OFFICE OF THE MEDICAL SUPERINTENDENT

E.S.I.C. HOSPITAL,VARANASI E-mail : ms-varanasi.up@esic.in

No.282-U16/26/2017 Date 30.05.2018

EXPRESSION OF INTEREST

The Medical Superintendent, ESIC Hospital, Pandeypur Varanasi invites sealed quotations for empanelment of Recognized/Registered Hospital/Institutions for Secondary care Treatment on contract basis initially for a period one year which can be extended upto two years. The interested parties may submit their proposals. The tender document may be obtained on submission of a Demand Draft (only SBI) of Rs.1000/- in favour of “ESIC FUND A/C NO.1” Varanasi. The document may be obtained from this hospital from 30/05/2018 to 27/06/2018 during working hours and the duly filled documents must be deposited latest by 27/06/2018 at 1.00PM and it will be opened on 27/06/2018 (2.00PM). The tender document can also be downloaded from our website www.esic.nic.in and in this case the cost of tender may be submitted along with tender application.

The Medical Superintendent, ESIC Hospital, Pandeypur, Varanasi reserves all rights to reject one or all the tenders without assigning any reason thereof.

( )

Medical Superintendent

OFFICE OF THE MEDICAL SUPERINTENDENT

E.S.I.C. HOSPITAL, VARANASI E-mail : ms-varanasi.up@esic.in

To

DOCUMENT COST RS. 1000/- (Non-Refundable)

EXPRESSION OF INTEREST (Please read all terms and conditions carefully)

The Medical Superintendent, ESIC Hospital, Pandeypur Varanasi invites Expression of Interest from Government/Semi-Government/CGHS approved/Private Hospitals for empanelment of centers for Secondary care treatment which are not available in Medical Superintendent, ESIC Hospital, Pandeypur Varanasi, on cashless basis at latest CGHS Allahabad rates, BBSR (given at website)/ ESIC rates, in a sealed envelope. Application forms along with Terms and Conditions can be downloaded from the website www.esic.nic.in duly filled in forms, complete in all respect along with EMD should reach the office of Medical Superintendent by 27/06/2018 at 1.00PM. Bids will be opened on 27/06/2018 (2.00PM) in the office of the Medical Superintendent. If the opening date happens to be a holiday, it will be accepted and opened on the next working day. Tenderer/authorized person may choose to be present at the time of opening of bids.

TENDER DOCUMENT FOR SECONDARY CARE TREATMENT

Tenderer downloading the form from website shall have to deposit Rs. 1000/- (Non Refundable) separately as Tender Document cost along with EMD of Rs. 20,000/- in the form of DD drawn on (only SBI) in favour of “ESI Fund Account No.1” payable at Varanasi.

Document Acceptance: Documents may be dropped either in the tender box or sent by Registered Post. Documents received by ordinary post will not be accepted at all. Documents received after the scheduled date and time will be rejected out rightly.

Tenderers will be informed about date and time of inspection of their centre by a duly constituted committee on the address given in Document Form.

(I) CONDITIONS FOR AWARD OF CONTRACT

Only those applications will be considered for award of contract which fulfill all conditions and also have satisfactory report of Inspection Committee.

1(a) Rates of package for procedure / treatment should be as per revised / latest CGHS RATE BBSR for only NABH/NON NABH centers. CGHS (Delhi rates will be applicable where CGHS, Allahabad package rates are not available). ESIC PACKAGE RATES (where CGHS PACKAGE rates are not available / or any other rates prescribed by ESIC Hqrs. time to time. In case both are not available, AIIMS rate will be applicable.

(b) Rate list of the hospital/centre to be submitted, which is for non ESIC/general patients.

2. Tenderer is at liberty to apply for any number of specialties as per Annexure-II.

3. Successful tenderer shall have to deposit a security amount of Rs.1,00,000/- (Rupees one lakh who apply for multiple specialties) and Rs.50,000 (Fifty thousand who apply for single specialty) in the form of Account payee demand draft from any of the nationalized bank having vality of 24 plus 2 months (60 days extra from the expiry of contract) which will be refunded after termination/completion of contract without any interest.

4. Bid must be accompanied by the following :-

(a) EMD (Earnest Money Deposit) Rs.20,000/- (twenty thousand) in the form of DD drawn on

any nationalized bank in favour of ESI Fund Account No.1 payable at Varanasi. EMD of unsuccessful tenderers will be refunded within 30 days after award of contract without any interest. EMD of successful tenderers will be refunded after deposit of security money without accrual of any interest.

(b) Documents as per annexure-I must be submitted. 5. Every page of tender document must be signed and also Annexure-I & II should be duly signed. 6. Centers de-empanelled by any Govt. organization within last 3 years will not be considered. Affidavit of not having been de-empanelled or black listed by ESIC/Govt. Organization must be submitted with tender form. 7. An agreement on stamp paper of Rs.100/- shall be signed after finalizing and verification/ physical verification of records / Institutions and incidental charges related to agreement shall be borne by the empanelled centre. Agreement will be effective with effect from date of signing of the agreement. 8. Award of contract may be given to one or more Tenderers.

