GOVERNMENT OF INDIA

MINISTRY OF LABOUR & EMPLOYMENT

“National Empanelment of audit agencies to conduct medical

audits for Rashtriya Swasthya Bima Yojana [RSBY]”

Request for Empanelment (RFE)Ministry of Labour and Employment

10/30/2014

(MoLE reserves the right to cancel this request for empanelment (RFE) and / or invite afresh with or without amendments to this request for empanelment, without liability or any obligation for such request for empanelment and without assigning any reason. Information provided at this stage is indicative and MoLE reserves the right to amend / add further details in the RFE document.)

Table of Contents1. Fact Sheet.................................................................................................................22. Request for Empanelment (RFE)...........................................................................33. Part I – General information...................................................................................43.1. Definitions............................................................................................................43.2. Procedure for obtaining RFE document................................................................43.3. Language of bid and correspondence..................................................................43.4. Forwarding of bids................................................................................................43.5. Clarification regarding contents of the RFE..........................................................43.6. Modification and withdrawal of bids.....................................................................43.7. Clarification regarding contents of bids................................................................43.8. Submission of bids...............................................................................................43.9. Price of RFE document.........................................................................................53.10. Time and date for opening of bids........................................................................53.11. Opening of RFE documents..................................................................................53.12. Place of opening of the bids.................................................................................53.13. Rejection of bids...................................................................................................53.14. Validity of bids.....................................................................................................53.15. Special instructions..............................................................................................53.16. Content of the bids...............................................................................................63.17. Amendments in RFE.............................................................................................63.18. Validity of empanelment......................................................................................64. Part II: Essential details for empanelment..........................................................74.1. Genesis of Rashtriya Swasthya Bima Yojana (RBY)..............................................74.2. Benefits of Rashtriya Swasthya Bima Yojana (RBY)..............................................74.3. Objective of the scheme......................................................................................74.4. Financing of the scheme......................................................................................84.5. Current status of the scheme...............................................................................84.6. Ecosystem of RSBY...............................................................................................84.7. Processes of RSBY................................................................................................94.8. Current challenges within RSBY.........................................................................104.9. Need for audit within RSBY.................................................................................104.10. Objectives of third party medical audit..............................................................114.11. Scope of Audit....................................................................................................125. Part III – Standard Conditions of RFE.................................................................146. Part IV: Evaluation of bids for empanelment....................................................166.1. Pre-conditions....................................................................................................166.2. Pre-qualification criteria.....................................................................................166.3. Documents required...........................................................................................176.4. Validity of empanelment....................................................................................176.5. De-empanelment or termination of empanelment.............................................176.6. Effect of de-empanelment..................................................................................177. Part V: Annexures..................................................................................................18Annexure 1: Format for pre-bid query....................................................................18Annexure 2: Documents required to be submitted with bid...............................18Annexure 3: Details of zone applied for and calculation of required turnover 19Annexure 4: Organisational Profile.........................................................................19Annexure 5: Financial turnover of company in last 3 financial years................20Annexure 6: Experience of conducting audit involving field survey..................21Annexure 7: Undertaking for qualification bid......................................................23

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REQUEST FOR EMPANELMENT (RFE) FORMAT

(Director General of Labour and Welfare, Ministry of Labour and Employment)

Invitation of bid for “National Empanelment of audit agencies to conduct medical audit for Rashtriya Swasthya Bima Yojana [RSBY]”

Request for Empanelment (RFE)1. Fact Sheet

No.

Item Information

1 Description of work National empanelment of agencies by Ministry of Labour and Employment (MoLE), Government of India to conduct medical audits for RSBY. The qualified agencies shall be eligible to bid in respective zones (comprising of states) as and when notified by the respective states or its authorised representatives.

2 Date of issue of RFE

30th October, 2014

3 Last date of submission of RFE

21st November, 2014 by 1700 hrs

4 Submission of RFE Every bid should be properly sealed and should be in accordance with instructions given in Point 3.8 of Part I – General Information of this document.

5 Interactive Session There will be an Interactive Session on 7th November, 2014 at 11:30 am at Mini Conference Room at Shram Shakti Bhawan, New Delhi.

6 Clarifications/queries regarding bid

Clarifications/queries, if any, can be sent to Assistant Director (RSBY- Monitoring) in format provided in Annexure 1, by 7th

November, 2014 before 5 pm. The queries can be sent at following address:

Assistant Director (RSBY - Monitoring),Office of Director General Labour and Welfare,Ministry of Labour and Employment, Government of India, Jaisalmer House, 26, Man Singh Road, New Delhi- 110001, Phone: 011- 2338 5241 e-mail: suresh.singh25@nic.in

Interested bidders can raise their queries in advance in the prescribed format in Annexure 1. MoLE shall publish the response to the queries on the RSBY website – www.rsby.gov.in. Bidders are requested to check the published responses on a regular basis.

7 Receipt of RFE – Last date and time

21st November, 2014by 1700 hrs

8 Opening of bid At 11am on 25th November, 2014 at Conference Room, Jaisalmer House, 26, Man Singh Road, New Delhi- 110001

9 Designated Ministry for

Ministry of Labour and Employment, Government of India

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No.

Item Information

execution of work

10

Terms & conditions of work

As per the RFP document which would be issued to empaneled agencies in that zone.

