrepancies or missing documents are  found,  the  DEC  will  raise  queries  for  clarification,  and  the hospital  must  address  these.  This  is  followed  by  a  physical inspection by the District Empanelment Committee (DEC), district

nodal officer, or TPEA, ensuring the hospital's compliance with the application details

After Physical  verification, the report,  including  pictures  and documents,  is  uploaded  on  the  HEM  portal. In  case  of  noncompliance of  the  requisite  standard,  the  application  request  for empanelment  may  be  rejected  for  specific  specialty  or  may  be rendered ineligible for empanelment as the case may be.

## 5.1.2.1 DEC Recommendations:

DEC can exercise the following options while forwarding the case to the SEC:

- Recommend Approval: if the hospital meets the required standards and findings are satisfactory as per applicable norms, DEC can send the application to SEC for approval of the application.
- Recommend Rejection: For applications that do not meet the minimum standards or where healthcare providers have been found to be misreporting information, the DEC will recommend rejection. All rejections will be subject to review by the SHA.
- Recommend  relaxation  and  approval:  DEC  where  they  find requirement of empanelling a hospital to ensure the availability  of  an  adequate  number  of  empaneled  facilities within the district may recommend relaxations in empanelment criteria for approval to the SHA. This recommendation must be approved by the SHA, with a clear and documented rationale provided. SHA to ensure that the quality  of  medical  care  rendered  to  the  patient  is  not compromised by this relaxation.

## SEC Approval

## 5.1.2.2

- SEC will review the reports and recommendations submitted by the DEC. SEC/ SHA will also consider the DEC's recommendations  for  ‗relaxation  criteria  of  empanelment based on the review, SEC/ SHA shall make the final decision

## on empanelment

- In  case  the  empanelment  is  approved,  the  same  will  be updated on the PMJAY webbased portal and the healthcare provider will be notified through SMS/email of the final decision
- In  case  of  rejection  of  an  empanelment  request,  the  SEC/ SHA will  state  the  reasons  for  rejection  of  the  request  and share  it  with  the  healthcare  provider.  The  decision  (and reasons) will also be updated on the PM-JAY web portal
- Healthcare  providers  will  have  the  right  to  file  a  review against the rejection with the State Empanelment Committee (SEC). In case the review request for empanelment  is rejected by the SEC, the healthcare providers can approach the competent authority as defined in the Grievance Redressal Mechanism for remedy.

## 5.1.3 Empanelment in Brownfield states

- Empanelment of hospitals for the states not using NHA's IT application will continue in the same manner. These states should  comply  with  the  guidelines  laid  for  the  MoRTH scheme.

## 5.2 On-boarding Processes after Approval

- Once the application is approved, SHA will ensure that the  status  of  the  application  is  updated  on  the  PM-JAY portal  and  the  respective  healthcare  service  provider  is informed  about  the  decision  through  email  /  SMS  on  the registered phone number. Once the hospital  is  empaneled, a  user  admin  login  will  be  created  for  the  hospital  for providing timely medical treatment to road accident victims, especially during the critical golden hour.
- SHA  will ensure creation of relevant application login credentials through the  system  after  onboarding  under  the scheme
- SHA will also ensure that training on systems and processes like beneficiary identification system, transaction

management  system,  health benefit package, standard treatment guidelines, claim settlement process is provided to HCP.

## 5.3 AB PMJAY empanelled hospital

- AB-PMJAY empanelled hospitals having trauma and polytrauma  services  will  be  deemed  empanelled  for  the CTRAV scheme.

## 6. Incentive Structure for Empanelment

- An  Incentive  (in  addition  to  the  Package  amount)  will  be provided  as  per  the  current  AB  PMJAY  scheme  guideline  / latest Health Benefit Package (HBP) rates.

## 7. Disciplinary Proceedings and De-Empanelment

## 7.1 Rationale for Disciplinary Proceedings

- Hospitals may face disciplinary actions if found indulging in fraudulent activities, violating treatment guidelines, or failing to provide quality care.
- Disciplinary proceedings/de-empanelment may be conducted for  an  Empaneled  Healthcare  Provider  (Hospital)  under  the scheme if they fail to meet and uphold the necessary criteria agreed upon during empanelment or indulge in wrongful acts during treatment (detailed in section below). The key objectives  of  NHA  and  SHA  are  to  increase  empanelment, ensuring that quality care is provided and curtailing unnecessary leakages in the form of fraud and abuse which may bring disrepute to the scheme. Disciplinary proceedings/de-empanelment processes have been introduced primarily as a deterrence and control mechanism in  the  scheme  to  ensure  that  medically  appropriate  quality treatment  is  provided  to  beneficiaries  at  all  times  and  all wasteful and unnecessary expenditure is curtailed.

