Pradhan Matri Jan Arogya Yojana (Ayushman Bharat)- PMJAY Assam Online Apply - www.pmjay.gov.in

Pradhan Matri Jan Arogya Yojana (Ayushman Bharat)

Pradhan Matri Jan Arogya Yojana (Ayushman Bharat)
Pradhan Matri Jan Arogya Yojana (Ayushman Bharat)

Pradhan Matri Jan Arogya Yojana (Ayushman Bharat)

Ayushman Bharat - PRADHAN MANTRI JAN AROGYA YOJANA (AB PM-JAY) WAS LAUNCHED ON SEPTEMBER 23, 2018

Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (PM-JAY), is a flagship scheme of Government of India to provide cashless secondary and tertiary care treatment from the empanelled public and private hospitals providing coverage to more than 10 crore poor and vulnerable beneficiary families are eligible for these benefits.

National Health Authority (NHA) is the apex body responsible for the implementation of Ayushman Bharat PM-JAY

 

Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PM-JAY) provides a cover of up to Rs. 5 lakhs per family per year, for secondary and tertiary care hospitalization.


Benefits

Pradhan Pradhan Mantri Jan Arogya Yojana (PM-JAY) beneficiaries are entitled to following health care benefits:

  1. Health cover of up to Rs. 5 lakhs per family per year, for secondary and tertiary care hospitalization through a network of empaneled public and private providers
  2. No restrictions on family size, age or gender
  3. Cashless access to services for the beneficiary at the hospital
  4. All pre−existing conditions are covered from day one. Covers up to 3 days of pre-hospitalisation and post-hospitalisation expenses such as diagnostics and medicines
  5. Benefits of the scheme are portable across the country where a beneficiary can visit any empaneled public or private hospital for cashless treatment
  6. Services include 1393 procedures covering all the costs related to treatment, including but not limited to drugs, supplies, diagnostics services, physician's, room charges etc.

Eligibility Criteria:

  1. The 10.74 crore entitled beneficiary families have been identified based on Socio Economic Caste Census (SECC) data by applying deprivation and occupation criteria for rural and urban areas respectively. In addition, such families that were already covered under Rashtriya Swasthya Bima Yojana (RSBY) but are not part of SECC are also covered.

Where to Apply and How to Apply:

  1. Personalized letter with unique family code are in process of being sent to the identified families in the Additional Data Collective Drive(ADCD). This will drive awareness amongst the beneficiaries and further ease the identification process when they visit point of CARE of CSC center.
  2. Common service Centres (CSC) will help citizens and will utilize over 3 lakhs village level entrepreneurs for identifying beneficiaries basis SECC list.

Documents required:

  1. Eligibility under PM-JAY may be checked by visiting nearest Common Service Center or PM-JAY empanelled hospital with individual (Voter id, Adhaar) and family id (Ration card) proof

For more information:

  1. For more information, assistance, questions and complaints contact 24X7 helpline number − 14555/ 1800 111 565
  2. Visit: www.pmjay.gov.in
  3. Check Eligibility: www.mera.pmjay.gov.in
  4. Twitter: AyushmanNHA
  5. Facebook: AyushmanBharatGOI
  6. Download Ayushman Bharat PM-JAY android app

PM-JAY Apply Link in Assam : Click Here

PM-JAY Download Link in Assam : Click Here

Search PM-JAY Hospital in Assam : Click Here


PMAJY FAQs:

What is Pradhan Mantri Jan Arogya Yojana(PM-JAY)?

Pradhan Mantri Jan Arogya Yojana(PM-JAY) is a pioneering initiative of Prime Minister Modi to ensure that poor and vulnerable population is provided health cover. This initiative is part of the Government’s vision to ensure that its citizens – especially the poor and vulnerable groups have universal access to good quality hospital services without anyone having to face financial hardship as a consequence of using health services.

What benefits are available under PM-JAY?

PM-JAY provides an insurance cover upto Rs 5 lakh per family, per year for secondary and tertiary hospitalization. All pre-existing conditions are covered from day 1 of implementation of PM-JAY in respective States/UTs.

What health services are available under PM-JAY?

The health services covered under the programme include hospitalization expenses, day care surgeries, follow-up care, pre and post hospitalization expense benefits and new born child/children services. The comprehensive list of services is available on the website.

Who is eligible to avail benefits under PM-JAY?

PM-JAY covers more than 10 crore poor and vulnerable families across the country, identified as deprived rural families and occupational categories of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data. A list of eligible families has been shared with the respective state government as well as ANMs/BMO/BDOs of relevant area. Only families whose name is on the list are entitled for the benefits of PM-JAY. Additionally, any family that has an active RSBY card as of 28 February 2018 is covered. There is no capping on family size and age of members, which will ensure that all family members specifically girl child and senior citizens will get coverage.