9. Criteria for empanelment of Health care organization (Hospital/Clinic/Diagnostic

Laboratories/Imaging centers)

A. Multispeciality Hospital (Specialities given in Annexure-II) having 50 beds or more (Which includes ICU beds) can apply as a multispeciality hospital. A single specialty hospital (EYE and Dental) can also apply. B. The health care organization should be approved by State Government/CGHS copy of state registration certificate/Registration to be attached. C. The Health care organization should preferably be accredited by NABH, similarly Diagnostic Laboratories should preferbly be accredited by NABL copy of NABH/NABL accreditation. Copy of NABH/NABL application in case of non NABH/non NABL accredited health care organization must be attached. D. Registration under PNDT act for empanelment of ultrasound facility. E. AERB approval for tie-up for radiological investigations wherever applicable. F. The health care organization must have the capacity to submit all claims/bills in computerized format to the Medical Superintendent, ESIC Hospital, Pandeypur Varanasi. G. Intensive care unit (ICU) with minimum four beds (4 beds and 4 ventilators) preferably optional H. Provision of dietary service.

II. GENERAL TERMS AND CONDITIONS

1. All services will be provided cashless to the patients under no circumstances referred ESI

Patients to be charged. 2. Rates to be charged :-

A) Where CGHS package rates exist-rate only for NABH/Non-NABH will be paid.

(a) Package rate shall mean and include lump sum cost of in-patient treatment/day care/diagnostic procedure for which a ESI beneficiary / ESI Staff (serving and retired) has been permitted by the competent authority or for treatment under emergency from the time of admission to the time of discharge including (but not limited to):

(1) Registration charges (2) Admission, accommodation charges (3) including patients diet (4) Operation charges (5) Injection Charges (6) Dressing charges (7) Doctor / Consultant visit charges (8) ICU/ICCU charges (9) Monitoring charges (10) Transfusion charges (Anesthesia charges) (12) Operation Theater charges (13) Procedural charges / Surgeon’s Fee (14) Cost of surgical disposable and all sundries used during hospitalization (15) Cost of medicines (16) all other related routine and essential investigation (17) Physiotherapy (18) Nursing care (19) charges for its services and all other incidental charges related thereto.

(b) Cost of implant/stents/grafts is reimbursable in addition to package rates as per CGHS/ESIC ceiling rates.

(c) The package rates/rates given in rate list are for semi-private wards. If the beneficiary is entitled for general ward there will be a decrease of 10% in the rates. For private ward entitlement, there will be an increase of 15%. However, the rates shall be same for

investigation irrespective of entitlement, whether the patient is admitted or not and the test, per se, does not require admission.

(d) No charges admissible for post op complications.

B) Where CGHS rates do not exist

(a) Package rates have been devised for the treatments/procedures not prescribed by

CGHS. They will be called as ESIC rates. If there are also not available, AIIMS rates will be paid.

(b) Discounts on Drugs/treatment/procedures/devices have been finalized. These are :-

1. 15% discount on hospital rates which already exist for other patients in case ESIC/AIIMS rates are also not available.

2. For devices / stents etc. 15% discount on MRP (Maximum Retail Price) 3. In case of drugs, discounts as follow: 15% discount on drugs and consumable.

C) Expenses on toiletries, cosmetics, telephone bills etc. are not reimbursable.

D) The centre whose rates for treatment procedure/test are lower than the CGHS prescribed rates shall charge as per the rates charged by them from Non-ESIC patients and will furnish a certificate that rates charged are not more than from non-ESIC patients. Rate list of the hospital/empanelled centre to be submitted alongwith technical conditions. DISCOUNT : ANY DISCOUNT ON CGHS/ESIC PACKAGE FOR SURGERIES ETC. TO BE MENTIONED.

E) If one or more minor procedures form part of a major treatment procedure then package charges would be permissible for major procedure and only 50% of charges for minor procedures.

3. Duration of Indoor treatment :-

(a) As per package rates :-

1. Major Surgery – 7 days. 2. Laparoscopy Surgery/Normal Delivery – 3 days. 3. Day Care / Minor procedures – 1 day For non package procedures / management – 7 days.

(b) Increased duration of indoor treatment due to infection, or the consequences of surgical procedure or due to any improper procedure if not justified will not be reimbursed.

(c) For extended stay more than the period covered in package rate, in exceptional cases, supported by relevant documents and medical records and certified as such by hospital, the additional reimbursement shall be limited to accommodation charges as per entitlement, investigation charges at approved rates, doctors visit charges (two visit/day) and cost of

medicine. The approval from this office or the ESIC Model Hospital, Rourkela is required in the matter. The approval must be attached with the bill so sent for payment to the concerned.