## 7.2 Process for Disciplinary Proceedings

- Disciplinary  proceeding  should  be  initiated  based  on investigation  findings and establishment of fraud
- Hospitals  will  be  issued  show-cause  notices  within  7 working days of investigation findings.

## 7.2.1 Empanelment Disciplinary Committee (EDC)

EDC will initiate disciplinary proceedings against errant health service providers in the state. The  institutional structure established for empanelment  will  also  be  responsible  for  processes  leading  upto disciplinary proceeding/ De-empanelment. The SHA, SEC and DEC at the state  and  District  level  will  form  the  key  institutions  in  enforcing  this mechanism.

Process for Disciplinary Proceedings and De-empanelment

## 7.2.1.1 Show-Cause Notice to the Hospital

Based on the investigation report received, if there is sufficient evidence/suspicion of the Hospital indulging in malpractices, a show cause- notice shall be issued to the Hospital. All attempts will be made to issue show cause notice within 7 working days from receipt of the investigation report and in case of any delay, the report must be submitted to CEO SHA, citing the reasons for the same.

- In  the  show cause notice sent to the Hospital, it should be explicitly  communicated to not contact the beneficiaries in question as this would lead to tampering of evidence, as per the  applicable  laws.  In  case  any  such  tampering  is  found, legal action may be taken accordingly.
- The  show-cause  notice  will  be  sent  both  to  the  Hospital's registered email ID provided at the time of empanelment or the most current one available/updated with SHA and a hard copy will be sent via speed post or delivered by hand through district coordinator to the Hospital's notified address.
- The show-cause notice will mention the email ID of the SHA where the response to the show- cause needs to be sent by the  Hospital.  The  receipt  of  the  registered  speed  post  or acknowledgement of receipt by Hospital (in case delivered by hand) should be kept securely as proof by the SHA. The show-cause notice will also be updated in the online portal used by the Hospital.
- The hospital shall respond to the show-cause notice within 5 working days from the date of receipt of show cause notice. The response will be sent to the SHA at the email id provided in the show-cause letter or address specified for registered post  along  with  supporting  evidence  collected  as  per  the applicable laws of India.
- In case, the response is not received within 5 working days, the  Hospital  will  be  suspended.  All  its  operations  will  be blocked under PM-JAY through its web portal, for a specified

- time  frame  not  exceeding  6  months  or  till  a  decision  has been  taken on the proceedings, so that no new  preauthorizations  can  be  raised  by  the  Hospital.  However,  the treatment of existing patients will continue as usual till they are  discharged.  The  notification  of  suspension  will  be  sent through email and registered speed post. All attempts shall be  made  to  send  the  notification  within  2  working  days  of the  decision  and  in  case  of  any  delay  report  must  be submitted to CEO SHA, citing the reasons for the same.
- In case, the response to the show cause received from the hospital is found satisfactory, it will continue to function as usual.  However,  if  the  response  is  not  found  satisfactory, further  information  or  evidence  may  be  requested  through email. The Hospital shall provide the requested documents/information within 3 working days through email, failing which the Hospital may be suspended for a specified time  frame  not  exceeding  6  months  or  till  a  decision  has been  taken  on  the  proceedings.  During  suspension,  the Hospital  will  not  be  allowed  to  conduct  any  new  preauthorizations. All  admitted  patients  under  the  scheme  will be  provided  continued  treatment  as  usual  till  they  are discharged.  The  notification  of  suspension  will  be  sent through email and registered speed post. All attempts will be made to send this notification within 2 working days of the decision taken by SHA. In case of any delay, a report must be submitted to CEO SHA, citing the reasons for the same.
- If  the  above-mentioned  timelines  are  not  met,  then  either party can approach competent authority as per the grievance redressal guidelines.
- If  there  is  no  documentary  evidence  to  suggest  that  the show  cause  notice  was  received  or  the  Hospital  denies having received the show cause notice, the SHA may share the notice again either through physical delivery or

registered  email  ID  and  receive  an  acknowledgement  of  the  receipt. Hospital  will  have  to  respond  within  3  working  days  from  the  date  of receipt of the show-cause notice.

