Revised MA hospital tender - Health and Family Welfare Department

RFP DOCUMENT 

RFP Document for Empanelment of Hospitals under 

Mukhyamantri Amrutum (MA) Yojana 

in Gujarat 

Government of Gujarat 

Health and Family Welfare Department 

Gandhinagar 

Issued / Released on 19 th July, 2012 

RFP FOR HOSPITAL EMPANELMENT UNDER ‘MA’ YOJANA-GUJARAT Page 1

GOVERNMENT OF GUJARAT 

DEPARTMENT OF HEALTH AND FAMILY WALFARE 

RE-TENDER NOTICE 

MUKHYAMANTRI AMRUTUM (MA) YOJANA 

Sealed bids are invited from the entities owning reputed private hospitals 

having experience of treating cancer patients with Radiotherapy under 

Mukhyamantri Amrutum (MA) implemented for Below Poverty Line (BPL) 

families in all the 26 districts of Gujarat, Yojana for cluster 10 Radiation 

Oncology. 

The bids are invited in two parts i.e., Technical Bid and Financial Bid. The RFP 

document for this may be downloaded from the website www.nprocure.com. 

The RFP document can also be obtained from in person from the date of 

release 18/8/2012 from the below mentioned address on any working day 

between 10.30 A.M and 4.00 P.M. 

The Technical Bids should be sealed by the Bidder in an envelope duly superscribed 

“Technical Bid for empanelment under Mukhyamantri Amrutum 

(MA) Yojana”. The Financial Bids is to be submitted through online only. The 

Technical Bids will be evaluated by the Technical Bid Evaluation Committee. 

Financial Bids of only the technically qualified Bidders shall be opened before 

the qualified Bidders by the State Nodal Cell (SNC) for awarding of the contract. 

All the technically qualified bidders will be informed about financial bid 

opening date. 

The following schedule will be observed in this regard: 

1. Pre bid meeting: 21/8/2012 (at 16.00 noon) 

2. Last date for online submission of Bids: 25/8/2012 (up to 14.00 noon) 

3. Last date for physical submission of Bids: 25/8/2012 (up to 16.00 hrs) 

The dates for opening the financial bids 

The completed bid documents should be submitted before 14.00 hrs. of 

25/8/2012, at the following address:- 

Additional Director (FW), Commissionerate of Health and Family Welfare, MS 

and ME, Block No. 5, Dr. Jivraj Mehta Bhavan, Gandhinagar, Gujarat, Phone: 

079-232-53311, Fax: 079-232-56430 Email: mayojanagujarat@gmail.com. 


TABLE OF CONTENTS 

A. PART-1 

1. Introduction 4 

2. Eligible health services providers 7 

3. Implementation procedure 8 

4. Empanelment procedure and disciplinary proceedings 10 

5. Grievance redressal mechanism 15 

6. IT infrastructure needed for empanelment 17 

7. Amendment of bidding document 18 

8. Notification of award and signing of agreement 19 

B. PART-2 

9. Submission of bids/proposals 21 

10. Draft Agreement between ISA and Hospital 30 

11. Detail of technical proposal (Annexure-2) 70 

12. Evaluation of technical bid process (Annexure-3) 90 

13. Financial Bid (Annexure-5) 93 

14. General guidelines on the benefit package (Anexure-6) 159 

15. General guidelines on Hospital Services (Anexure-7) 161 

16. Follow up surgeries for MA Yojana Beneficiaries (Annexure-8) 163 

17. Process Note for De-empanelment of Hospitals (Annexure-9) 165 

18. Roles and responsibility of Arogya Mitra (Annexure-10) 168 

19. Roles and responsibility of Hospital Arogya Mitra (Annexure-11) 170 

20. Role of Hospital Arogya Mitra in Medical Camp(Annexure-12) 172 

21. Network Hospital Do‟s & Don‟ts (Annexure-13) 175 

22. Undertaking to provide infrastructure at MA Kiosk (Annexure-14) 177 

23. Guidelines for poly trauma (Annexure-15) 178 

24. Guidelines for Laparoscopic Procedures (Annexure-16) 181 

25. Guidelines for Genito Urinary Procedure (Annexure-17) 182 

26. Guidelines for Triple Vessel Disease (Cardiothoracic) (Annexure-18) 183 

27. Guidelines for Cancer (Annexure-19) 184 

28. Guidelines for Burns (Annexure-22) 191 

29. Display of Bed status at MA Kiosk (Annexure-23) 192 

30. Format for Affidavit (tied up diagnostic facility)(Annexure-24) 193 

31. Health camp guidelines (Annexure-26) 195 

32. Undertaking to share core banking number (IFC Code) (Annexure-27) 214 

33. District Wise BPL family Details (Annexure-28) 215 

34. Checklist (Annexure-30) 217 

35. Performance Security (Annexure-31) 218 


PART-I 

TERMS OF REFERENCE FOR SELECTION OF PRIVATE HOSPITALS FOR 

EMPANELMENT UNDER MUKHYAMANTRI AMRUTUM (MA) YOJANA 

1. INTRODUCTION: 

A large number of households are pushed into poverty as a result of high 

costs of household spending on health care. The Below Poverty Line (BPL) 

population is especially vulnerable to catastrophic health risks. To address 

this key vulnerability faced by the BPL population in the state, the 

Government of Gujarat has taken a decision to launch a medical care 

scheme – to be called Mukhyamantri Amrutum (MA) Yojana – providing 

cashless treatment and coverage of catastrophic care targeted at the BPL 

population (hereinafter referred to as the “Scheme”). The proposed Scheme 

will cover the entire State of Gujarat. 