2. Request for Empanelment (RFE)

This RFE is divided into four parts as follows: a. Part I – Contains general information and instructions for the bidders about the RFE,

such as the time, place of submission and opening of RFE, validity period of RFE etc.

b. Part II – Contains essential details of the requirements for empanelment of medical audit agencies with MoLE.

c. Part III – Contains standard conditions of RFE, which will form part of the contract with the successful bidder. Some additional conditions will be communicated at RFP stage.

d. Part IV – Contains evaluation criteria for “Empanelment of medical audit agencies”.

Part I – General information 2.1. Definitions

Unless repugnant to the subject or context of usage, the following expressions used herein shall carry the meaning hereunder respectively assigned to them, namely:

The expression “MoLE” occurring in the RFE document shall mean Ministry of Labour and Employment, Shram Shakti Bhawan, Rafi Marg, New Delhi – 110001 (India) and shall include Secretary, Labour and Employment, his /her successors and assigns.

The expression “Bidder or Agency” means an agency that submits the bid and shall include the successors and permitted assigns. In context of this RFE, the terms “Bidder‟ and “Agency‟ have been used, interchangeably.

“Empanelled audit agency” shall mean an agency declared qualified for empanelment by MoLE. Qualified bidders shall be eligible to bid for RSBY medical audit request for proposals (RFPs) during the empanelment validity period.

“PAN” shall mean Permanent Account Number allotted by Income Tax Department, Government of India.

“RSBY” means “Rashtriya Swasthya Bima Yojana”. “SNA” shall mean the State Nodal Agency, responsible for implementation

of RSBY in the respective State/UT.

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2.2. Procedure for obtaining RFE document The RFE document can be downloaded from the RSBY website at www.rsby.gov.in .

2.3. Language of bid and correspondence The language of bid, documents exchanged and correspondence on any matter incidental thereto between the bidder and MoLE shall be English.

2.4. Forwarding of bids Bids should be forwarded by bidders under their original memo on letter head. All pages of the response to RFE submitted shall contain initials of the authorized signatory on behalf of the bidder.

2.5. Clarification regarding contents of the RFE A prospective bidder who requires clarification regarding the contents of the bidding documents shall notify to MoLE in writing about the clarifications sought in the format provided in Annexure 1 through e-mail to suresh.singh25@nic.in, not later than 5 pm on 7th November 2014. Copies of the query and clarification by MoLE will be made available to all bidders.

2.6. Modification and withdrawal of bids No bid shall be modified or withdrawn after the deadline for submission of bids.

2.7. Clarification regarding contents of bids During evaluation of bids, MoLE may, at its discretion, ask the bidder for clarification on their bid. The request for clarification will be given in writing and no change in substance of the bid will be sought, offered or permitted. No post-bid clarification on the initiative of the bidder shall be entertained.

2.8. Submission of bids The RFE documents must be submitted in a sealed envelope. On the cover of the envelope, following details should be written:“<Title of the RFE><Date of submission of response><Number and names of zones applied for>”. in three clear and different lines.For example – the last line can be written as “2 Zones – North and South”The envelope should be addressed to:

Assistant Director (RSBY- Monitoring),Office of Director General of Labour & Welfare,

Ministry of Labour and Employment,Government of India,

Jaisalmer House, 26, Man Singh Road,New Delhi- 110001

The sealed envelope should contain two sealed envelopes:- 1. First sealed cover (marked as “C1 – Tender Fee”) – containing RFE

document tender fee of INR 1000/- as DD/Bankers Cheque addressed to “Pay & Accounts Officer (MS), Ministry of Labour and Employment, New Delhi” along with letter as per Annexure 4.

2. Second sealed cover (marked as “C2 – Response to RFE”) –Bid as per Annexure-2.

The response to the RFE should be put in RFE box at Reception Office, Office of DGLW, Jaisalmer House, 26, Man Singh Road, New Delhi – 110001. Responses sent through courier/registered post or any other means will not be

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entertained. One bidder should submit only one bid, even if it is bidding for more than 1 zone.

2.9. Price of RFE document RFE document price INR 1000/- as DD/Bankers Cheque of any bank drawn in favour of the “Pay & Accounts Officer (MS), Ministry of Labour and Employment, New Delhi”, submitted along with letter as per Annexure 4. RFE submitted without instrument of cost of RFE will not be entertained. No exemption shall be granted on this account for any reason.

2.10. Time and date for opening of bids At 11 am on 25th November, 2014 (If due to any exigency, the due date for opening of the bids is declared a holiday, the bids will be opened on the next working day at the same time. If this is not feasible, then it will be opened at any other day/time, as notified by MoLE).

2.11. Opening of RFE documents The envelopes containing the bids and cost of RFE will be opened on the day of opening of the RFE by a designated officer/committee. Bidders or their representatives may be present at the time of opening of bids. Bids that are not according to the RFE requirements will be returned in due course of time. The names of all bidders and other such details will be read out / announced at the time of the opening of bids, at the sole discretion of MoLE or as MoLE may consider appropriate.

2.12. Place of opening of the bids Office of Director General of Labour and Welfare, Jaisalmer House, 26, Man Singh Road, New Delhi- 110001. The bidders may depute their representatives, duly authorized in writing, to attend the opening of bids on the due date and time. This event will not be postponed due to non-presence of a representative from any bidder.

2.13. Rejection of bids Canvassing by the bidder in any form, unsolicited letter/communication and post-RFE submission corrections may invoke summary rejection of bid. All conditional bids will be rejected.