Where can beneficiaries avail of services under PM-JAY?

Services under the scheme can be availed at all public hospitals and empaneled private health care facilities. Empanelment of the hospitals under PM-JAY will be conducted through an online portal by the state government. Information about empaneled hospitals will be made available at through different means such as government website, mobile app. Beneficiaries can also call the helpline number at 14555. Regular updates will also be provided through ASHAs, ANM and other specific touch points This information will be activated shortly.

Will beneficiaries have to pay anything to get covered under this scheme?

No. All eligible beneficiaries can avail free services for secondary and tertiary hospital care for identified packages under PM-JAY at public hospitals and empaneled private hospitals. Beneficiaries will have cashless and paperless access to health services under PM-JAY.

What is the enrolment process? Is there any time period for enrolment?

PM-JAY is an entitlement based mission. There is no enrolment process. Families who are identified by the government on the basis of deprivation and occupational criteria using the SECC database both in rural and urban areas are entitled for PM-JAY.

How are the beneficiaries identified?

The beneficiaries are identified based on the deprivation categories (D1, D2, D3, D4, D5, and D7) identified under the SECC (Socio-Economic Caste Census) database for rural areas and 11 occupational criteria for urban areas. In addition, RSBY beneficiaries in states where RSBY is active are also included.

Can those families whose names are not on the list avail the benefits under PM-JAY?

In this phase, no additional new families can be added under PM-JAY. However, names of additional family members can be added for those families whose names are already on the SECC list.

Will a card be given to the beneficiary?

A dedicated PM-JAY family identification number will be allotted to eligible families. Additionally, an e-card will also be given to beneficiary at the time of hospitalization.

If I am listed as a beneficiary and I need to be hospitalized, what documents do I need to bring to the hospital?

At the time of admission to the hospital, beneficiaries should carry ration card or any other government recognized photo identity document like Aadhaar etc.

What happens if I fall ill during my travel or when I am out of my district or state?

The scheme will have portability of benefits across the country. Beneficiary can avail services all across the implementing States/UTs. You can call helpline number 14555 for details.

How will this scheme effect previous schemes like RSBY, Senior Citizen Health Insurance Scheme or any other health insurance scheme implemented within a certain state?

The scheme will subsume the functional RSBY schemes – Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme (SCHIS).

What is the grievance redressal mechanism in case of any complaints or denial of service?
A well-defined three tier complaint and grievance redressal mechanism will be in place. This includes constitution of various committees, use of electronic, mobile platform, an All-India helpline number 14555 internet as well as social media. Robust safeguards to prevent misuse/fraud/abuse by providers and users will also be in place.
 

CGRMS FAQs:-

What is CGRMS? What is its purpose?

CGRMS (Central Grievance Redressal Management System) is an online portal used to address the complaints registered from different stakeholders under AB-PMJAY. Through this mechanism any one can lodge a complaint or grievance on the portal which will be addressed within a defined time frame

Who can register a grievance?

A complaint can be registered by the beneficiaries, their family members, empaneled 
hospitals, insurance companies, ISA, TPA or SHA and any other stakeholder who is relate
to implementation of PMJAY. 

How do I lodge a complaint or grievance?

Through online grievance redressal portal - CGRMS of AB PMJAY (https://cgrms.pmjay.gov.in/) Offline Mode

  • AB PMJAY Call center helpline operated by the State/ NHA.
  • Through letter, telephone, e-mail, and fax to the official addresses of the SHA or the NHA
  • Directly with the DGNO of the district where such stakeholder is located or where such grievance has arisen
  • DGNO shall enter the particulars of grievances received via offline mode in the portal.
Should I have to login to register grievance?

No login required. Grievance can be registered directly by filling the form online.

What happens when I lodge a grievance?

A Unique Grievance Number will be generated against each grievance case. The case will appear in the concerned officer login for necessary action.

How do I track my Grievance?

Grievance can be tracked on the AB PMJAY Grievance portal (CGRMS), using your Unique Grievance Number - (UGN)

What type of grievance can be lodged by beneficiary?

Grievances can be against various stakeholders when there is lack of service or poor quality 
service. Ex. Denial of treatment by hospital, Money sought by hospital, misconduct of 
PMAM, PMAM not providing correct information, Poor facility in the hospital etc. For more 
details drop down in the grievance form can be referred.

What will happen to the grievances?