(4)Room Rents

(a) The maximum room rent for different categories would be : General Ward Rs.1000/- per day, Semi-private Ward Rs.2000/-, day Private Ward Rs.3000/- per day, Day Care ( 6 to 8 hours) Rs.500/- (Same for all categories) (b) Room rent is applicable only for treatment procedures for which there is no CGHS prescribed package rate. Room rent will include charges for occupation of Bed, diet for the patient, charges for water and electricity supply, linen charges, nursing and routine up keeping. (c) During the treatment in ICU, no separate room rent will be admissible. (d) Private ward is defined as a hospital room where single patient is accommodated and which has an attached toilet (lavatory and bath). The room should have furnishings. The room shall have furnishings like wardrobe, dressing table, bedside table, sofa set etc. as well as a bed for attendant. The room has to be air conditioned. (e) Semi private ward is a hospital room where 2 or 3 patients are accommodated which has attached toilet facilities and necessary furnishings. (f) General ward is defined as Halls that accommodate 4 to 10 patients. (g) Normally treatment in higher category of accommodation that the entitled category is not permissible. However, in case of an emergency when entitled category accommodation is not available, admission in immediate higher category is to be allowed till entitled accommodation is available. Even in this case the empanelled centre has to charge as per entitlement of the patient.

5. Any legal liability arising out of such service shall be the sole responsibility of the 2nd Party and shall be dealt with by the concerned empaneled hospital/diagnostic center. 6. Patient will be referred with a Permission letter signed by the competent authority. Cases referred between 4 pm to 9 AM next morning (Emergency cases) will be signed by Casualty Medical Officer. The empaneled hospital has to take regular permission from MS in prescribed format on next working day. These cases will be referred only after discussion with the concerned specialist which has to be mentioned on the referral form.

7. In case of any natural disaster/epidemic, the hospital/diagnostic hospital shall have to fully cooperate with the ESIC and will convey/reveal all the required information, apart from providing treatment.

8. The EMPANELLED CENTRE will investigate / treat the ESI beneficiary patient only for the condition for which they are referred with permission, and in the specialty and/or purpose for which they are approved by ESIC. In case of unforeseen emergencies of these patients during admission for approved purpose/procedure, necessary life saving measures be taken and concerned authorities may be informed accordingly later with justification for approval.

9. The tie-up hospital will not refer the patient to other specialist/other hospital without prior permission/intimation of ESIC authorities.

10. The empanelled centre will have to report on daily basis to Medical Superintendent on e-mail address ms-varanasi.up@esic.in giving details of ESI Insured Persons under indoor treatment failing which hospital may be de-empanelled.

11. Feed back form will be filed by the patient/attendant after discharge.

12. Refusal to entertain a referred ESI Patient will result in de-empanelment/black listing of the hospital.

(III) PAYMENT SCHEDULE

The empanelled hospital/diagnostic centre have to engage UTI-ITSL as bill processing

agency (BPA) for scrutiny and processing of all bills for beneficiaries referred from ESIC MH, Rourkela. The empanelled hospital will have to enter (Mandatory) into MOU with UTI-ITSL to engage them as BPA (Bill processing agency in relation to payments and re-imbursement of medical expenses. The empanelled hospital/diagnostic centre will send bills along with necessary supportive documents to UTI_ITSL. Copy of the discharge slip incorporating brief history of the case, diagnosis, details of procedure done, reports of investigations, discharge summary, original receipt of medicines/implants, sticker of implant, wrappers of costly medicines/equipment (costing more than Rs.2000/-, treatment given and advised shall be submitted by the hospital/diagnostic centre along with the bill in duplicate in prescribed proforma as in ANNEXURE -A.

(IV) DUTIES AND RESPONSIBILITIES OF EMPANELLED HOSPITAL/DIAGNOSTIC CENTRES.

It shall be the duty and responsibility of the hospital at all times, to obtain, maintain and sustain the valid registration and high quality and standard of its services and healthcare and to have all statutory/mandatory license, permits or approvals of the concerned authorities as per the existing laws.

Display board regarding cashless facility for ESI beneficiary will be required. The documents like referral from ESI Hospital, eligibility etc. must be mentioned on the board. The ESI patient must be entertained without any queue/wait.

(V) DURATION OF EMPANELLMENT

The agreement shall remain in force for a period of one year and may be extended by one year, at a time for amendment of 2 years at the sole discretion of the Medical Superintendent subject to fulfillment of all terms and conditions of this agreement and with mutual consent. Agreement to be signed on Stamp Paper of appropriate value before starting services. Cost of stamp paper and incidental charge related to agreement shall be borne by the empanelled centre. Agreement will be effective from the date of signing the agreement by both parties.