- Beneficiaries  needing  continued  care  beyond  current  preauthorization may be referred to another hospital to ensure there is no disruption of services.

## Detailed Investigation of Hospital

## 7.2.1.2

- A  detailed  investigation  will  be  carried  out  in  case  the Hospital is  suspended due to the reasons mentioned above or  if  a  complaint  containing  sufficient  material  to  raise suspicion  has  been  filed  by  the  beneficiary.  A detailed investigation may include field visits to the Hospital, examination of case papers, interaction with the beneficiaries (if needed), examination of hospital records etc.
- All attempts will be made to complete the investigation and submit  the  report  within  10  working  days  of  show-cause issued. In case of any delay, a report must be submitted to CEO SHA, citing the reasons for the same.
- All statements of the beneficiaries will be recorded in writing in  the  language  known  to  the  beneficiary  and  ensured  that the said statement  is  read  over  to the beneficiary for confirmation.  The  statement  will  be  self-attested  by  the beneficiary  via  signature  or  thumb  impression  for  use  as evidence.  Wherever  possible,  video  recording  will  be  taken and  if  possible,  a  copy  of  photo  identity  proof  of  such beneficiary will be maintained.
- If the detailed investigation reveals that the report/complaint/allegation against  the hospital is not valid  and  no  malpractices  are  detected,  suspension  will be  revoked  and  operations  as  usual  will  be  initiated.  All attempts will be made by SHA to revoke the suspension within 5 working days of the investigation report submitted. In case  of any delay, a report  must  be submitted to CEO SHA, citing the reasons for the same.
- If the detailed investigation reveals that
- the

- suspicion/alleged malpractice on the part of the Hospital are valid  ,  the  SHA  may  recommend  suspension for a specified
- time, not exceeding 6 months.
- However, if the original cause of suspicion/alleged mischievous activities on the part of Hospital are not valid but additional malpractices are identified, a new show-cause notice  will  be  issued  to  the  Hospital.  All  attempts  will  be made to issue the show cause notice within 7 working days of  noticing  such  malpractices.  The  Hospital  will  not  be allowed more than 10 working days to respond, and a similar process of investigation will be followed. The time duration may be decided by the SHA on a case-to-case basis.

## 7.2.1.3 Suspension of the Hospital

-  Upon receiving an investigation  report  indicating  sufficient evidence  or  suspicion  of  malpractice  by  an  Empanelled Health  Care  Provider  (Hospital),  the  State  Health  Agency (SHA) will issue a show-cause notice to the Hospital within 5 working days
-  This  investigation  includes  field  visits,  examination  of case papers, discussions with beneficiaries, and review of hospital records. The investigation aims to be completed  within  10  working  days  of  issuing  a  showcause notice
-  The  notice  will  instruct  the  Hospital  not  to  contact  the beneficiaries involved, as this could lead to evidence tampering,  which  may  result  in  legal  action.  Beneficiary statements are recorded in their known language, confirmed by them, and self-attested, with video recordings and photo IDs collected when possible
-  Notices are sent to the Hospital's registered email and via speed post or hand delivery. The notice will specify the SHA email for response submission, and proof of receipt must be secured by the SHA.
- 
- The Hospital must respond within 5 working days, providing supporting evidence. SHA to confirm receiving the notice to the  hospital  within  5  working  days,  if  the  Hospital  denies

- receiving the notice, SHA will resend it, requiring acknowledgment, and the Hospital must  respond  within  5 working days.
-  If  no  response  is  received,  the  Hospital  will  be  suspended, blocking new pre- authorizations for up to 6 months, though existing patient treatments will continue.
-  Suspension notifications will be shared with the Hospital on registered mail/SMS.
-  If response received but is unsatisfactory, further information  may  be  requested,  and  failure  to  provide  it within 5 working days could result in immediate suspension not extending 6 months
-  If response received and is satisfactory, then the suspension may be revoked
-  If  no  malpractices  are  found,  the  suspension  is  revoked  on immediate basis of the report submission
-  If malpractices are confirmed, suspension but not extending 6 months timelines
-  Direct suspension along with show-cause, if the SHA obtains irrefutable evidence that the action of Hospital have or may cause grievous harm to the patient's health or life, SHA may immediately suspend the Hospital not extending 6 months timelines

## 7.3

## De-Empanelment

- Hospitals may be de-empanelled based on SEC recommendations if found non- compliant.
- De-empanelled hospitals cannot seek  re-empanelment for  a minimum period of 1 year.