“State Nodal Cell” has been set up by the Government of Gujarat, for the 

implementation of the Scheme. The State Nodal Cell will implement, 

establish, provide, administer, modify and supervise the Mukhyamantri 

Amrutum (MA) Yojana for providing medical care to the Beneficiaries. 

The Department of Health and Family Welfare, Government of Gujarat 

invites proposals for the empanelment of hospitals, for providing tertiary 

care health services under the Mukhyamantri Amrutum (MA) Yojana. 

Proposals are invited from the entities owning Private hospitals. Only the 

entities who are in agreement with the Scheme and the Terms of Reference 

contained in this FRP document, need to participate in the bidding and any 

disagreement in this regard may invite disqualification / rejection of bid at 

technical level. Hence all the Bidders are requested to go through the 

Scheme carefully and submit their Bids in the specific formats given in this 

RFP and agree to enter into the Service Agreement in the format given in 

this RFP, in case of empanelment. 

Finally, the award will be given to the entities owning the Hospitals that are 

selected by the Bid Evaluation Committee on the basis of both the Technical 

and Financial Bids, following due procedure. The selected Hospitals have to 

start the work immediately after the award. In case a selected Bidder 

declines to take up this work after a notice of award has been issued, it 

would be barred from applying for any such work or assistance of any kind 

from Department of Health and Family Welfare, Gandhinagar, Gujarat for a 


period of 3 years from the date of such award. The decision of the Bid 

Evaluation Committee shall be final, and no enquiries, or application for 

review, shall be entertained. 

2. OBJECTIVE : 

The objective of the Scheme is to improve access of BPL families to quality 

medical and surgical care for treatment of identified diseases involving 

hospitalization, surgeries and therapies through an empanelled network of 

health care providers. 

3. BENEFICIARIES: 

The Scheme is intended to benefit Below Poverty Line (BPL) Families of the 

26 districts of Gujarat, namely Banaskantha, Sabarkantha, Dang, 

Narmada, Tapi, Bharuch, Dahod, Kutch, Jamnagar, Patan, Anand, 

Vadodra, Valsad, Surat, Navsari, Ahmedabad, Gandhinagar, Mehsana, 

Kheda, Panchmahal, Surendranagar, Rajkot, Amreli, Bhavnagar, Junagadh, 

and Porbandar. According to a recent enumeration made by the Rural and 

Urban Development Department, there are approximately 39 lakh BPL 

families in the said twenty six districts of the State. Database and 

photographs of these families are available in the form of Bar Coded Plastic 

Cards issued by the Commissionerate of Health and Family Welfare, 

Gandhinagar. However the number of Bar Coded Plastic Card holders is 

subject to increase or decrease. District-wise profile of the BPL families is 

given in Annexure-28. 

4. BPL FAMILY: 

A family would comprise the head of the family, spouse, and up to three 

dependents. The dependents would include such members as listed as part 

of the family in the beneficiary database provided by the Rural and Urban 

Development Department, Gandhinagar. 

5. SUM INSURED ON FLOATER BASIS: 

The Scheme provides coverage for meeting expenses of hospitalization 

and surgical procedures of the beneficiary members up to Rs.2.0 lakhs 

per family of five members per year subject to limits, in any of the 

Network Hospitals. The benefit on family will be on floater basis i.e. the 

total reimbursement of Rs.2.0 lakhs can be availed of individually or 

collectively by members of the family. 


6. BENEFITS: 

All predefined medical procedures and other services as part of the 

disease/treatment packages would be provided on a complete cashless basis. 

An enrolled BPL beneficiary may go to any Network Hospital with the Bar 

Coded Plastic Card and come out without making any payment to the 

Hospital for these procedures covered under the Scheme. 

1 Burns (a total 12 Benefit Packages) 

2 Cardiovascular Surgeries (a total 153 Benefit Packages) 

3 Renal (a total 21 Benefit Packages) 

4 Neurosurgeries (a total 49 Benefit Packages) 

5 Poly Trauma (Not covered by Motor Vehicle Insurance) (a total 8 Benefit 

Packages) 

6 Neo-natal diseases (a total 23 Benefit Packages) 

7 Cancer (Surgical Oncology, Chemotherapy & Radiation Oncology) (a total 

210 Benefit Packages) 

In addition, there will be no pre-existing condition exclusions. Pre-existing 

diseases are also covered from day one which means that any illnesses 

existing prior to the inception of the Scheme shall also be covered. 

Provision for transport allowance of Rs.300 per visit subject to an annual 

ceiling of Rs.3000 shall be a part of the total coverage of Rs 2,00,000/- per 

family. 

7. ELIGIBLE HEALTH SERVICES PROVIDERS: 

7.1 Empanelment of Public/Grant in Aid hospitals: 

All Government/Grant in Aid hospitals as decided by the State 

Government shall be empanelled. 

7.2 Criteria for Empanelment of Private Providers: 

The empanelment criteria of the Health Services Providers is defined and 

listed in Part II of this RFP Document, under the head of Eligibility 

Criteria. The Implementation Support Agency (ISA) shall sign Service 

Agreements with the entities owning all the Hospitals to be empanelled 

under the Scheme. The empanelled Hospitals shall extend medical aid to 

the Beneficiaries as per the Scheme. 


8. ADDITIONAL BENEFITS TO BE PROVIDED BY HEALTH SERVICES 

PROVIDERS 

In addition to the benefits mentioned above, both Public and Private 

Health Services Providers should provide free Registration and free OPD 

consultation to the MA enrolled Beneficiaries. 