Grievance will be sent to concerned authorities for investigation and resolution

After redress can the grievance be escalated if complainant is not satisfied?

Yes, if complainant is not satisfied with the decision then grievance can be escalated to the higher authority by reopening the case.

What is the Turn Around Time (TAT) to resolve the grievances?

As per guidelines if the grievance is emergency in nature it shall be resolved by DGNO within 48 hours. In non-emergency cases it will be 15 days. However, if the case is escalated to DGRC, 30 days will be the TAT.

 

TMS FAQs:-

Can the hospitals break the treatment packages?

As a part of hospital empanelment process, hospitals must agree to the pre-fixed package rates, and it cannot be changed during the contract period.

How will a patient traveling to another state get to know whether the hospital provides a relevant package?

The patient may contact the toll-free helpline number 14555 for support or reach out to the Ayushman Mitra in the hospital. 

What to do when there is no connectivity with the system

Treatment may be provided as per the guideline issued by NHA on usage of TMS in intermittent / poor connectivity locations

Who will pay for the treatment cost in case of portability?

The home state where the benficiary originate from will pay for the treatment expenses

Which package rate will be applicable in case of portability?

The packages rate applicable in the State where the hospital is situated will be applicable in case of portability

Government should provide tenders for insurance companies all over India

Government has stopped its policy for posting an all India partner

Is there a standard definition of HDU/ICUs?

Need to set up a standard definition on HDU/ICU for effective settlement of claims

What about tendering process of smaller states? is state grouping allowed?

States can explore the option of group tendering.

What would the situation be if the Insurance company decides to back out?

The state will work in trust mode until new Insurance company is on board for, the scheme.

What will happen in cases where medical and surgical procedures are done together?

Such a case will require enhancement in TMS

Can we use the golden card to search for patients for TMS?

Yes, we can use the QR code, or we can use the HHID

Can the same registration be used for OP and IP?

No, IP and OP will have different registration number.

What if a new doctor is recruited and his name is not listed in TMS

The new Doctor's information should be informed to ISA/IC in writing immediately after joining. If there is technical delay in updating the Doctor's information in TMS, "others" option may be selected from the doctor list in TMS. But it should only be used as a contingency option.

Can a hospital provide treatment for specialties which are not specified at the time of empanelment?

No. Only those specialties specified in the hospital empanelment module will be visible in the Transaction Management Software

What is the process for updating specialties in case of a hospital facility upgrade?

The information will need to be informed to the SHA in writing. The hospital will either be permitted to update the information through HEM portal or will be updated in backend by the SHA/ISA/TPA

If the patient is admitted for a 5-day package and the patient dies on 2nd day, what do we do in this case?

Patient mortality details may be updated in the TMS application and discharged. Payment for the services provided will be determined by the ISA/TPA after verifying the documents.

In MedicoLegal, we can have two cases: 1. Police has brought, 2. Patient comes self

When Medico legal case is added as Yes, the police station number is mandatory but legal case number is optional. Both should not be mandatory

What if the patient leaves the hospital against the medical advice (LAMA)?

Patient should be discharged in TMS and relevant information may be updated in the discharge summary

Possibility that after discharge a patient comes to know that he is NHPM beneficiary. Will he receive the benefit?

Patient will not be able to receive the benefits; However, he can utilize the same for next visit.

Is there a provision for re-consideration if the claim panel doctor gives a wrong rejection?

Yes. The hospital can challenge the decision in writing to the ISA/TPA. If the issues are not resolved, the same may be brought to the attention of grievance redressal committee.

What are the criteria for enhancement in TMS?

Need to codify enhancements- Days, Surgery+Surgery, Medical+Surgery

What services are excluded under PMJAY?

Any outpatient care, drug rehabilitation, cosmetic treatments, organ transplants and fertility treatment are not covered.

What happens if the disease is not in the package?

Any surgery that is not in the package will need to be pre-authorized after which the price will be negotiated between the hospital and SHA/IC and then the procedures can be planned. This is capped to an amount of Rs 1 lakh. This option is available for surgical procedures only.

I am a diabetic since years, will I now also get treatment?

Yes. PMJAY benefits will be available from Day 1 of the roll out of the scheme for inpatient hospital care. Any inpatient hospital care for pre-existing diseases will be covered. However, OPD will not be covered.

Do I need to pay for medicines I receive under this scheme?

No. Under PMJAY, medicines will be included in the package for the duration of treatment, including up to 15 days after discharge from hospital, as needed.

Are maternity benefits covered under JSY a part of AB-NHPM?