2.14. Validity of bids The bids shall remain valid for 180 days from last date of submission of the bids.

2.15. Special instructions All communication including any changes in content of RFE, date of events, clarifications etc. shall only be published on the RSBY website www.rsby.gov.in and may not be communicated separately to agencies (prospective bidders).

2.16. Content of the bids The bid should not contain alterations, omissions or additions, unless such alterations, omissions or additions are signed by the authorized signatory of the bidder. The bidder should attach clearly marked and referenced continuation sheets if the space provided in the prescribed formats is insufficient. Alternatively, the bidder may format the prescribed forms making due provision for incorporation of the requested information, but without changing the contents of such prescribed formats.

2.17. Amendments in RF E MoLE at its discretion may amend the RFE and all such amendments shall become part of this RFE. No interpretation, revision or communication regarding this RFE is valid, unless made in writing.

2.18. Validity of empanelment The validity of empanelment would be for 5 years from the date of empanelment.

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3. Part II: Essential details for empanelment

3.1. Genesis of Rashtriya Swasthya Bima Yojana (RBY)

Social security and healthcare for all has been the motto of Government of India, and it has taken various steps in this regard.One of the important policy milestones is the Unorganized Workers Social Security Act (2008) enacted by the central government to provide for the social security and welfare of the unorganized workers. This act recommends that the central government provide social security schemes to mitigate risks due to disability, health shocks, maternity, and old age, which all unorganized workers get exposed to, and are likely to suffer from. A number of Central schemes are in operation and have provided protection to the beneficiaries from the unorganized worker segment. Additionally, a large number of labour welfare funds set up by both central and state governments on non-contributory basis provide social security as well as financial assistance in some cases to the unorganized workers in certain occupations.One such policy initiative in the health insurance space is RSBY that was launched in early 2008 and became operational from 1st April 2008. RSBY was initially designed to target only the Below Poverty Line (BPL) households, but has recently been expanded to cover a number of non-BPL categories of informal sector workers, including street vendors, domestic workers, beedi workers, building and construction workers, and most importantly the workers who have worked for more than 15 days under MGNREGS. Government of India and the State Governments are co-financing the premium cost for enrolled beneficiaries. The program has the target to cover 70 million households by the end of the Twelfth Five Year Plan (2012-17). Its service delivery model – demand financing, freedom of choice among accredited government and private hospitals, and cashless service reimbursable to provider on a pre-determined package price basis, could become a strong pillar for the universal health care system laid down by Government of India.

3.2. Benefits of Rashtriya Swasthya Bima Yojana (RBY)

RSBY has been launched by Ministry of Labour and Employment, Government of India to provide health insurance coverage for Below Poverty Line (BPL) families. The objective of RSBY is to provide protection to BPL households from financial liabilities arising out of health shocks that involve hospitalization. The beneficiaries under RSBY are entitled to hospitalization coverage up to INR 30,000/- for most of the diseases that require hospitalization. The government has even fixed the package rates for the hospitals for a large number of interventions. Pre-existing conditions are covered from day one and there is no age limit. The coverage extends to five members of the family which includes the head of household, spouse and up to three dependents. The beneficiaries need to pay only INR 30/- as registration fee while Central and State Government pays the premium to the insurer selected by the State Government on the basis of a competitive bidding.

3.3. Objective of the scheme

The main objective of RSBY scheme is to provide the enrolled beneficiaries from the unorganized sector with a health insurance cover, thereby protecting them from the

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financial shocks arising out of an emergency medical situation. It aims to reduce the out of pocket expenses of the target population for every visit to hospital.

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3.4. Financing of the scheme

RSBY being a centrally sponsored scheme, majority of the funding comes from central government, i.e. 75% of premium is paid by central government, while remaining 25% of premium is paid by state government (number changes to 90% & 10% in case of north eastern states and Jammu and Kashmir). The beneficiary has to pay a one-time fee of INR 30/- at the time of enrolment. Apart from this, the central government also pays 100% of the card cost. As of now the notional cost of issuance of card is INR 60/-. The beneficiaries contribution of INR 30/- is used by the State Nodal Agency (SNA) to meet their administrative expenses. In subsequent years at the time of renewal of policy INR 30/- will be adjusted from the premiums.

3.5. Current status of the scheme

As of now the scheme is operational in 398 districts of 25 states. There are 10,116 hospitals empaneled across these states out of which 5,941 are private sector hospitals and 4,175 are public sector hospitals. During FY 2013-14 approximately 3 crore families were in possession of active RSBY cards.

3.6. Ecosystem of RSBY

Note: Changes in roles and any policy decisions shall be communicated by MoLE / SNA

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3.7. Processes of RSBY

A brief of the various processes under RSBY is provided below:a. Data preparation and pre-enrolment : The benefits of RSBY scheme, which was

launched for BPL families, have been extended to various other categories viz. Beedi worker, MGNREGA worker, Porters/coolies, taxi drivers etc. Government has identified different ministries/departments to identify the beneficiaries from these categories. These ministries/departments provide the list of beneficiaries to State Nodal Agency (SNA) of respective state. SNA, in turn, consolidates the data and passes it on to MoLE after validating and removing the duplicates. MoLE, then generates URN (Unique relationship number), a unique number provided to each eligible family. The data is then provided to enrolment agency to capture photographs and biometric details of identified family members.