(VI) INTEGRITY AND OBLICATIONS DURING AGREEMENT PERIOD

The Hospital is responsible for and obliged to provide all facilities in accordance with the Agreement, using state-of-the-art methods and economic principles and exercising all means available to achieve the performance specified in the Agreement. The Hospital is obliged to act within its own authority and abide by the directives issued by the ESIC. The hospital is responsible for managing the activities of its personnel and will hold itself responsible for their misdemeanor, negligence, misconduct or deficiency in services, if any.

(VII) LIQUIDATED DAMAGES

Empanelled centre shall provide the services as specified by the ESIC under terms and

conditions of this agreement in case of violation of the provisions of the agreement by the empaneled centre there will be forfeiture of payment of the incoming/pending bills. For over billing and unnecessary procedure, the extra amount so charged will be deducted from the bills and the ESIC shall have exclusive right to terminate the contract at any time, and also render forfeiture of security amount.

(VIII) TERMINATION FOR DEFAULT

a. Medical Superintendent, ESIC Hospital, Pandeypur Varanasi may without prejudice to any

other remedy and for breach of Agreement in whole or part may terminate the contract. b. The Second Party will not terminate the agreement without giving notice of three (3) months. If

they do so security money will be forfeited. c. The Institution shall be de-empanelled if ;

(i) the Hospital fails to provide any or all of the services for which it has been

recognized within the period(s) specified in the Agreement, or within any extension period thereof if granted by the ESIC pursuant to condition of Agreement or

(ii) the Hospital, in the judgment of the ESIC is engaged in corrupt or fraudulent practices in competing for or in executing the Agreement, or

(iii) The hospital fails to follow instruction, guidelines, repeated submission of bills as per instt. own way and repeated deficiencies etc, the Institution shall be de-empanelled without giving any opportunity.

d. The Hospital is found to be involved in or associated with any unethical illegal or unlawful activities, the Agreement will be summarily suspended by ESIC without any notice and thereafter may terminate the Agreement, after giving a show cause notice and considering its reply, if any, received within 10 days of the receipt of show cause notice. Terms and conditions can be modified at sole discretion of the First Party only.

(IX) PENALTY CLAUSE

Patient can’t be denied treatment on the pretext of non availability of beds/specialists failing which treatment may be arranged from other hospital and any excess payment made to the other centre for the management of such cases will be deducted from the pending bills/security money.

(X) INDEMNITY

The Hospital shall at all times, indemnify and keep indemnified ESIC against all actions,

suits, claims and demands brought or made against in respect of anything done or purported to be done by the Hospital in execution of or in connection with the services under this Agreement and against any loss or damage to ESIC in consequence to any action or suit being brought against the ESIC, along with (or otherwise), Hospital as a party for anything done or purported to be done in the course of the execution of this Agreement. The Hospital will at all times abide by the job safety measures and other statutory requirements prevalent in India and will keep free and indemnify the ESIC from all demands or responsibilities arising from accidents or loss of life, the cause or result of which is the Hospital negligence or misconduct. The Hospital will pay all the indemnities arising from such incidents without any extra cost to ESIC and will not hold the ESIC responsible or obligated.

ESIC may at its discretion and shall always be entirely at the cost of the tie-up Hospital defends such suit, either jointly with the tie-up Hospitals or separately in case the latter chooses not to defend the case.

(XI) ARBITRATION If any dispute or difference of any line whatsoever (the decision whereof is not being otherwise provided for) shall arise between the ESIC and the Empanelled Centre upon or relation to or in connection with or arising bout of the Agreement, it shall be referred to for arbitration by the Medical Superintendent who will give written award of his decision to the parties. Arbitrator to be appointed by Medical Superintendent. The decision of the Arbitrator will be final and binding. The provision of Arbitration and Conciliation Act, 1996 shall apply to the arbitration proceedings. The venue of the arbitration proceedings shall be at office of Medical Superintendent. Any legal dispute to be settled in Varanasi jurisdiction only.

(XII) MISCELLANEOUS

a) Nothing under this Agreement shall be construed as establishing or creating between the Parties

any relationship of Master and Servant or Principle and Agent between the ESIC and Empanelled Centre.

b) The Empanelled Centre shall not represent or hold itself out as an agent of the ESIC. c) The ESIC will not be responsible in any way for any negligence or misconduct of the

Empanelled centre and its employees for any accident, injury or damage sustained or suffered

by the referred patient/ESIC beneficiary or any third party resulting from or by any operation conducted by or on behalf of the Hospital or rendering its services under this Agreement or otherwise.

d) The Empanelled Centre shall notify the ESIC Hospital of any material change in their status and their shareholdings or that of any Guarantor of the Empanelled Centre in particular where such change would have an impact in the performance of obligation under this Agreement.

e) This Agreement can be modified or altered only on written Agreement signed by both the parties.

f) Should the Empanelled Centre get wound up or partnership be dissolved, the ESIC shall have the right to terminate the Agreement. The termination of Agreement shall not relieve the Empanelled Centre or their heirs and legal representatives from their liability in respect of the services provided by the Empanelled Centre during the period when the Agreement was in force.

g) The Empanelled Centre shall bear all expenses incidental to the preparation and stamping of this Agreement.