## 7.3.1

## Presentation of case to the SEC and De-empanelment

-  Presentation  of  case  for  de-empanelment  may  be  initiated by SHA after conducting proper disciplinary proceedings as outlined  above.  The  SEC  will  meet  within  30  working days/emergency meeting could be scheduled in exceptional circumstances of the case being referred. All relevant

documents including the detailed investigation report will be submitted to the SEC either at the time of case filing or at least 10 working days prior to the meeting. The SEC must ensure that the Hospital has been issued  a  show-  cause  notice  seeking  an  explanation  for  the  alleged malpractice.  Both  parties  (SHA  and  Hospital)  will  be  provided  a  fair opportunity  to  present  their  case  with  necessary  evidence  at  the meeting conducted by SEC.

-  If  the  SEC  finds  that  the  complaint/allegation  against  the Hospital  is  valid,  it  will  order  de-  empanelment  of  the Hospital  based  on  appropriate  legal  advice  along  with additional disciplinary actions like penalties, FIR etc. as it may deem fit.
-  In case the SEC  does not find adequate supporting evidence against the Hospital, it may revoke the suspension  of  the  Hospital  or  reverse/modify  any  other disciplinary action  taken  by  SHA  against  the  Hospital, while  making  clear  observations  and  reasons  underlying the final decision.
-  All attempts shall be made to take the final decision within 30  working  days  of  1st  SEC  meeting  and  in  case  of  any delay,  a  report  must  be  submitted  to  CEO  SHA,  citing  the reasons for the same.
-  All  attempts  shall  be  made  to  implement  any  disciplinary proceeding as decided by SEC within 30 working days of the decision  taken  by  SEC  and  in  case  of  any  delay,  a  report must  be  submitted  to  PS/AS-Health  and  Family  Welfare Department of the State, citing the reasons for the same.
-  If either party is not satisfied by the decision of SEC, they can approach competent authority as per the grievance redressal guidelines.

## 7.3.2

## Actions to be taken after De-empanelment

Once the hospital has been de-empaneled, a letter/email will be sent to the  Hospital  regarding  the  decision  at  registered  address/registered email  ID/of  the  Hospital  within  3  working  of  the  decision.  Once  de-

empaneled,  new  pre-  authorization  will  be  disabled,  and  the  existing pre- authorizations/ treatment will have to be completed.

-  A  decision  may  be  taken  by  the  SEC  to  ask  the  SHA  to either  lodge  an  FIR  in  case  there  is  suspicion  of  criminal activity  or  take  such  other  permissible  legal  action  under applicable laws of India.
-  In  case  of  confirmed  acts  of  professional  misconduct  and violation  of  medical  ethics,  the  appropriate  professional medical bodies/council at the national/state level should be informed of the details of the case, the treating doctor and the hospital involved. The Medical Council and State Medical Council should take it up and take appropriate action as per the  Code  of  Medical  Ethics  Regulation,  2002  and/  or  such necessary action as  may  be  required  as  per  the  applicable laws.  This  information  will  be  sent  with  other  Insurance Companies, ESIC, CGHS, IRDAI and other relevant regulatory bodies and to NHA.
-  A list of de-empaneled hospitals will be enlisted on NHA and SHA websites. The list should be prominently displayed and easily  accessible  on  the  website  to  ensure  beneficiary awareness.  SHA  may  notify  in  the  local  media  about  the entities  where  malpractice  is  confirmed,  and  the  action taken against the Hospital engaging in malpractices.
-  The  period  of  de-empanelment  would  be  for  1  year,  unless stated  otherwise.  Once  de-  empaneled,  the  Hospital  cannot seek  re-empanelment  until  completion  of  1  year  from  the date  of  such  de-empanelment.  Healthcare  service providers will not be allowed to change their names and re-apply. The concerned local teams will keep a check on such practices. In case  SHA/SEC  decides  to  re-empanel  an  hospital  within  a period  of  1  year,  the  same  may  be  flagged  in  the  system through the HEM portal. The reason for re- empanelment of the Hospital will also be documented in the HEM web portal.
-  If it is a hospital chain, only the branch will get de-empaneled while  the  other  branches  of  the  hospitals  will  continue  to function.
-  Based on the severity of the offence, SEC may de-empanel

the  Hospital  for  more  than  2  years  or  may  blacklist  a hospital.  In  such  cases,  the  SHA/SEC  will  inform  NHA  and PS/AS (Dept. of Health and Family Welfare) of the concerned state  of  its  decision  along  with  a  detailed  explanation/ recorded reason for the same.