9. ADDITIONAL RESPONSIBILITIES OF THE HEALTH SERVICES 

PROVIDERS 

In addition to providing cashless treatment, the Health Services 

Providers shall: 

a. Display clearly their status of being an empanelled provider of Health 

Services under the Mukhyamantri Amrutum (MA) Yojana, in the 

prescribed format given by State Nodal Cell, at their main gate. 

b. Maintain a functional help desk for giving necessary assistance to the 

MA Beneficiaries. At least two persons in the Hospital shall be 

nominated by the Hospital, who will be trained in different aspects of MA 

Yojana by the ISA. 

c. Display a poster near the reception/admission desks along with the 

other materials supplied by the ISA for the ease of Beneficiaries, 

Government and ISA. The template of empanelled status and poster for 

reception area will be provided by the State Nodal Cell. 

d. Send Hospitalisation data of MA patients electronically on a daily basis 

to the designated server. 

10. ADDITIONAL SERVICES TO BE PROVIDED BY THE NETWORK 

HOSPITALS: 

The Health Services Providers / Network Hospitals shall provide the 

following additional services to the Beneficiaries: 

a) Provide space and separate Mukhyamantri Amrutum (MA) Yojana 

counter / kiosk as per the design provided by ISA for Arogya Mitras 

(Health Coordinators). 

b) Provide computer with networking (dedicated broadband with minimum 

2 mbps speed), printer, webcam, scanner, bar code reader, biometrics, 

digital camera and digital signatures. 

c) Provide free food for the patient and also provide transport / 

transportation charges for the patient on discharge (Rs. 300/- with a 

ceiling of maximum Rs.3000/- per year) which will be the part of package 

rates. 


d) Provide free OPD/diagnostic tests irrespective of surgeries/procedures 

and medical treatment required for the Beneficiaries irrespective of the 

procedure. There shall not be any cash transaction for MA patients. 

11. SPECIAL FUNCTIONARIES TO BE PROVIDED BY THE NETWORK 

HOSPITALS: 

The Network Hospitals shall Provide the services of a dedicated Medical 

Officer to work as „Hospital Arogya Mitra‟ for the Scheme and he will be 

responsible to the State Nodal Cell and the ISA for doing various 

activities under the Scheme including Health Camps, Follow-up of 

referred patients from camps, diagnosis, out-patient details, e- 

preauthorization, surgeries, feedback on the patient‟s condition and 

services offered by the Hospital during Hospital stay of the patients, 

discharges, deaths if any, follow-up free consultation of the patients and 

distribution of medicines after discharge etc. At the Hospital level, the 

Hospital Arogya Mitra will coordinate with Arogya Mitra and the 

Beneficiary. The role of Hospital Arogya Mitra (HAM) is attached as 

Annexure-11. 

12. IMPLEMENTATION PROCEDURE: 

The entire Scheme is intended to be implemented as cashless 

Hospitalization. 

a) Package Rates: The package rates would include consultations, 

medicine, diagnostics, food, Hospital charges, etc. as indicated in the 

treatment package. 

b) Health Camps: Health Camps are to be conducted by the Network 

Hospitals in various Taluka Head Quarters/ Gram Panchayats/ 

Municipalities/ Municipal Corporations. The Implementation Support 

Agency will assist the Hospital in conducting such medical camps at the 

place and time suggested by the Authorities of District/ Municipal 

Corporation/State Nodal Cell. Network Hospitals shall provide necessary 

screening equipment and the required specialists and other para-medical 

staff for the Health Camps. 

c) Procedure for availing treatment in the Network Hospitals by 

the Beneficiaries: 

Step 1: The Beneficiaries approach the nearby Sub District 

Hospital/District Hospital/Medical College & Hospital/Network 


Hospital. Arogya Mitras would facilitate the Beneficiary. If the 

Beneficiary visits any other Government hospital other than the 

Network Hospital, the doctors will give him/her a referral card to 

the Network Hospital after preliminary diagnosis. The Beneficiary 

may also attend the Health Camps being conducted by the Network 

Hospitals and can get the referral card based on the diagnosis. 

Step 2: The Arogya Mitras engaged by the Implementation Support 

Agency examine the referral card and the Bar Coded Plastic Card 

and facilitate the Beneficiary to undergo preliminary diagnosis and 

basic tests. 

Step 3: The Network Hospital, based on the diagnosis, admits the patient 

and sends preauthorization request to the Implementation Support 

Agency. 

Step 4: Doctors/Specialists of the Implementation Support Agency 

examine the preauthorization request and approve preauthorization 

within 24 hours on receiving the preauthorization request from the 

Network Hospitals, if all the conditions are satisfied. 

Step 5: The Network Hospital extends cashless treatment and surgery to 

the Beneficiary subject to the limits prescribed under the Scheme. 

Step 6: The Network Hospital after discharge of the patient, forwards the 

original bill, discharge summary with signature of the patient and other 

relevant documents within one week from the date of discharge of the 

patient, to the Implementation Support Agency for processing and 

settlement of the claim. 

Step 7: The Implementation Support Agency scrutinizes the bills and 

forwards the payment request of the bill to the State Nodal Cell within 

seven days of the receipt of bills from the Network Hospital. 

Step 8: The State Nodal Cell after verification of the bills in respect of the 

services provided, will directly make the payment by way of electronic 

transfer to the Network Hospital(s) within 30-days of receiving the bills 

from the Implementation Support Agency. 