(XIII) TDS DEDUCTIONS

TDS will be deducted as per Income Tax Rules.

(XIV)NOTICES

(i) Any notice given by any party to other pursuant to this Agreement shall be sent to other party in writing by Registered Post at the official address given in tender form.

(ii) A notice shall be effective from the date on which it is served or on the notice’s effective date, whichever is later. Registered communication shall be deemed to have been served even if it returned with the remarks like refused, left, premises locked etc.

* Medical Superintendent reserves the right to accept or reject any tender without

assigning any reason thereof.

Signature of Medical Superintendent

UNDERTAKING

I/We (name of proprietor) have carefully gone through and understood the contents of the Document Form and I/we undertake to abide by all the terms and conditions set

forth. I/We legally bound to provide services as per rates/terms and conditions of Tender

documents filing which Medical Superintendent, ESIC Hospital, Pandeypur Varanasi is liable to

take action as deemed fit. I/We undertake to provide uninterrupted services or alternative

arrangement will be made at the risk and cost of our institute. We undertake that the information

submitted along with document and annexure –I is correct and also fully understand that in case of

default the security money shall be forfeited.

Dated Signatures Name Place (with seal/rubber stamp)

Annexure A (Ref to of ESIC Hospital /SMC Office Letter No. dated )

ADDENDUM TO MEMORANDUM OF AGREEMENT DATED

This Memorandum of Understanding (MOU) entered into on this the day of 2017 between (Herein after referred to as ESIC, which expression shall, unless repugnant to the context or meaning thereof, be deemed to mean and include its successors and assigns) of the First Part

AND (Name of Empanelled Private Hospital/Diagnostic Centre) having its registered office at , India, herein referred to as “Empanelled hospital” which expression shall unless repugnant to the context or meaning thereof be deemed to mean and include its successors, liquidators, Administrators and permitted assigns) of the second part.

WHEREAS the ESIC is providing comprehensive medical care facilities to the beneficiaries,

AND WHEREAS ESIC proposes to provide treatment facilities through its hospitals & dispensaries to the Beneficiaries in the Empanelled Hospitals,

AND WHEREAS empanelled hospital offered to give the treatment /diagnostic facilities/ health benefits to ESIC Beneficiaries in the Empanelled Hospital,

Each of these empanelled Hospitals shall hereinafter be referred individually as a “Party” and collectively as the “Parties”

Whereas the Parties have entered into this MOU to record their intention to jointly engage UTIITSL as Bill Processing Agency (BPA) in relation to payments and re -imbursement for Medical Expenses.

The parties shall abide by the following undertakings in addition to ESIC Policy and Standard Operating Procedures, the clauses mentioned in the Memorandum of Agreement with ESIC Hospital/SMC Office and for the purpose of bill processing:

A. The empanelled hospital shall acknowledge the referral from ESIS/ESIC Hospital/institution online . B. The empanelled hospital on admission of an ESI Hospital/institution Beneficiary shall intimate online to BPA the complete details of the patient, proposed line of treatment, proposed duration of treatment with Clinical History within 24 hours of admission.

C. After the patient is discharged, the hospital will upload the claim related documents as per SOP and ESIC policy viz Referral letter, Bills, Lab reports, Discharge Summary, Doctors report, indoor papers etc to BPA through the web based application within seven (7) working days.

D. The hard copies of the claim will be delivered /dispatched to the concerned referring ESI Hospital/institution within seven (7)working days but not later than 30 days.

E. The empanelled hospital shall submit all the medical reports in digital form as well as in physical form as per ESIC policy and SOP

. F. The empanelled hospital agrees that the actual processing shall start when physical copies of the bills submitted by the empanelled hospitals to the concerned referring ESIC/ESIS Hospital, are verified by them on behalf of respective ESIC/ESIS Hospital. Counting of days shall start from such date for the purpose of TAT.In case of query raised on the bills the TAT for the purpose of BPA shall start from the date of reply to the last query raised by the Tie-up Hospital.

G. In case of absence of certain physical documents, the “Need More Information” (NMI) status will be raised by the Verifier of the respective ESIC/ESIS Hospital, BPA or Medical processing team of respective ESIC Hospital/SMC office to the

empanelled hospital/diagnostic center for the missing/ambiguous physical documents (As per SOP). Empanelled hospitals/diagnostic centers shall have to submit the clarifications/information inter -alia for all bills returned online at any level under “Need for more Info” category (NMI), within 15 days failing which these claims will be processed by the respective levels and BPA on the basis of available documents without any further intimation and such bills/claims will be closed not to be opened further.