b. Enrolment : The enrolment agency downloads the data from the central database of MoLE using FTP and visits all the assigned villages as per route plan approved by district authorities. It captures photographs and biometric data of all family members. To identify the family head, and other family members, district authorities deploys a Field Key Officer (FKO). FKO authenticates all the family with his biometric credentials. One smart card is provided to every eligible family, with photograph of head of family on card and biometric details of 4 other family members. Before delivering the card to the head of family, the enrolment operator checks the data written on the card to ensure that the finger prints recorded are of acceptable quality for future authentication purposes. Details of all the beneficiary cards issued during the day of enrolment are also available in the FKO card. The enrolment agency is also required to carry out awareness exercise using IEC materials to improve the % of family enrolled.

c. Wellness check 1 : One member from each enrolled family which has received the card is entitled to avail free wellness check at identified public health facilities (PHFs). The basic health details of the member undergoing wellness check are captured on the smart card and detailed wellness check data is retained with MoLE too in the central database. The PHFs conducting wellness checks shall receive a payment of INR 100/- per card. The insurance company is responsible for mobilizing the beneficiaries for wellness check at the PHFs. Failure to mobilize beneficiary for wellness check will attract penalty for the insurance company.

d. Premium payment : The insurance company will receive the premium for all the cards issued at a rate discovered through open tender. To ascertain the number of cards issued, data received from FKO card will be taken in account.

e. Hospitalisation : Any member of the eligible family, which has received RSBY card can avail cashless medical services upto INR 30,000/- from any RSBY empaneled hospital. All the hospitals with required facility can be empaneled under RSBY scheme. After providing services to beneficiary, hospital reimburses a sum of INR 100/- as transportation charges to beneficiary and raises a claim with insurance company for services provided. Claims raised for a particular service should be as per approved package rates only.

1 Initiation of wellness check will be notified by MoLE.

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f. Claim settlement : The insurance company verifies the claims and makes the payment to hospital for services provided to beneficiary.

g. Kiosk management : A kiosk is set up at every district to provide different services to beneficiaries. The main services offered at kiosk are issue of duplicate and split cards. A duplicate card is issued to a beneficiary in case they have lost the card or the card has become non-functional. A split card is issued to a family, if some of its members are migrating to other place and want to carry part of the insurance cover with them. The cover amount is split between the two cards, as per request from head of family.

h. Complaint and grievance redressal management : Any stakeholder can log a complaint, using following channels to be made available - web portal, email, SMS, phone call to call center. A unique ticket number will be provided for every complaint logged, and every complaint will be tracked /escalated until resolved.

Note: The detailed process can be found in the operational manual published on the RSBY website at: http://www.rsby.gov.in/Documents.aspx?ID=2

3.8. Current challenges within RSBY

The RSBY scheme involves multiple types and number of transactions for each type of process above. Due to a large number of stakeholders at the field, the scheme is faced with challenges at the implementation level. Some of the key challenges encountered at the field level from a medical point of view are:

a. Hospital empanelment and de-empanelment is sometimes not transparent and some of the good hospitals are either not empaneled or their claims are not settled within time leaving them with no option but to refuse treatment or opt out of RSBY.

b. Beneficiaries are denied cashless treatment on several grounds such as non-functioning equipment, out of pocket expenses prior to initiating treatment, unavailability of services as compared during the hospital empanelment process

c. Hospitals often provide unauthorized/inappropriate treatment, either to charge more from the IC and/or beneficiary, or to discourage beneficiaries from availing services under RSBY.

d. Beneficiary has no flexibility to opt out of the hospital once a procedure is blocked on his card, nor he can go to any other hospital for availing treatment.

e. Fraudulent claims being raised and settled. Claims are also being rejected on flimsy grounds such as delayed claim request by hospital, paper requirements from hospital by IC, URN number not found in insurance company database, chip serial number not matching etc.

f. Claims are not reconciled - claims appearing in hospital books as outstanding are appearing as settled in insurance company books.

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g. Non-compliance to the decisions of SGRC/ DGRC/ NGRC by insurance companies and hospitals.

3.9. Need for audit within RSBY

Due to the multiple stakeholders and complexities involved in the operations, there is a need to monitor and keep checks on the processes in a regular manner. To make the monitoring of the scheme effective, various types of audits are being introduced. An illustrative description of the activities within medical audit envisaged is listed in Table 1 below, and further elaborated in the sections to follow.

Third party audit shall involve examination of field level procedures on a regular basis to ensure accuracy, authenticity and compliance to procedures and guidelines. It is an ongoing appraisal of the health and functioning of the program to determine whether the internal control mechanisms are effective. Audit inputs will also be used to identify areas of improvement in the program.

Note: This RFE document lists down illustrative audit requirements only for the purpose of empanelment, so as to provide an indication to the bidders on the nature of audit activity which is expected. The actual audit type, process, activities, data details, timelines and related information would be defined at the RFP stage by the stakeholder (such as an SNA) requesting for proposals from empaneled vendors.