Note: The Network Hospital has to regularly display/update and 

report the total bed occupancy against availability. Looking to the 

patients load and in order to maintain quality of services, the State 

Government may direct patients to a particular Network Hospital. 

d) MIS/ IT Platform: 

The Network Hospital will use the IT platform developed by the ISA/State 

Nodal Cell to conduct all transactions related to the Mukhyamantri 

Amrutum (MA) Yojana. Transactions including planning and schedules of 

medical camps, e-preauthorization, processing of claims and claims 

settlement among others will be conducted on the MUKHYAMANTRI 

AMRUTUM „MA‟ WEB PLATFORM. 

e) Arogya Mitra and District Level Co-ordination: 

The ISA is responsible for identifying, engaging, training and positioning 

the Arogya Mitras at the Network Hospitals and District Coordinators at 

districts. The Network Hospitals shall provide the Arogya Mitras with 

necessary infrastructure, including table, computer and broadband 

connectivity etc. They should ensure that health camps are held as per 

schedule, arrange for canvassing for the camp, mobilize patients and 

follow up the Beneficiaries. 

13. PUBLICITY: 

The Implementation Support Agency on its part will ensure that proper 

publicity is given to the Scheme. The publicity materials including list of 

empanelled Network Hospitals, brochures, banners, display boards etc. 

supplied by the State Nodal Cell, shall be displayed in public places. 

14. EMPANELMENT PROCEDURE AND DISCIPLINARY PROCEEDINGS: 

i. Empanelment: 

The District Advisory and Grievance Redressal Committee (DAGRC) 

will ensure that the Network Hospitals are having adequate 

infrastructure, man power, equipment etc., as per the standards 

listed for empanelment of Hospital under the Scheme. 

ii. Disciplinary actions and De-listing: 

On recommendation by the District Advisory and Grievance Redressal 

Committee (DAGRC), the SNC/ISA shall take various disciplinary 

actions against any Network Hospital including de-listing from the 


empanelment if it is found that guidelines of the Scheme are not 

followed by it and services offered are not satisfactory as per laid 

down standards. The Hospital may also be delisted or de-empanelled 

if the infrastructure in the Hospital is found below the standards laid 

down by State Nodal Cell any time during the empanelment period. 

15. EARNEST MONEY DEPOSIT (EMD): 

15.1 Each Proposal shall be accompanied by EMD of Rs.1,00,000 

(Rupees one lakh only). 

15.2The EMD shall be in the form of a crossed demand draft / banker‟s 

cheque drawn in favour of “State Health Society, Gandhinagar”, on 

any scheduled bank, payable at Gandhinagar. 

15.3 The EMD of unsuccessful Bidders would be returned within a period 

of eight weeks from the date of announcement of the Successful 

Bidder. The EMD submitted by the Successful Bidder would be 

released upon furnishing of the Performance Security amounting to 

Rs.10.00 Lakhs (Rupees ten lakhs only) for the first year. For the 

second year onwards for every renewal year, the Performance 

Security amount would be equivalent to 10% of the total claims 

occurred under „MA‟ Yojana in the previous year at the Network 

Hospital. 

Failure of the Successful Bidder in furnishing the Performance 

Security as above shall constitute sufficient grounds for the 

annulment of the Letter of Award (LoA) and discontinuation of the 

Successful Bidder from MA Yojana. 

16. EARNEST MONEY REFUND: 

16.1 In case the Bid is rejected on technical grounds, the Earnest Money 

would be refunded within 7 days from the bid opening. 

16.2 In case the Bid is rejected after inspection, on the grounds of 

submitting incorrect information, then 50% of the Earnest Money 

would be forfeited and the balance would be refunded in due course. 

16.3 In case, the Bidder refuses to sign the Service Agreement, 50% of 

the Earnest Money would be forfeited. 


17. PERFORMANCE SECURITY: 

17.1 The Successful Bidders shall have to furnish within a period of 7 

(seven) days from the date of issue of Letter of Award, Performance 

Security in the form of Bank Guarantee of any scheduled bank, of 

Rs.10.00 Lakhs (Rupees ten Lakhs only) valid for a period of one 

year, in favour of State Health Society, Gandhinagar to ensure 

efficient service and to safeguard against any default. The 

Performance Security shall be in the format provided in Annexure – 

31. 

17.2 From the next year onward for every renewal year, the Performance 

Security amount would be equivalent to 10% of the total claims 

occurred under „MA‟ Yojana in the previous year at the Network 

Hospital. 

17.3 The Performance Security shall be discharged and released on 

submission of the Performance Security for the next year, as 

mentioned above. 

18. LIQUIDATED DAMAGES: 

18.1 The Network Hospital shall provide the services as per the 

requirements specified by the „MA‟ Yojana and in terms of the 

provisions of the Agreement with ISA. In case of initial violation of 

the provisions of the Agreement by the Hospital such as refusal of 

service or direct charging from the „MA‟ Beneficiaries or defective 

service and negligence, the amount equivalent to 50% of the amount 

of Performance Security will be charged as agreed Liquidated 

Damages by the ISA/SNC. The Liquidated Damages shall be 

adjusted against the amounts payable to the Network Hospital. In 

the event of the amount payable to the Network Hospital being less 

than the amount of Liquidated Damages, the balance amount shall 

be recovered by invoking the Performance Security. In such event, 

the Network Hospital shall replace the Performance Security by a 

fresh Bank Guarantee, for the full amount as required. 

18.2 In case of repeated defaults by the Network Hospital, the total 

amount of Performance Security shall be forfeited and action will be 

taken for removing the Hospital from the empanelment of „MA‟ 

Yojana as well as termination of the Service Agreement 


18.3 For over-billing and unnecessary procedures, the extra amount so 

charged will be deducted from the pending / future bills of the 

Hospital and the ISA/SNC shall have the right to issue a written 

warning to the Hospital not to do so in future. 

18.4The recurrence, if any, of over-billing and unnecessary procedures or 

defaults will lead to the stoppage of referral to that Hospital. 