H. The BPA will audit the medical claims of the ESI Hospital/institution Beneficiaries in respect of the treatment taken by them in the empanelled hospital and make recommendations for onward payment to ESIC Hospital/SMC Office in a time bound manner within a period of 10 working days from the date of submission of bills in physical format or reply to last query, whichever is later.

I. The empanelled hospitals shall have the necessary IT infrastructure for interaction with BPA such as Desktop PC with internet connectivity features, High Speed High resolution multi page Document Scanner, Printers, etc.

J. In case of some mistakes in the scrutiny of claims recommendations thereto by BPA resulting in excess payment to the empanelled hospital by ESIC Hospital/SMC Office the excess amount shall be recovered from the future bills of the empanelled hospital.

K. Subject to BPA rendering bill-processing services as per terms and conditions of this agreement, the empanelled hospitals/diagnostic centers/claimants shall pay to the BPA, the service fees and service tax/GST/any other tax by any name called as applicable on per claim basis, as detailed below, through ESIC.

L. The amount deducted towards fee and service tax/GST/any other tax by any name called from the payable claims of hospitals/diagnostic centers shall be forwarded by ESIC to BPA simultaneously along with the payments to empanelled hospital through ECS or any other mode of money transfer, as decided by ESIC.

M. The processing fee admissible to BPA will be at the rate of 2% of the claimed amount of the bill submitted by the empanelled hospital/diagnostic center (and not on the approved amount) and service tax/GST/any other tax by any name thereon. The minimum admissible amount shall be Rs.12.50 (exclusive of service tax/GST/any other tax by any name, which will be payable extra) and maximum of Rs. 750/-(exclusive of service tax/GST/any other tax by any name, which will be payable extra) per individual bill/claim .The fee shall be auto - calculated by the software and prompted to the ESI Hospital/SMC Office by the system at the time of generation of settlement ID.

N. The fee shall also mean to include any additional payment of Service Tax, GST or any other taxes by whatever name called as applicable on such fee amount admissible to BPA.

O. If the claim is rejected or results into non payment to the empanelled hospital/diagnostic center, ESIC Hospital/SMC Office shall recover the service charge and service tax/GST/any other tax by any name due to the BPA from the subsequent claims of the respective empanelled hospital/diagnostic center and shall pay to the account of the BPA.

P. MEDICAL AUDIT OF BILLS: There shall be continuous medical audits of the services provided / claims raised by the empanelled hospital by ESIC / BPA.

IN WITNESS WHEROF the parties have caused this Agreement/MOU to be signed executed on the day, month and year first above -mentioned.

Signed by (Authority of ESI Institution) In presence of (Witnesses)

1

2

Signed by (For and behalf of (empanelled hospital /diagnostic centre name) duly Authorized vide resolution No. Dated

In the presence of (Witnesses)

1

2

ANNEXURE-I

MINIMUM REQUIREMENT

(To be submitted duly filled along with document form)

1. Name of the Hospital with complete address

2. Telephone No._

3. Fax No.

4. Mobile No. _

5. Distance of the centre from ESIC Hospital, Varanasi (Not more than 15Km).

6. Name, designation along with contact numbers(landline and mobile) of authorized person:

(attach authority letter) _

7. Bed strength of the Hospital (a) Multispecialty _ (b) Single specialty _

8. No. of ICU/NICU/PICU/SICU Beds (not less than 4 beds with 4 ventilators) if available

9. No. of functioning Operation Theatres :

10. Name of existing empanelled organizations/Institutions:

11. List of availability of full time specialist along with their Degrees/certificates along with

under taking from the concerned specialist that he/she is working full time in the organization

for which centre is going to empanelled : (separate sheet to be attached)

12. List of available specialties/facilities for which the hospital is interested for tie-up

arrangement : (As per Annexure-II) _

13. List of available equipments i.e., name and year of mfg/installed : (separate sheet be attached

with invoice copy)

14. List of all doctors, para-medical and non-medical :- (separate list for doctor, paramedical

and non-medical be attached) _

15. Daily and monthly no. of patients (specialty-wise) (separate sheet be attached)

16. Daily and monthly no. of procedures (all specialty-wise) (separate sheet be attached)

17. Category of the hospital (As per CGHS) NABH,NON-NABH,(attach proof)

18. (a) E.M.D. Rs. 20,000/-

Demand Draft to be submitted along with tender document

Name of Bank

Branch_

Amount _

Date

(b)Tender document cost Rs. 1000/- in case the tender document has been downloaded from

the website.