Normal Labour and delivery, including high risk deliveries, C-sections and associated treatments are covered under PMJAY. But JSY and another voucher scheme benefit are not given under PMJAY

If there are five members in a family who have already availed benefit under PMJAY, will a new-born be covered?

Yes. There is no limit of family size. The neonate will be provided care provided the benefit is not exhausted

Is there any provision for payment of transportation charges?

There is no provision of payment of transportation charges under the scheme.

What if an empanelled government/ private hospital is refusing to treat a beneficiary?

A dedicated Grievance Redressal Committee will be appointed at district, state and national level and all grievance will be addressed within a period of 30 days.

Any escalation matrix in case customer is unhappy with Arogya Mitra’s response or assistance?

Yes – Grievances against the Arogya Mitra can be escalated to the District Grievance Nodal Officer.

What if the hospital, after admitting a beneficiary, conducts the investigation and finding nothing worthy of a -surgery?

This will be handled on a case to case basis and the required process will be escalated for resolution within the grievance framework.

Can a hospital provide treatment for specialties which are not specified at the time of empanelment?

No. Only those specialties specified in the hospital empanelment module will be visible in the TMS.

Can a MEDCO share the information / record of patient to anyone?

The hospital is required to maintain complete confidentiality of patient information and must not be shared to unauthorized persons. For further details please refer to detailed guidelines

Can the hospital claim for treatment in event that the patient dies during the process of treatment?

Yes, the hospital can claim if the patient has undergone treatment but does not survive. The same would be subject to verification / approval of the CPD.

Can the MEDCO use the same login ID for HEM application in TMS application?

As of now MEDCO cannot. Currently, TMS application and HEM application have separate login IDs.

Under TMS, does IP and OP have same registration numbers?

No, IP and OP cases will have different registration numbers.

Does a beneficiary need to pay for getting medicines for the treatment received under this scheme?

No. Under PMJAY, medicines will be included in the package for the duration of treatment

Does the scheme only entitle beneficiary for admission to general ward?

Yes. If beneficiary wants an upgrade in room the all expenses for treatment will not be covered under PMJAY scheme. Admission to ICU for specified packages is allowed

How can MEDCO convert OP registered cases as IP or vice versa?

This provision is currently not built in TMS. The beneficiary can be re-registered correctly after discharging or cancelling registration in TMS.

How will a beneficiary get registered for treatment in a hospital?

The beneficiary has to provide NHPM-ID / Ration Card / Mobile Number / Aadhaar / Other Valid Identity Proof to the Medco or AM. The details of the beneficiary if available in the BIS will be retrieved in TMS for case registration.

If a beneficiary comes to know that he / she is an NHPM beneficiary, can such benefit be claimed later after treatment is complete or discharged?

In such cases, beneficiary will not be able to claim the benefits retrospectively.

If the patient is admitted for a 5-day package and the patient dies on 2nd day, what do we do in this case?

Patient mortality details may be updated in the TMS application and discharged. Payment for the services provided will be determined by the ISA/TPA after verifying the documents.

If there are five members in a family who have already availed benefit under PMJAY, will a new-born be covered?

Yes. There is no limit of family size. The neonate will be provided care provided the benefit limit is not exhausted and the neonate is added to a family with at least one PMJAY verified beneficiary

In which languages is the TMS application available?

The TMS application is only available in English

What are the various types of Users in TMS?

The Hospital TMS has the following types of Users:

  • Hospital User - Pradhan Mantri Arogya Mitra or Medical Coordinator (MEDCO)
  • Preauthorization Panel Doctor (PPD)
  • Claim Executive (CEX)
  • Claim Panel Doctor (CPD)
  • State Health Agency (SHA)
Is it mandatory to upload Preauthorization Request Form (PRF)?

PRF was earlier a mandatory upload. However, since 23 Oct 2018, PRF has been removed

Is post-hospitalization expense covered in PMJAY?

Post-hospitalization expense is part of the package amount for the treatment. No expenditure is to be done by the patient or beneficiary post-discharge. Prior to discharge, the hospital has to provide a follow-up date for such treatment

Is the cost of diagnosis or investigation included?

The package amount includes the cost of diagnosis / investigation as needed after the patient has been registered.

Is the TMS application available for general public?

TMS application has not been made public for the general public

The primary diagnosis list does not populate even after entering 4 characters (minimum required). Why?

Please check that you have entered the word correctly as per the list of words available in primary diagnosis drop down menu. Therefore, enter valid characters only.

What do the beneficiaries have to pay to get be covered under this scheme?

All eligible beneficiaries can avail free services for secondary and tertiary inpatient hospital care as per identified packages under PMJAY at all public/government hospitals and empanelled private hospitals. Beneficiaries will have cashless and paperless access to inpatient hospital care under PMJAY.