19 MEDICAL AUDIT: 

The success of the Scheme rests on ensuring that all the stakeholders 

adhere to the highest level of medical ethics. The ISA shall recruit 

specialized doctors for regular inspection of Hospitals, to attend to 

complaints from Beneficiaries directly or through Arogya Mitras for any 

deficiency in services by the Hospitals and also to ensure proper care and 

counseling for the patients at Network Hospitals by coordinating with 

Arogya Mitras and Hospital authorities. 

20 CASHLESS SERVICE: 

The Hospitals have to ensure that all the Beneficiaries are provided with 

adequate facilities and treatment without the need to pay any deposits 

right from the entry into the Hospital, till the expiry of 10 days post 

discharge, for all the procedures covered under the Mukhyamantri 

Amrutum (MA) Yojana. It is envisaged that for each Hospitalization the 

transaction shall be cashless for covered procedures. Enrolled BPL 

Beneficiary will go to Hospital and come out without making any 

payment to the Hospital subject to procedure covered under the Scheme. 

The same is the case for diagnostics if eventually the patient does not 

end up in undergoing the surgery or therapy. 

21. CLAIMS: 

The Beneficiaries would be identified by the Mukhyamantri Amrutum 

Bar Coded Plastic Card at the Mukhyamantri Amrutam Assistance 

Counter at the Network Hospital, by the Arogya Mitra Hospital. After the 

verification of the patient, the treatment will be cashless for all the 

covered procedures. The State Nodal Cell will make payment of the 

claims directly to the Hospital within 30 days of the receipt of all 

documents from the ISA. The cost of various tests conducted on BPL 

family members who ultimately do not undergo surgery or therapy, will 

not be included in the claims. However the Hospital will ensure that such 

tests are done free of cost to the patient. The claims procedure will be 


carried on the electronic platform of the ISA/MA portal. The processing of 

the claims will be handled by the ISA. The claims procedure will be 

undertaken as detailed below (preferably electronically): 

1. Claim Intimation: 

The Hospital will submit the request to the ISA after verifying the 

patient through Bar Coded Plastic Card in the form as agreed under 

the Scheme, and after treatment and discharge of the patient. The 

ISA/State Nodal Cell portal will have reports indicating claim 

intimations received. 

2. Collection of Claim documents: 

The Network Hospital will send the claim documents along with the 

electronic medical records or as directed by ISA via the ISA/MA web 

portal to the ISA. The ISA will scrutinize the claim documents at the 

initial stage from the stand point of non-medical and medical 

eligibility criteria. Deficiency of any documents shall be 

communicated to the Hospital within 7 working days. A reminder for 

the same will again be forwarded to the Hospital once every 3 days of 

first intimation if the deficient documents are not received or are 

partially received. 

3. Repudiation: 

In case of repudiation of the claim not covered under the Scheme, ISA 

will mention the reasons for repudiation in writing and online to the 

Network Hospital. 

4. Appeal and Reopening: 

The Network Hospital shall have a right to approach the ISA if the 

Network Hospital feels that the claim is wrongly repudiated. If the 

Network Hospital does not agreed with the ISA‟s decision in this 

regard, it can appeal to the DAGRC of the respective district. The 

decision of the DAGRC will be final and binding on the ISA and the 

Network Hospital. This right of appeal will be mentioned by the ISA in 

every repudiation advice as mentioned above. The DAGRC can reopen 

the claim if proper and relevant documents as required are 

submitted. 


5. Review: 

The State Nodal Cell/ISA will have the right to reopen a settled claim. 

The Network Hospital further agrees to provide access to its records 

for this purpose. All the claims settled by the State Nodal Cell to the 

Network Hospitals based on the bills received from the Hospitals in 

conformity with the package rate arrived at and also based on the preauthorization 

given by the ISA may be verified by the State Nodal Cell 

for grievances. 

22. GRIEVANCE REDRESSAL MECHANISM: 

There shall be the following set of Grievance Redressal Committees to 

attend to the grievances of various stakeholders at different levels: 

22.1 District Advisory & Grievance Redressal Committee (DAGRC): This will 

be constituted by the State Nodal Cell in each district. The District 

Advisory & Grievance Redressal Committee (DAGRC) will be as follows: 

a) District Magistrate- Chairman 

b) District Development Officer- Co-Chairman 

c) Regional Deputy Director 

d) Chief District Medical Officer- Convener 

e) Chief District Health Officer 

f) Representative of the ISA 

g) Parties with grievances (Beneficiary/hospital/ISA/District) 

In Municipal Corporation area the Advisory & Grievance Redressal 

Committee will be Municipal Corporation Advisory & Grievance 

Redressal Committee (MCAGRC): 

a) Municipal Commissioner- Chairman 

a) Deputy Municipal Commissioner (Health)- Co-Chairman 

b) Regional Deputy Director 

c) Medical Officer of Health - Convener 

d) Chief District Health Officer 

e) Representative of the ISA 

f) Parties with grievances (Beneficiary/hospital/ISA/District/ Municipal 

Corporation) 

District and Municipal Corporation administration may co-opt more 

members for this purpose. 