Name of Bank and Account No. (ECS Transfer Details)

19. Photocopy of the PAN/TAN/GST number of firm/proprietor

20. Rate list of hospital/centre which already exists for non-ESI/general patients. Enclosure : List as per Index.

(Name and signature of Proprietor)

Note :- Evaluation of the centre shall be based on information provided by the tenderer on the

above mentioned points 1 to 20 and the tenderer will have to mandatorily provide documentary

proof for the same. No future correspondence in this regard shall be entertained in this regard. A

duly constituted committee will visit those centers for inspection which qualify technical bid/need

requirement as mentioned in the document.

ANNEXURE-II

SPECIALITIES/SERVICES FOR EMPANELMENT ( Secondary care)

Sl.NO Name of speciality

1 OPD , INDOOR and emergencies facilities to provide secondary care facilities in

department of Medicine (ICU), Surgery (SICU), O&G (NICU is must for obstetrics

empanelment), Orthopedics (Except joint replacement and reconstructive surgeries),

Ophthalmology, ENT,TB& Chest, Pediatrics (NICU, PICU), Dental (Crown and

Bridge work etc) with mandatory in house facility for ultrasonography and X-Ray and

preferably CT Scan, ECHO, MRI, TMT, PFT, Endoscopy and 24 hours sophisticated

Lab investigations.

Exclusive Eye and Dental Centers can also apply.

The hospital must be registered as an authorized centre to conduct the above

investigations, authorization letter from competent authority under PCPNDT and

AREB is mandatory.

*Relevant documents like authorization letter with permission to perform the above

investigations from competent authority is mandatory and has to be submitted while

applying. from competent authority is mandatory.

ANNEXURE III

- - Letterhead of Referring ESI Hospital (P-I)

Referral Form (Permission letter)

Referral No : I. P/Beneficiary/Staff:

Name of the Patient : Age/Sex :

Address/Contact No F/M/S/D/Other

Entitled for Speciality/Super Sptt : Yes/No

Identification marks (if any) :

I. P/Beneficiary/Staff:

Relationship with IP/Staff :

Diagnosis/clinical opinion/case summary:

Relevant Treatment given/ Procedure/Investigation done in referring hospital :

Treatment/Procedure for which patient is being referred (mention specific diagnosis for referral):

Treatment/Procedure for which patient is referred is available in the referring hospital.:

I voluntarily choose Hospital for treatment of self or my

Sign/Thumb Impression of IP/Beneficiary/Staff

Referred to Hospital/Diagnostic Centre for

Date:

Sign & Stamp of Authorized Signatory ** • In case of emergency, signature of referring doctor or Casualty Medical Officer. Record to be maintained in the register. New form duly filled will be sent after signature of the competent authority on thenext working day.

•

Mandatory Instructions for Referral Hospital:

- Referral hospital is instructed to perform only the procedure/treatment for which the patient has been referred to.

- In case of additional procedure/treatment/investigation is essentially required in order to treat the patient for which he/she has been referred to, the permission for the same is essentially required from the referring hospital either through e-mail, fax or telephonically (to be confirmed in writing at the earlier.

The referred hospital is requested to raise the bill as per the agreement on the standard proforma along with supporting documents within 6 days of discharge of the patient giving account number and RTGS number etc.

Checklist (Referring Hospital)

1. Duly filled & signed referral perform.

2. Copy of Insurance Card/Photo I card of IP.

3. Referral recommendation of the specialist/concerned medical officer.

4. Copy of entitlement evidence of Specialty/super specialty treatment.

5. Reports of investigations and treatment already done.

6. Photograph Date:

Signature of the Competent Authority

ANNEXURE-IV

To be used by Tie-Up hospital (for raising the bill) (P-1)

Letterhead of Hospital with Address & Email/Fax/TeleFax Number

(NABH accredited Superspeciality Hospital) (Attach documentary Proof)

Date of Submission Individual Case Format

Name of the Patient :Referral S.No.(Routine)/

Address :

Contact No :

Insurance Number/Staff Card No/Pensioner Card No:

Date of Referral :

Diagnosis :

Condition of the patient at discharge :

(For Package Rates)

Treatment/Procedure done/Performed : Existing in the package rate list's CGHS/other Code no/nos for chargeable procedures :

Emergency/through MEDICAL SUPDT/SMC :

SL.No Chargeable Procedure

CGHS Code no

with Page

No.(1)

Other if not on

(1) Prescrib ed code No. with Page No

Rate Amount Claimed with Date

Amount Admitted with Date

(X)

Remarks (X)

Charges of Implant/device used ……………….

amount Claimed…............................ Amount Admitted Remarks

(To be filled up by ESIC official(s))

Sl.No Chargeable Procedure

Amt. Claimed with date

Amt. admitted with date

Remarks(X)

. III. Additional Procedure Done with rationale and documented permission

SL.No Chargeable Procedure

CGHS Code with page no.(!)

Other if not on code no with page

no.(!)

Rate Amount claimed with date

Amount admitted with date

Remarks(X)

Total Amount Claimed(I+II+III) Rs. ………………..