Table 1: Category of audit

Category of Audit

Purpose (indicative) Initiator

Medical audit

(will be conducted by qualified medical audit professionals, mainly at hospitals and at times at field level)

The detailed scope, focus and purpose will be decided by SNA and will be shared at the RFP stage. The broad purpose, however is to ensure:

• Empaneled hospitals have requisite facility• Treatment actually provided to beneficiary

is as per norms• Hospitals are not resorting to unfair means• Insurance companies are not harassing

hospitals• Examine exceptions in treatment cases• Field verification of exceptions / treatments

State Nodal Agency (SNA)

The illustrative list of medical audits required at different processes/ entities is given in Figure 1 given below:

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Figure 1: Processes of RSBY and types of audit required (Illustrative only)

As per Figure 1 above, for the purpose of this RFE for empanelling medical audit agencies, there will not be any medical audit requirement for data preparation and pre-enrolment, enrolment and kiosk management processes respectively. Additionally, some audit types may not be applicable for agencies empaneled for medical audit.

3.10. Objectives of third party medical audit The overall objective of the audit is to conduct timely assessment of the medical aspect of the operations of the scheme with a view to obtaining reasonable assurance of adherence to the defined operational procedures. In particular, the third party auditors shall:a) Provide an independent opinion on the performance of the scheme on various

parameters in general and medical parameters in particular and report any exceptions which are in violation to the agreed procedures and guidelines of RSBY.

b) Provide an overall assessment of the operational and internal control systems that are in place, for the management of the scheme, so that related processes and protocols are followed in accordance with RSBY to achieve the stated objectives.

c) Suggest areas of improvement based on the assessment conducted to achieve the goals of the scheme.

3.11. Scope of Audit Some activities, identified so far, under different processes that are required to be audited are illustrated in the following section. MoLE / SNA can change/ add additional audits, as well as modify the audit parameters, activities, and periodicity based on the requirements and the status of the project/ issues observed in operations. Note: a. The audit categories, activities, sample type and periodicity are illustrative in

nature and exact scope shall be detailed in the RFP released by the State Nodal Agency (SNA).

The indicative medical audits to be conducted for RSBY are tabulated below:

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No

Activity to be audited (indicative)

Activities to be performed (indicative)

Sample type (indicative)

Periodicity (indicative and to be finalized by SNA)

1Audit for wellness checks at PHFs

Auditor will visit randomly selected wellness check centres on various days of wellness check, to ascertain that all laid down procedures are being followed.

System generated random sample

Ongoing during the wellness check window

2 Wellness check

For randomly selected system generated sample, auditor will verify the genuineness of reports submitted by well check agency

System generated random sample from wellness check conducted data

During wellness check window

3 Claims raised by hospital

For selected sample the auditor should verify the claim documents and meet/ call the beneficiary for appropriateness of claim. Cost of treatment of different kinds to be examined for any pattern

Randomly selected system generated records from the master set

Ongoing exercise

4

Empaneled hospitals for facilities claimed to be available & de-empanelled hospitals

 For selected sample, auditor will verify the facilities available in the hospital against the claims made at the time of request for empanelment. The auditor will also verify the grounds of de-empanelment of hospitals

Randomly selected system generated records from the master set, as well as field reports from beneficiaries, call center complaints, reports from pensioners

Once in a year

5

Assessment of hospital facilities to cater to the dominant forms of ailment vis-à-vis industry benchmarks

Look for most treated ailments in all hospitals and assess the competence of the hospital for treating such cases in terms of facilities

All empanelled hospitals

Once in six months

6

Audit to check utilization of RSBY card at hospitals pertaining to treatment provided

 For selected sample auditor will visit/call beneficiaries to ascertain treatment provided

System generated

Once in three months

7 Beneficiary rejection at hospital

Check from hospital data if there is any beneficiary track record of rejection. The auditor shall check all such smart card numbers

If no evidence maintained in hospital then ascertain during field visits for

Once in three months

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No

Activity to be audited (indicative)

Activities to be performed (indicative)

Sample type (indicative)

Periodicity (indicative and to be finalized by SNA)

through actual visits to beneficiaries

other items, the findings on rejection

8Claims rejected by insurance company

 For selected sample, auditor will verify reasons for rejection of claims

System generated random sample from hospital claim data

Continuous process with audit at hospital

9

To investigate complaints referred to DGRC/ SGRC/ NGRC

Agency will investigate the case, if instructed by DGRC/SGRC/NGRC

Cases referred by DGRC/SGRC/NGRC

Throughout the year

10

To investigate exceptional trends in medical cases at hospitals

Agency will investigate such patterns both at hospital level and through visits to ascertain from beneficiaries

Taken from typical exceptions seen in hospital treatment records

Once in six months

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4. Part III – Standard Conditions of RFE

The bidder is required to give confirmation of their acceptance of the standard conditions of the Request for Empanelment (RFE) mentioned below which will automatically be considered as part of the contract for “empanelled audit agencies” selected and empanelled by MoLE. Failure to do so may result in rejection of the bid submitted by the bidder.

4.1. Law: The contract shall be considered and made in accordance with the laws of the Republic of India. The contract shall be governed by and interpreted in accordance with the laws of the Republic of India.

4.2. Effective date of the empanelment of agencies: The empanelment of agency as an “empaneled audit agency” shall come into effect on the date of notification by MoLE or its assigns. The list shall also be put on website and shall remain valid for a period and manner laid down in conditions of this RFE.

4.3. Arbitration: Any dispute, disagreement or question arising out of or relating to the status of agency as “empanelled audit agency” which cannot be settled amicably, may be resolved through arbitration as per extant laws in India. Location for any legal action/settlement would be New Delhi.