22.2 State Empanelment Grievance Redressal and Disciplinary Committee 

(SEGRDC): This will be constituted by the State Government. The State 

Empanelment Grievance Redressal and Disciplinary Committee will be 

as follows: 

a) Principal Secretary (PH) and Commissioner (Public Health): Chairman. 

b) Principal Secretary (Expenditure), ex- officio 

c) Mission Director, NRHM, ex- officio 

d) Project Director, State Nodal Cell- Convener 

e) Deputy Secretary (FW & RH) 

f) Additional Director (FW) 

g) Additional Director (Public Health) 

h) Additional Director (ME) 

i) Additional Director (MS) 

j) Representative from U. N. Mehta Hospital, Ahmedabad. 

k) Representative from Kidney Hospital, Ahmedabad. 

l) Representative from Cancer Hospital, Ahmedabad. 

m) Representative from Civil Hospital, Ahmedabad. 

n) Representative from Civil Hospital, Ahmedabad. 

o) Representative from Civil Hospital, Ahmedabad. 

p) Representative from Civil Hospital, Ahmedabad. 

q) State Representative of the ISA 

r) Managing Director (n) Code Solutions. 

s) Parties with grievances (Beneficiary / hospital/ ISA/ District/ Municipal 

Corporation) 

State Nodal Cell may co-opt more members for this purpose. 

If any stakeholder has a grievance against another one, in connection 

with the validity, interpretation, implementation or alleged breach of any 

provision of the Scheme, it will be settled in the following way: 

A. GRIEVANCE OF A BENEFICIARY: 

If a Beneficiary has a grievance on issues relating to enrolment or 

Hospitalization against the ISA, Hospital or their representatives, the 

Beneficiary will approach DAGRC. The DAGRC should take a decision 

within 30 days of receiving the complaint. 

If either of the parties is not satisfied with the decision of DAGRC, they 

can appeal to the SEGRDC. The SEGRDC shall decide the appeal within 

15 days of receiving the appeal. The decision of the SEGRDC on such 

issues will be final. 


B. GRIEVANCE OF A HOSPITAL: 

If a Hospital has any grievance with respect to a Beneficiary, ISA or their 

representatives, the Hospital will approach the DAGRC. The DAGRC 

should reach a decision within 30 days of receiving the complaint. 

If either of the parties is not satisfied with the decision, they can go to 

the SEGRDC which shall take a decision within 15 days of receipt of 

appeal. The decision of the SEGRDC shall be final. 

C. GRIEVANCE OF AN ISA: 

If an ISA has any grievance with respect to a Beneficiary, or District 

Authorities, it will approach the DAGRC. The DAGRC should take a 

decision within 30 days of receiving the complaint. 

If either of the parties is not satisfied with the decision, they can Appeal 

to the SEGRDC. The SEGRDC shall decide the appeal within 15 days of 

receiving the appeal. The decision of the SEGRDC on such issues will be 

final. 

If ISA has a grievance against the District Key Manager or an agency of 

the State Government, it can approach the SEGRDC for resolution. The 

SEGRDC shall decide the matter within 30 days of the receipt of the 

grievance. The decision of SEGRDC shall be final. 

23 IT INFRASTRUCTURE NEEDED TO BE PROVIDED BY THE HOSPITALS 

EMPANELLED UNDER THE MUKHYAMANTRI AMRUTUM („MA‟) 

YOJANA. 

Both public and private Hospitals which fulfill the criteria for 

empanelment and are selected for empanelment under the MA Yojana by 

the ISA will need to put in place such infrastructure and install such 

hardware and software as given in Annexure-4, within a period of 

……days from the date of issue of the Letter of Award. It will be the 

responsibility of the empanelled Hospitals to procure and install Bar 

Coded Plastic Card related devices in the Hospital. The cost of 

procurement installation and maintenance of these devices will also be 

the responsibility of the empanelled Hospitals. 

24 CLAIM FLOAT AND BANK ACCOUNT: 

The Network Hospital shall open and maintain a separate Bank account 

to receive payments against valid claims and all payments will be 


electronically cleared on the MA portal. Detailed reports will be made 

available online on a real-time basis. 

25 PERIOD OF CONTRACT: 

The ISA will sign the Service Agreement / contract with the successful 

Bidder. The period of contract will be for one (1) year from the date of 

signing the Service Agreement. 

26 INSPECTION BEFORE EMPANELMENT: 

The Hospital will be inspected by the experts from the District/ISA/State 

Nodal Cell before empanelment. The District Empanelment and 

Disciplinary Committee will scrutinise the application, inspection reports 

and other material facts for empanelling the Hospital. 

27 DELISTING AND OTHER DISCIPLINARY ACTION: 

An empanelled Hospital would be de-listed from the MA network if, it is 

found that guidelines of the Scheme are not followed by it and / or the 

services offered are not satisfactory as per laid down standards. The ISA 

will follow the Guidelines for de-empanelment for Hospitals as given in 

Annexure-9. 

A Hospital once de-empanelled from the Scheme, in accordance with the 

procedures laid down in Annexure-9, Scheme shall not be empanelled 

again for at least a period of one year. 

The State Empanelment Grievance Redressal and Disciplinary 

Committee will look into all complaints and grievances received from the 

patients, and the field, vigilance and other inspection teams with regard 

to the quality of services and compliance with the Service Agreement 

clauses and may recommend disciplinary action including delisting of 

the Hospital. 

28 AMENDMENT OF BIDDING DOCUMENTS: 

a) At any time prior to the deadline for submission of bids, the State 

Government/State Nodal Cell may, for reasons to be recorded in 

writing, modify the Bidding documents. 

b) The amendments will be notified in writing or by fax or email or 

through State Government website to all prospective Bidders who 


have acquired the Bidding documents and the amendments will be 

binding on them. 

c) In order to afford prospective Bidders reasonable time to take the 

amendments into account in preparing their bids, the State 

Government/State Nodal Cell may, at its discretion, extend the 

deadline for the submission of the Bids. 

NOTE: Oral statements made by the Bidder at any time regarding 

quality of service or arrangements or any other matter shall not be 

considered. 