Total Amount Admitted (X) (I+II+III) Rs. …………………

Remarks

Certified that the treatment/procedure has been done/performed as per laid down norms and the charges in the bill has/ have been claimed as per the terms & conditions laid down in the agreement signed with ESIC.

Further certified that the treatment/ procedure have been performed on cashless basis. No money has been received /demanded/ charged from the patient/ his/her relative.

Sign/Thumb impression of patient with date Sign & Stamp of Authorized Signatory with date (for Official use of ESIC)

Total Amt payable:

Date of payment :

Signature of Dealing Assistant Signature of Medical Superintendent

Date: Signature of ESIC Competent Authority Medical Superintendent

1. Discharge Slip containing treatment summary & detailed treatment record. 2. Bill(s) of Implant(s) / Stent(s) /device along with Pouch/packet/invoice etc. 3. Photocopies of referral proforma, Insurance Card/ Photo I card of IP/ Referral recommendation of medical officer & entitlement certificate. Approval letter from SMC/MEDICAL SUPDT in case of emergency treatment or additional procedure performed. 4. Sign & Stamp of Authorized Signatory. 5. Patient/Attendant satisfaction certificate.

6. Document in favour of permission taken for additional procedure/treatment or investigation.

X) to be filled by ESIC Official(s).

ANNEXURE V To be used by Tie-up hospital (P-III) Letterhead of Hospital with Address & Email/Fax/Telefax

Consolidated Bill Format

Bill No ………………………………… Date of Submission……………….. Bill Details (Summary) Sl.no Name

of Patient

Ref.No Diag/Procedure for which referred

Procedure performed /Treatment

Given

CGHS code (with

page)No.Nos

Other if not

in CGHS

rate list

Amount claimed

with date

Amount entitled

with date

Remarks

Certified that the treatment/procedure has been done/performed as per laid down norms and the charges in the bill has/ have been claimed as per the terms & conditions laid down in the agreement signed with ESIC. Further certified that the treatment/ procedure have been performed on cashless basis. No money has been received /demanded/ charged from the patient/ his/her relative.

The amount may be credited to our account no RTGS no and intimate the same through email/fax/hard copy at the address.

Date: Signature of the competent authority of the hospital

Checklist 1. Duly filled up consolidated proforma.

2. Duly filled up Individual Pt Bill .proforma.

Certificate: It is certified that the drugs used in the treatment are in the standard pharmacopeia IP/BP/USP.

It is certified that total amount of Rs has been credited to your account no. , RTGS no on

Date: Signature of the Competent Authority. (To be filled up by ESIC official(s))

ANNEXURE VI

Letterhead of Referring ESI Hospital _(P-IV) Sanction Memo/Disallowance Memo

Name of Referral Hospital (Tie-up Hospital)

Bill No ………………Date of Submission…………..

SL.No Name of the

Patient&Referance No.

Amount Claimed With Date

Amount Sanctioned /Admitted with date

Reasons(s) For Disallowance

Remarks

.

Date:

Signature of Competent Authority With Stamp

(To be filled up by ESIC official(s))

ANNEXURE VII Letterhead of Tie-up Hospital with Address details(P- V) Monthly Bill Special Investigations For diagnosis centres/referral Hospitals

Bill No ………………Date of Submission………….. SLNo Name of the

patient With Insurance/Staff.No.

Date of referance

Investigation Performed

CGHS/Othe r code in package rate list

Amount admitted with date

Amount claimed

with date

Remarks Disallowances with Reasons

Certified that the procedure/investigations have been done/performed as per laid down norms and the charges in the bill has/ have been claimed as per the terms & conditions laid down in the agreement signed with ESIC.

Further certified that the procedure/investigations have been performed on cashless basis. No money has been received /demanded/ charged from the patient / his/her relative . The amount may be credited to our account no RTGS no andintimate the same through email/fax/hard copy at the address.

Date: Signature of the Competent Authority of Tie-up Hospital

Checklist 1. Investigation Report of each individual/Pt. 2. Copy of Referral Document of each individual/Pt. 3. Serialization of individual bills as per the Sr. No. in the bill. It is certified that total amount of Rs has been credited to your account no. , RTGS no on

Signature of Account department with stamp

Signature of Competent Authority Date: Referral Hospital.

(To be filled up by ESIC official(s)) Patient Referral No

ANNEXURE VIII PATIENT/ATTENDANT SATISFACTION CERTIFICATE (P-VI)

1. I am satisfied/ not satisfied with the treatment given to me/ my patient and with the behavior of the hospital staff.

2. If not satisfied, the reason(s) thereof.

3. It is stated that no money has been demanded/ charged from me/my relative during the stay at hospital.

Sign/Thumb impression of patient/Attendant Date &Time:

Name of the Patient/attendant Name of IP Insurance No/Staff no

Date of Admission Date of Discharge