4.4. Penalty for use of undue influence: The bidder undertakes that he has not given, offered or promised to give, directly or indirectly, any gift, consideration, reward, commission, fees, brokerage or inducement to any person in service of MoLE or otherwise in procuring the contracts or forbearing to do or for having done or forborne to do any act in relation to the obtaining or execution of the present contract or any other contract with the Government of India for showing or forbearing to show favour or disfavour to any person in relation to the present contract or any other contract with the Government of India. Any breach of the aforesaid undertaking by the bidder or anyone employed by him or acting on his behalf (whether with or without the knowledge of the bidder) or the commission of any offers by the bidder or anyone employed by him or acting on his behalf, as defined in Chapter IX of the Indian Penal Code, 1860 or the Prevention of Corruption Act, 1986 or any other act enacted for the prevention of corruption shall entitle MoLE to cancel the empanelment of agency and all or any other contracts with the agency and recover from the agency the amount of any loss arising from such cancellation. A decision of MoLE or his nominee to the effect that a breach of the undertaking had been committed shall be final and binding on the bidder. Giving or offering of any gift, bribe or inducement or any attempt at any such act on behalf of the bidder towards any officer/employee of MoLE or to any other person in a position to influence any officer/employee of MoLE for showing any favour in relation to this or any other contract shall render the bidder to such liability/ penalty as MoLE may deem proper, including but not limited to termination of the contract and imposition of penal damages.

4.5. Access to books of accounts: In case it is found to the satisfaction of MoLE that the agency has engaged an agent or paid commission or influenced any person to obtain the contract as described in clauses relating to agents/agency commission and penalty for use of undue influence, the agency, on a specific request of MoLE, shall provide necessary information and allow inspection of the relevant financial documents / information.

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4.6. Non-disclosure of contract documents: Except with the written consent of MoLE/ bidder, other party shall not disclose the contract or any other information it may come across during its status as “empanelled audit agency” from MoLE, SNAs, information technology setup of RSBY or any other source thereof to any third party. Failure to do so may result in disqualification for empanelment as “empaneled audit agency” for minimum 5 years or more at the sole discretion of MoLE.

4.7. Notices: Any notice required or permitted by the contract shall be written in English and may be delivered personally or by registered pre-paid mail/airmail, addressed to the last known address of the party to whom it is sent.

4.8. Patents and other intellectual property rights: The prices stated in the contract resulting from an RFP under this empanelment shall be deemed to include all amounts payable for the use of patents, copyrights, registered charges, trademarks and payments for any other intellectual property rights. The bidder shall indemnify MoLE against all claims from a third party at any time on account of the infringement of any or all the rights mentioned in the previous paragraphs, whether such claims arise in respect of manufacture or use.

4.9. Amendments: MoLE at its discretion may amend the RFE and all such amendments shall become part of this RFE. No interpretation, revision or communication regarding this RFE is valid, unless made in writing.

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5. Part IV: Evaluation of bids for empanelment

5.1. Pre-conditions

a. The third party audit agencies will be empaneled on a zonal basis. For the purpose of this RFE, all the States and Union Territories have been divided into five zones and agencies will have to apply for empanelment separately for each zone. The five zones are as follows:

Note: Not all states are operating the RSBY scheme. States have been included in the zonal list should they come under the RSBY scheme in future.

Zones States

North Uttar Pradesh, Punjab, Himachal Pradesh, Jammu & Kashmir, Haryana, Uttarakhand, Chandigarh, Delhi

West Rajasthan, Gujarat, Madhya Pradesh, Maharashtra, Goa, Daman & Diu

East West Bengal, Bihar, Jharkhand, Orissa, Chhattisgarh

South Seemandhra, Telangana, Karnataka, Kerala, Pondicherry, Tamil Nadu, Andaman Nicobar & Lakshadweep

North East Assam, Manipur, Meghalaya, Nagaland, Mizoram, Tripura, Arunachal Pradesh, Sikkim

b. The States shall invite/release the RFP for audit agencies empanelled for the zone.

c. The bidder can bid for more than one zone provided they meet the criteria for each zone.

d. Consortium bids are not allowed.e. No sub-contracting of work shall be allowed.f. Third Party Administrators registered to work with insurance companies shall

not participate due to possible conflict of interest. g. Institutions such as medical colleges & hospitals can also participate provided

they meet the criteria for empanelment.

5.2. Pre-qualification criteria There will be no marking for evaluation. All the agencies satisfying the following criteria will be empaneled for conducting medical audits. Only the audit agencies which fulfil the below mentioned criteria should submit their bids.

a. The bidder should be a registered private or public owned company incorporated under Companies Act 1956, in India or a Limited Liability Partnership Company under Limited Liability Partnership Act, 2008.

b. The agency shall have a minimum annual turnover of INR 1 crore from medical audit services for each of the last 3 financial years (FY 2013-14, 2012-13, 2011-12), for each zone. In case the firm is applying for more than

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one zone, the annual turnover shall be a multiple of INR 1 crore for the number of zones applied for.

c. The firm must have at least one office in the zone they are applying for.

d. The firm must have at least 20 full-time employees specializing in the field of medical audit as on 30th June 2014 in the zone.

e. The firm must have conducted at least 3 medical audits, each of value INR 20 lakhs, within the last 3 financial years.

5.3. Documents required The documents required to be submitted along with bid are listed in Annexure 2.

5.4. Validity of empanelment The agency shall remain on the list of “empanelled audit agencies” for a period of five years.