29 STATE GOVERNMENT/ STATE NODAL CELL‟S RIGHT TO ACCEPT 

OR REJECT ANY OR ALL BIDS: 

The State Government/State Nodal Cell reserves the right to accept or 

reject any Bid or annul the Bidding process and reject all Bids at any 

time prior to award of contract, without assigning any reason therefore, 

and without thereby incurring any liability or obligation to the affected 

Bidder(s). The State Government/State Nodal Cell is not bound to accept 

the lowest or any bid. 

Note: Incomplete technical bids and financial bids with extra 

attachments/remarks are liable to be disqualified. 

30 VALIDITY OF RFP: 

This RFP will be valid for a period of one (1) year from the date of issue 

and if implementation of the Scheme in any district does not commence 

by way of issue/renewal of Bar Coded Plastic Cards within that time, a 

new RFP will need to be floated by the State Nodal Cell. 

31 NOTIFICATION OF AWARD AND SIGNING OF AGREEMENT: 

The Notification of Award will be issued with the approval of the 

Executive Committee constituted as per the GR dated 2 nd June, 2012. 

The terms of Agreement will be discussed with the representatives of the 

successful Bidders and the successful Bidder is required to sign the 

Service Agreement with the ISA in duplicate within 15 days of issue of 

the Letter of Award. 


32 CANVASSING: 

Bidders are hereby warned that canvassing in any form for influencing 

the process of notification of award would result in disqualification of the 

Bidder. 

33 SIGNATURE ON EACH PAGE OF BID DOCUMENT: 

Each page of Bid Document submitted by the Bidder must be signed by 

the authorized signatory of the Bidder. The Bidder shall also submit 

along with the Bid, the authorization / Power of Attorney issued in 

favour of the authorized signatory. Any document/sheet not signed 

shall tantamount to rejection of the Bid. 

34 DEADLINE FOR SUBMISSION BIDS/PROPOSALS: 

Complete bid documents should be submitted at the address mentioned 

below not later than 12.00 hours on July, 2012. Bid documents received 

later than the prescribed date and time will not be considered for 

evaluation. 


SUBMISSION OF BIDS/ PROPOSALS 

PART-II 

35. SUBMISSION OF BIDS 

The Government of Gujarat/Mukhyamantri Amrutum („MA‟) Agency seeks 

detailed proposals from the entities owning Hospitals interested in 

empanelment under Mukhyamantri Amrutum (MA) Yojana in the State. 

Hospitals having branches in various districts will be considered as a separate 

entities and needs to apply separately. The bid/proposal document should 

include the following: 

36. TECHNICAL PROPOSAL: 

Technical Proposal shall be provided in the format given in Annexure –2 and as 

per instructions contained in Annexure - 1. 

1. The Bidder shall provide the details of infrastructure available in the 

Hospital, i.e., no. of available beds, services available at the Hospital etc. 

for performing the assignment. 

2. The Bidder shall provide adequate proof to show that it owns the 

Hospital whose services are being offered under the Scheme. 

3. Format for evaluation of technical proposal has been given in Annexure- 

3. 

4. Technical bid evaluation will be done in following steps: 

a. The Bidders will be shortlisted based on the qualifying criteria. The 

Inspection Committee will visit the Hospitals and submit its 

recommendation to the technical evaluation committee. 

b. All the successful bidders (recommended by inspection committee) 

who qualify after the technical bid evaluation will be eligible for the 

financial bid evaluation. 


37. Eligibility Criteria: 

1. The Hospital should have at least 25 beds with following infrastructure: 

1) General Ward: 

1 Nurse: Per 10 patients with 24 hrs services in 3 shifts in a day 

1duty doctor: Per 10 patients with 24 hrs service in 3 shifts in a day 

The space between two beds should be at least 5 feet 

The Hospital should have separate male and female wards 

2) ICU Beds: 

The Hospital should have at least 3 ICU beds. 

1 Nurse: Per 1 patient with 24 hrs service in 3 shifts in a day. 

1 duty doctor: Per 4 to 5 patients with 24 hrs service in 3 shifts in a day. 

The ICU ward should be equipped with ventilators, defibrillators, monitors, 

central oxygen line, suction apparatus and pulse oxymeter. 

3) The Step down ICU ward: 

The Hospital should have at least 2 Step down ICU beds 

1 Nurse: Per 3 patients with 24 hrs service in 3 shifts in a day. 

1 duty doctor: Per 4 to 5 patients with 24 hrs services in 3 shifts in a day 

The Step down ICU ward should be equipped with defibrillators, monitors, 

central oxygen line, suction apparatus and pulse oxymeter. 

4) The post operative ward: 

The Hospital should have at least 2 beds in the post operative ward 

1 Nurse: Per 1 patient with 24 hrs service in 3 shifts In a day 

1 duty doctor: Per 4 to 5 patients with 24 hrs services in 3 shifts in a day. 

The post operative ward should be equipped with ventilators, defibrillators, 

monitors, central oxygen line, suction apparatus and pulse oxymeter. 

Note: Fully qualified nursing staff and allopathic doctors should be available 

round the clock as aforesaid under the protocol of the Hospital. Further ICU 

ward is not essential for ophthalmology speciality Hospital. 