|                                                                       | Timeline for Disciplinary empanelment                                 | Proceedings                                                           | and                                                                   | De-                                                                   |
|-----------------------------------------------------------------------|-----------------------------------------------------------------------|-----------------------------------------------------------------------|-----------------------------------------------------------------------|-----------------------------------------------------------------------|
| Investigation of suspect claims                                       | Investigation of suspect claims                                       | Investigation of suspect claims                                       | 10 working days of flagging the cause                                 | 10 working days of flagging the cause                                 |
| Show-cause Notice Issuance                                            | Show-cause Notice Issuance                                            | Show-cause Notice Issuance                                            | 7 working days submission investigation report                        | of of                                                                 |
| Response Hospital                                                     | to Show-cause                                                         | Notice by                                                             | Within 5 working days                                                 | Within 5 working days                                                 |
| Clarification Hospital                                                | of the                                                                | Response from                                                         | Within 3 working days                                                 | Within 3 working days                                                 |
| Issuance Decision                                                     | of Show-cause                                                         | Notice post                                                           | Within 2 working days                                                 | Within 2 working days                                                 |
| Detailed Investigation along with submission of Investigation Report  | Detailed Investigation along with submission of Investigation Report  | Detailed Investigation along with submission of Investigation Report  | Within 10 working days                                                | Within 10 working days                                                |
| Response to Suspension by Hospital                                    | Response to Suspension by Hospital                                    | Response to Suspension by Hospital                                    | Within 5 working days                                                 | Within 5 working days                                                 |
| Hospital can file an appeal against suspension Within 30 working days | Hospital can file an appeal against suspension Within 30 working days | Hospital can file an appeal against suspension Within 30 working days | Hospital can file an appeal against suspension Within 30 working days | Hospital can file an appeal against suspension Within 30 working days |
| Final decision to suspend/suspend with fine/ revoke suspension/de-    | Final decision to suspend/suspend with fine/ revoke suspension/de-    | Final decision to suspend/suspend with fine/ revoke suspension/de-    | Within 30 working days of the 1st SEC meeting                         | Within 30 working days of the 1st SEC meeting                         |

## 7.4 Gradation of Offences

Based on the investigation report/field audits, the following gradation  of  penalties  may  be  levied  by  the  SEC.  However, this  tabulation  is  intended  to  be  as  guidelines  rather  than mandatory rules.

These penalties are recommendatory in nature and the state may  inflict  larger  or  smaller  penalties  depending  on  the severity/regularity/scale/intentionality on a case-to-case basis. If any hospital is found to be involved in unethical practices/malpractices/severe offence, then legal action may also be taken by SHA.

## 7.4.1 Penalties

| Penalties for Offences by the Hospital   | Penalties for Offences by the Hospital                                                                                                                                                                                                          | Penalties for Offences by the Hospital                                                                                      | Penalties for Offences by the Hospital   |
|------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------|------------------------------------------|
| Case                                     | IssueFirst Offence                                                                                                                                                                                                                              | Second Offence                                                                                                              | Third Offence                            |
| Illegal cash payments by beneficiary     | Full refund and penalty upto 5 times of illegal payment to be paid to the SHA by the hospital within 7 working days of the receipt of notice. SHA shall thereafter transfer money to the beneficiary, charged in- actual, within 7 working days | In addition to actions as mentioned for first offence, rejection of claim for the case, suspension of hospital              | De- empanelme nt/ blacklisting           |
| Billing for services not provided        | Rejection of claim and penalty upto 5 times the amount claimed for services not provided, to SHA                                                                                                                                                | Rejection of claim and penalty of upto10 times the amount claimed for services not provided, to SHA, suspension of hospital | De- empanelme nt/ blacklisting           |
| Up coding/ Unbundling / Unnecessa ry     | Rejection of claim and penalty of up to 10 times the excess amount claimed due to up coding/unbundling/ unnecessary procedures, to SHA                                                                                                          | Rejection of claim and penalty of up to 20 times the excess amount claimed due to up coding/unbundli                        | De- empanelme nt/ blacklisting           |