5.5. De-empanelment or termination of empanelment MoLE shall have the right to terminate this empanelment in part or in full in any of the following cases:

a. The delivery of the services, in the event of entering into contract with SNA, is not found appropriate as per conditions which are not attributable to Force Majeure.

b. The agency has been blacklisted by SNA. c. The agency is declared bankrupt or becomes insolvent. d. The agency is involved in corrupt practices, any collusion with RSBY

stakeholders, or has used corrupt means to appropriate any contract under this empanelment.

e. As per decision of the Arbitration Tribunal.

5.6. Effect of de-empanelment a. A de-empaneled audit agency shall not be eligible to participate in any of the

RSBY audit RFP under this empanelment by any SNA or other RSBY stakeholder in the zone for de-empanelment. SNA/MoLE would decide whether the de-empanelment would be done for one zone or multiple zones. The de-empanelment shall be effective for the period decided by SNA/MoLE based on severity of the default.

b. If by the time of de-empanelment, it has already quoted for an RFP by an SNA and bids have not been opened then it will not be considered as valid “empanelled audit agency” and its bid shall not be opened for consideration by SNA. However, this will not affect its participation as valid bidder if the bids in such cases have already been opened by SNA.

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6. Part V: Annexures

Annexure 1: Format for pre-bid query

No. RFE clause

Para No Page No Statement of clarification/deviations

Bidder suggestions

1

2

3

4

5

Annexure 2: Documents required to be submitted with bidThe bidder must provide all the requisite documentation as per the annexure. Absence of any requisite document could lead to non-qualification for empanelment.

No

Documents Reference section

Formats Document(s) to be submitted

1 Organisation Profile 6.2. (a) Annexure 4

a. Certificate of incorporation

b. PAN numberc. Service tax

registration certificated. Other details as in

Annexure 4

2 Cover letter for instrument (demand draft/banker’s cheque) submitted towards cost of bid document (on company letter head)

Page 24 Annexure 7

Demand draft along with cover letter on company letter head

3 Detail and number of zones applied for

6.2. (c) Annexure 3

Details of number of zone applied for as per Annexure 3

4 Financial details of the organisation

6.2. (b) Annexure 5

a. Year wise details of turnover along with undertaking from CA in prescribed format and copies of audited statements of last 3 financial years as per Annexure 5

b. Year wise details of turnover from medical

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No

Documents Reference section

Formats Document(s) to be submitted

audit services for last 3 financial years as per Annexure 5

5 Details of experience of conducting medical audits (including work order / completion certificates)

6.2. (e) &6.2 (f)

Annexure 6

a. Copy of engagement letter / work order

b. Copy of completion certificate

c. Copy of transmittal letter

Annexure 3: Details of zone applied for and calculation of required turnover

The bidder must provide all the requisite documentation as per the annexure. Absence of any requisite document could lead to non-qualification for empanelment.

Sr. No.

Zone name Applied (Yes/No)

1 North zone2 West zone3 East zone4 South zone5 North East zone

Number of zones applied: …………………….. (In words ………………………………………………………………)

Annexure 4: Organisational ProfileThe bidder must provide all the requisite documentation as per the annexure. Absence of any requisite document could lead to non-qualification for empanelment.

No. ParameterDocuments to be

submitted1 Name of organization2 Name and designation of contact person

3Postal address of the organization (with PIN code)

4Permanent address, if different from postal address (with PIN code)

5 Telephone with STD Code

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No. ParameterDocuments to be

submitted

6 Fax No. with STD Code7 Mobile No. of contact person8 E-mail address of contact person9 Establishment details

a. Year established Certificate of incorporationb. Regd. No., Name and place of registration

authority Certificate of incorporation

10 Statutory registration detailsa. PAN number Copy of PANb. Service Tax number Copy of service tax registration

certificate11 Name of key zonal office contact, designation,

email address and phone number (Please indicate details in the same field using comma separation)

Provide number of offices in the zone along with address and key contact person details

a. North zoneb. West zonec. East zoned. South zonee. North East zone

12 Number of medical audit staff in each zone (certification from human resources)

Manpower details should be provided zone wise and certification should be provided separately for each zone

a. North zoneb. West zonec. East zoned. South zonee. North East zone

Annexure 5: Financial turnover of company in last 3 financial yearsThe bidder must provide all the requisite documentation as per the annexure. Absence of any requisite document could lead to non-qualification for empanelment.

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No. Financial year

Annual turnover of the

agency in INR Lakhs2

Annual turnover of the agency from audit activities in INR

lakhs from each zone3

Zone

1 2013-14 North Zone

2 2012-13

3 2011-12

1 2013-14 West Zone

2 2012-13

3 2011-12

1 2013-14 East Zone

2 2012-13

3 2011-12

1 2013-14 South Zone

2 2012-13

3 2011-12

1 2013-14 North East Zone

2 2012-13

3 2011-12

Annexure 6: Experience of conducting audit involving field surveyThe bidder must provide all the requisite documentation as per the annexure. Absence of any requisite document could lead to non-qualification for empanelment.