What if there is an emergency treatment has to be done?

In case of an emergency, when a surgery needs to be done immediately (emergency cases) telephonic approval is taken from concerned Approvers and a Telephonic ID is generated. Later the Arogya Mitra / Medco will need to register the case into TMS as per process.

What is auto-approved pre-authorization?

Certain procedures do not require pre-authorization approval from PPD. In such case, approval is done immediately by TMS after initiation by Medco and the treatment can be started immediately. There 914 such procedures in the National Package. Certain other procedures are pre-approved for only the 1st day of admission. For any extension of treatment, approval has to be taken by Medco from PPD after every 5 days' interval. There are 164 such procedures in the National Package.

What is meant by packages?

A package includes end to end treatment for the entire episode of care required. i.e. Diagnosis, doctor and nursing charges, pre-hospitalization investigation, bed charges, consumables, medicines, food for the patient and post-surgery investigations and medicines.

What is the criteria for enhancement of package in TMS?

Enhancement is allowed only for surgery cases for another surgery. Enhancement to surgery is not allowed for Medical cases.

What is the process to be followed in empanelled hospitals?

Please refer to the detailed process flow.

What to do if I forgot the login ID or password?

In such cases please reach out to your SHA

What to do in case stay of patient in the hospital needs to be extended?

As per guidelines, extension of stay is not applicable for medical cases which are paid in packages. Extension would be required only for packages which are paid on ward basis. The same can be done through Pre-authorization within the existing case.

What to do when there is no internet connectivity at hospital during transaction?

Hospital will call Central Helpline and using IVRS enter AB-NHPM ID or Aadhaar number of the patient. IVRS will speak out the details of all beneficiaries in the family and hospital will choose the beneficiary who has come for treatment. It will also inform the verification status of the beneficiary - If eligible and verified then beneficiary will be registered for getting treatment by sending an OTP on the mobile number of the beneficiary. In case beneficiary is eligible but not verified then she/he can be verified using Aadhaar OTP authentication and can get registered for getting cashless treatment.

Hospitals with poor connectivity must always keep a print out of the authorized package list including the package code names and rates.

NHA has issued guidelines for usage of software when there is intermittent connectivity or no connectivity. This has to be followed in such hospitals / scenarios.

What will happen in cases where medical and surgical procedures are done together?

Such cases will require enhancement to be preauthorized in TMS.

When can a hospital initiate the claim for the treatment?

A hospital can initiate claim after the procedure has been completed and patient has been either discharged or marked as dead in TMS.

Which are the types of treatment available for a beneficiary?

More than 1350 procedures including Medical and Surgical are available under PMJAY in the National Package list.

Why am I getting an error while trying to upload a file in TMS?

Please check the file type allowed. Only JPG or PDF file are allowed. The file size should not exceed 500 KB

Why am I unable to register a patient?

If a beneficiary is already registered in another hospital and has not been discharged, then such beneficiary cannot be registered

Why am I unable to view the case status though I have registered the beneficiary in TMS?

In registered patient view, registered patients will be displayed. After that primary diagnosis will be done by the MEDCO and then either the patient will be converted as IP or OP. Case Status is available for IP cases only.

Why does a hospital not able to select certain / any procedure?

This happens if the specialties have not been provided in HEM application. Procedures would appear in TMS only for specialties which have been approved in HEM application. Specialties must be updated in HEM application.

Why does an error pop up while uploading document in TMS?

TMS application does not allow file to be uploaded if a file with same name has been uploaded earlier for a patient.

Is cancer treated under PM-JAY?

Yes, however the type and duration of treatment is different for all cancers. Cancer care treatments need to undergo a whole treatment plan approval similar to a ‘tumor board concept’ on the best course of patient management. A clinical treatment approval process is mandated for cancer care, since it involves a multi-modal approach covering surgical, chemotherapy and radiation treatments and appropriate supportive care that could assess to determine the best course of patient management for such conditions. Pre-authorization is mandatory for all packages involving cancer treatment. There would be 2-step approach for Pre-auth Pre-auth for the complete course of treatment mentioning the various stages of treatment and the detailed Oncology Treatment Plan Approval form has to be filled, signed & uploaded (Annexure 1) as part of Pre-auth Pre-auth has to be sought at each pre-defined stage / selecting package

Under which category are the Cancer packages listed?

Packages have been enlisted under Medical, Radiation and Surgical oncology. In the case of Surgical packages, they are not exhaustive – since there are significant overlaps with packages under other specialty domains. Such packages may be used as deemed necessary.

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