| Procedures                           | SHA may decide amount based on severity of the breach                                                                                                                                                                    | the the ng/ unnecessary procedures, to SHA, suspension of hospital                                                    |                             |                                |
|--------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------|-----------------------------|--------------------------------|
| Wrongful beneficiary identificati on | Rejection of claim and penalty of up to 5 times the amount claimed for wrongful beneficiary identification to SHA if hospital is found to be in connivance SHA may decide the amount based on the severity of the breach | Rejection claim penalty of to 10 times amount claimed wrongful beneficiary SHA if hospital found to be in connivance, | of and up the for to the is | De- empanelme nt/ blacklisting |
|                                      |                                                                                                                                                                                                                          | suspension of hospital                                                                                                |                             |                                |
|                                      | In case of minor gaps:                                                                                                                                                                                                   |                                                                                                                       |                             |                                |

| Non- adherence to minimum criteria for empanelmen t, quality and service standards as laid under PM- JAY   | Show cause notice with compliance period of 2 weeks for rectification and rejection of claims related to gaps In case major gaps and wilful suppression/misrepresent ation of facts: Show cause notice with compliance period of 2 weeks for rectification, suspended if not rectified after 2 weeks and rejection of claims related to gaps and   | Penalty of up to 5 times of all the approved claims related to the gaps observed and suspension until rectification of gaps and validation by DEC De- empanelment and penalty of up to 5 times of all the approved claims related to the gaps observed   |
|------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|

## 8. Grievance Management

- The Grievances of the Hospital will be managed as per the Grievance redressal Guideline issued  by NHA and SHA.

## 9. Annexures

## 9.1 Annexure 1: Criteria for Empanelment

This annexure contains the basic minimum criteria for empanelment  for  all  the  healthcare  service  providers.  It  also covers the criteria in Aspirational Districts and additional criteria for empanelment of specialties under the scheme.

## 9.1.1 Minimum Criteria

A hospital would be empaneled as a network private hospital with the approval of the respective State Health Agency if it adheres to the following minimum criteria:

- Should have at least 10 inpatient beds with adequate spacing and supporting staff as per norms:
- General ward - @80 sq ft per bed, or more in a room with basic  amenities:  bed,  mattress,  linen,  water,  electricity, cleanliness,  patient-friendly  common  washroom,  etc.  NonAC but with fan/cooler and heater in winter.
- It  should  have  adequate  and  qualified  medical  and  nursing staff  (doctors  and  nurses),  physically  in  charge  round  the clock; (necessary certificates to be produced during empanelment). The state should have specific guidelines on the number of hospitals a doctor can work.
- Fully  equipped  and  engaged  in  providing  medical  and surgical services, commensurate to the scope of service/available specialties and number of beds.
- Round-the-clock  availability  (or  on-call)  of  Orthopaedic Surgeon, General Surgeon, and anaesthetist services.
- Qualified  nurses  per  unit  per  shift  shall  be  available  as  per requirement laid down by the Nursing Council/Clinical Establishment  Act/State  government  rules  &  regulations  as applicable from time to time. Norms vis-a-vis bed ratio may be spelled out.
- Hospital should have adequate arrangements for round-theclock support systems required for the above services like pharmacy, blood bank, laboratory, dialysis unit, endoscopy

- investigation  support,  post-op  ICU  care with ventilator support (mandatory for providing surgical packages), X-ray facility, etc., either ‗in-house' or with ‗outsourcing arrangements'  with  appropriate  agreements  and  in  nearby vicinity.
- Separate  male  and  female  wards  with  toilet  and  other  basic
- amenities.
- 24 hours emergency services managed by technically qualified  staff.  Casualty  should  be  equipped  with  monitors, defibrillator, nebulizer with accessories, crash cart, resuscitation equipment, oxygen cylinders with flow metre/tubing/catheter/face mask/nasal prongs, suction apparatus, etc., and with attached toilet facility.
- ●
- Round-the-clock ambulance services (own or tie-up).
- Fully equipped Operation Theatre of its own  with qualified  nursing  staff  under  its  employment  round  the clock.
- ●
- Post-op ward with ventilator and other required facilities.