N Title of completed / ongoing audits

Name, address, email and phone number of client

Month & year of initiation of audit

Month & year of completion of audit

Contract value & work order

Number of man-months

Geographical location/ states where the audit was conducted

Scope of work

North Zone

2 Please give annual turnover of the agency/organization as per audited statements of last three years

3 Please provide how much of the total annual turnover is from medical audit related activities for each zone

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N Title of completed / ongoing audits

Name, address, email and phone number of client

Month & year of initiation of audit

Month & year of completion of audit

Contract value & work order

Number of man-months

Geographical location/ states where the audit was conducted

Scope of work

12345West Zone12345East Zone12345South Zone12345North East Zone12345

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Annexure 7: Undertaking for qualification bid

<To be printed on company letter head of bidder>

Date: <Date>

From: [Name of bidder]

[Address of bidder] To:

_____________________ Assistant Director (RSBY-Monitoring)Office of Director General Labour and Welfare, Ministry of Labour and Employment Jaisalmer House, 26, Mansingh Road, New Delhi- 110001

Dear Sir, Sub: Qualification bid for “Empanelment of medical audit agencies” by MoLE.

With reference to your RFE No ___________ dated ________ we, [insert name of bidder], wish to submit our qualification bid for the empanelment of our company for the medical audit under Rashtriya Swasthya Bima Yojana in different States of India.

1. We hereby submit our empanelment bid, which is unconditional and unqualified. We have examined the RFE documents issued by MoLE.

2. The price of RFE document __________________________ is attached along with this letter as Demand Draft/ Bankers Cheque No. ………………., dated …………………….. of …………………………………….. (Name of Bank) in favour of “The Pay & Accounts Officer (Main Secretariat), Ministry of Labour and Employment, New Delhi.” payable at New Delhi.

3. We acknowledge that MoLE or its authorised representative will be relying on the information provided in the qualification bid and the documents accompanying such qualification bid for empanelment of the eligible bidders for implementing RSBY in states, and we certify that all information provided in the qualification bid is true and correct. Nothing has been omitted / concealed which renders such information misleading and all documents accompanying qualification bid are true copies of their respective originals.

4. We shall make available to MoLE, any clarification that it may find necessary or require to supplement or authenticate the qualification bid.

5. We acknowledge the right of MoLE to reject our qualification bid or not to declare us as an empanelled agency, without assigning any reason whatsoever and we hereby waive, to the fullest extent permitted by applicable law, our right to challenge the same on any account whatsoever.

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6. We undertake that: We satisfy/ do not satisfy the qualification criteria.

7. We agree and release MoLE and their employees, irrevocably, unconditionally, fully and finally from any and all liability for claims, losses, damages, costs, expenses or liabilities in any way related to or arising from the RFE documents and/or in connection with the bidding process, to the fullest extent permitted by applicable law and waive any and all rights and/or claims I/we may have in this respect, whether actual or contingent, whether present or in future.

8. We undertake that none of the partners / members of the team of auditors of the firm face any disciplinary action on account of frauds or collusion or any act which can be construed as moral turpitude, during the empanelment process.

9. Our agency/organization/institution is not blacklisted or/ and reprimanded by any client from the Government/ PSU/ State Government / Urban/ Local bodies.

10.We represent and warrant that: a. We have examined and have no reservations to the RFE document, including

all addenda issued by MoLE. b. We accept the terms and conditions including the special conditions laid

down in the RFE Document, and shall seek no material deviations from or otherwise seek to materially negotiate the terms of the draft contract, if declared as the successful bidder and consequently empaneled as audit agency for RSBY.

c. We have not and will not undertake any activity in any manner to influence or to try to influence the process of selection of the successful bidder.

d. The RFE document and all other documents and information that are provided to us shall remain the property of MoLE and are provided to us solely for the purpose of preparation and the submission of this bid in accordance with the RFE document. We undertake that we shall treat all information received from or on behalf of MoLE as strictly confidential and we shall not use such information for any purpose other than for preparation and submission of this bid.

e. MoLE is not obliged to return the qualification bid or any part thereof or any information provided along with the qualification bid.

f. We have made a complete and careful examination of the RFE Document and all other information made available by or on behalf of MoLE.

g. We have satisfied ourselves about all things, matters and information, necessary and required for submitting an informed bid.

h. Our bid shall be valid for a period of 180 days from the bid opening date.

11.We are submitting with this letter all the documents that are listed in Annexure 2 of the bid. Absence of any requisite document for all annexures could lead to non-qualification for empanelment.

12.We, hereby, irrevocably waive any right or remedy which we may have at any stage at law or howsoever arising to challenge the criteria for evaluation of the qualification bid or question any decision taken by MoLE in connection with the evaluation of the qualification bid, declaration of the eligible bidders, or in connection with the bidding process itself.

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13.We agree and undertake to abide by all the terms and conditions of the RFE documents, including all addenda, annexures and appendices.

14.We categorically and specifically state that we understand that this RFE by MoLE aims only at empanelling audit agencies based on criteria brought out in this document.

15.We confirm that there are no litigations or disputes against us, which materially affect our ability to fulfil our obligations in this regard.

16.Capitalized terms which are not defined herein will have the same meaning ascribed to them in the RFE documents.

17.In witness thereof, we submit this letter accompanying the qualification bid under and in accordance with the terms of the RFE documents.

18.The information given above is true to the best of my knowledge. The organization shall stand liable for any information given above which is later found to be false.

Dated this [insert date] day of [insert month], 2014 [Authorized Signatory] [Designation] ORDuly authorized to sign this bid for and on behalf of

[Name of Bidder][Signature]

In the capacity of__________

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