## It  is  mandatory  to  be  equipped  with  an  Intensive  Care  Unit  (for medical/surgical ICU/HDU)

DEC where they find a requirement of  empanelling  a  hospital  to ensure  the  availability  of  an  adequate  number  of  empaneled facilities within the district may  recommend  relaxations in empanelment criteria for approval to the SHA. This recommendation must be approved by the SHA, with a clear and documented rationale provided. SHA to ensure that the quality of medical care rendered to the patient is not compromised by this relaxation. The following minimum requirements cannot be compromised:

- Minimum  Number  of  Inpatient  Beds:  Should  have  5 inpatient  beds  with  adequate  spacing  and  supporting staff as per norms, unless providing daycare packages covered under PM- JAY.
- Minimum Number of Doctors and Nursing Staff as per the requirement of speciality for which the hospital is

## empanelled.

- Licences and Certificates: A hospital registration certificate as per state law is mandatory, if applicable.
- Equipment  Requirements:  The  hospital  needs  to  be  fully equipped according to the defined scope of services.
- Emergency Equipment: Must have life-saving and resuscitation equipment as required by the facility.
- ICU/HDU Positioning: The ICU/HDU unit must be situated in the same building or have a referral linkage with hospitals where  ICU/HDU  facilities  are  available  (mandatory  selfdeclaration) through an MoU or tie-up.
- OT Services: Fully equipped Operation Theatre with qualified nursing staff (minimum qualification: ANM Course) under its employment round the clock.
- Casualty  Equipment:  The  casualty  department  should  be equipped with a minimum Emergency Tray.

## 9.1.2 Qualified Medical Personnel

|   S.N o | Speciality         | Required Doctor's Qualification                            |
|---------|--------------------|------------------------------------------------------------|
|       1 | Ambulance Services | Trained certified in BLS                                   |
|       2 | Burns Management   | MCH/ DNB/ Equivalent in (Plastic Surgery)                  |
|       3 | Cardiology         | MD/DNB or equivalent to internal Medicine; DM (Cardiology) |
|       4 | CTVS               | MCH/DNB / equivalent (Cardiothoracic Surgery)              |

&

in

|   5 | Emergency Room Packages        | MD/DNB in Emergency Medicine, Medicine, DMin Cardiology                                                         | General                                                                                                         |
|-----|--------------------------------|-----------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------|
|   6 | ENT                            | MS/DNB/ Diploma or equivalent in (ENT)                                                                          | MS/DNB/ Diploma or equivalent in (ENT)                                                                          |
|   7 | General Medicine MBBS          | (Essential), MD/DNB(Medicine)/ DM/DNB (Paediatric) Desirable                                                    | (Essential), MD/DNB(Medicine)/ DM/DNB (Paediatric) Desirable                                                    |
|   8 | General Surgery                | MS/DNB/ equivalent (General Surgery)                                                                            | MS/DNB/ equivalent (General Surgery)                                                                            |
|   9 | Neurosurgery                   | MCH/ DNB/ Equivalent in (Neurosurgery)                                                                          | MCH/ DNB/ Equivalent in (Neurosurgery)                                                                          |
|  10 | Obstetrics & Gynaecology       | MS /DGO/DNB or equivalent in (Obstetrics Gynaecology)                                                           | &                                                                                                               |
|  11 | Ophthalmology                  | MD/MS/DNB/PG Diploma or equivalent Ophthalmology                                                                | in                                                                                                              |
|  12 | Oral & Maxillofaci al Surgery  | MDS (Oral & Maxillofacial Surgery)                                                                              | MDS (Oral & Maxillofacial Surgery)                                                                              |
|  13 | Orthopaedics                   | Diploma in Orthopedics with 5 years' Experience (Essential), MS /DNB or equivalent in Orthopaedics (Desirable ) | Diploma in Orthopedics with 5 years' Experience (Essential), MS /DNB or equivalent in Orthopaedics (Desirable ) |
|  14 | Paediatric Medical Management  | MD/DNB/DCH/ equivalent (Paediatric)                                                                             | MD/DNB/DCH/ equivalent (Paediatric)                                                                             |
|  15 | Paediatric Surgery             | MCH/ equivalent (Paediatric Surgery)                                                                            | MCH/ equivalent (Paediatric Surgery)                                                                            |
|  16 | Plastic Reconstructive Surgery | & MCH/ DNB- Plastic Surgery / Reconstructive Surgery                                                            | & MCH/ DNB- Plastic Surgery / Reconstructive Surgery                                                            |
|  17 | Polytrauma                     | MS/DNB/Equivalent (General MS/DNB/Equivalent (Orthopaedic surgery)                                              | Surgery);                                                                                                       |
|  18 | Urology                        | MS/DNB or equivalent in Urology                                                                                 | MS/DNB or equivalent in Urology                                                                                 |

*****