2. The Hospital should have well equipped operation theatre with the following 

equipments: 

1) Boyles apparatus 

2) Endoscopes as per requirement of speciality 

3) Monitor with defib. multipara monitor 

4) Diathermy (Bipolar, Unipolar cautery) 

5) Laproscopic Equipment if necessary as per the speciality treatment 


catered 

6) Operating Microscope if necessary as per the speciality treatment catered 

7) Suction apparatus 

8) Pulse oxymeter 

9) Sterility unit and other equipment as per the specialities treatment 

available (autoclaves, facility for sterilizing non autoclavable equipments 

instruments) 

3. The Hospital should have the following full equipped diagnostic facilities: 

The Hospital shall facilitate free diagnostic facilities and advance diagnostic 

tests in-house or either in the tied-up diagnostic centres, such as: 

1 In house mandatory diagnostic facilities 

Radiology: X-Ray, USG and ECG 

Biochemistry, Micro biology & Serology, Haematology. 

2 Advance diagnostic tests in house/tie-up 

CT, MRI, ECHO, Pathology etc. 

Note: The Hospital as well as tied up diagnostic centres shall furnish 

affidavit about extending free diagnostic tests for the Scheme members as 

tied up diagnostic centre. 

4. The Hospital shall have round the clock blood bank facility in house/tied 

up. 

5. The Hospital should have qualified anaesthetist round the clock in 

house/on call. 

6. The Hospital shall maintain complete record on day to day basis and shall 

provide records of the patients to ISA/State Nodal Cell as and when it is 

required. 

7. The Hospital shall ensure cashless facility to the Scheme members as per 

the surgery packages devised by the ISA/State Nodal Cell. The surgery 

package includes cost of consultation, medicine, diagnostics, implants, food, 

transportation charges, OT charges, professional fees, Hospitalization 

charges and follow up treatment with medicines, in other words the package 


includes entire cost of treatment of the patient from the date of admission to 

the date of discharge with follow-up treatment cost. 

8. The Hospital shall provide transportation charges to patients @ Rs.300/- 

per visit with a maximum limit of Rs.3000/- per year. 

9. The Hospital should have sufficient experienced specialists / super 

specialists in the specific identified fields (as per point no. 2) for which the 

Hospital is empanelled. 

10. For extending the treatment of chemotherapy and radiotherapy the 

Hospital should have infrastructure for radiotherapy and full time 

Radiation Oncologist and Medical Oncologist must be available. 

11. The Hospital shall furnish the chemotherapy drugs bills along with empty 

vials and quote the batch no. of the drugs with label intact. (Drugs with 

generics names should be preferred) 

12. The Hospital should have full time services of qualified plastic surgeon 

with requisite infrastructure for corrective surgeries for post burn 

contractures. 

13. The Hospital should have round the clock in-house pharmacy. 

14. The Hospital should have full time/on call services of pediatric surgeons / 

plastic surgeons / urologist surgeons related to congenital malformation 

in pediatric age group (less than 14 years). 

15. The Hospital shall provide the following additional facilities and benefits to 

the BPL patients: 

a) Shall ensure exclusive health cell/Kiosk for MA Yojana to enable the 

Arogya Mitra to execute his/her duties. 

b) Shall provide a computer with networking (dedicated broadband with 

minimum 2 mbps speed), Printer, Scanner and digital camera. 

c) Shall ensure a dedicated medical officer to work as Hospital Arogya 

Mitra ( medical coordinator) for the Scheme and he/she will be 

responsible for various activities of the Scheme such as health camps, 


follow up of referred patients from the camps, diagnosis, outpatient 

details, E-Preauthorization, surgeries, feedback on the patients 

condition and service offered by the Hospital duration during 

hospitalization of the patient, discharges, deaths if any, free 

consultation for the follow up patients and distribution of medicines 

after discharge etc. 

d) Shall conduct minimum number of free health camps as stipulated in 

the Service Agreement for identifying and screening of the BPL 

patients suffering from the identified ailments. The Hospital shall 

have a mobile team with the diagnostic equipments and team of 

doctors as specified by the ISA/State Nodal Cell for conducting health 

camps. For this purpose, the villages are identified by the District 

administration/ISA/State Nodal Cell and communicated to the 

Hospital. 

16. Specific criteria for Cancer: 

The Hospital shall agree to provide the services of fully qualified surgical 

oncologist and medical oncologist to treat patients requiring surgical and 

chemotherapy treatments. Further to treat patients requiring surgical, 

chemotherapy and radiotherapy treatments the Hospital shall provide 

the services of surgical oncologist, medical oncologist, radiation 

oncologist and equipment for cobalt therapy, linear accelerator radiation 

treatment and brachy therapy for empanelment under MA Yojana. In 

case facilities such as chemotherapy and radiotherapy are not available 

in the Hospital, the Hospital shall not perform surgery alone and refer 

the patients to other centers for follow-up treatments requiring 

chemotherapy and radiotherapy treatments. 

 

 

 

Chemotherapy and radiotherapy should be administered only by 

professionals well versed in dealing with the side-effects that the 

treatment can cause. 

Patients with hematological malignancies (Ex. Leukemia, Lymphomas 

and Multiple Myeloma) and pediatric malignancies (any patient below 14 

years of age) should be treated by qualified medical oncologist only. 

Chemotherapy has to be administered to the patient as in-patient 

treatment only. 


The Hospital shall agree to provide the services as per the packages and 

adhere to the treatment protocols, referred to in Annexures- 19, 20 and 

21. 

 

The Hospital shall agree to quote batch no. of the drugs and attach 

empty vials and ampules with labels intact along with the bills. 

 

The Hospital shall agree to give patient feedback through multimedia 

using webcam and mike. The provision for live viewing of the patient will 

be provided in the Implementation Support Agency (ISA) portal. 

17. Specific Criteria for Polytrauma: 

The Hospital shall have Emergency Room setup with round the clock 

dedicated duty doctor. 

 

The Hospital shall have round the clock anesthetist services. 

 

The Hospital shall provide round the clock services of Neurosurgeon, 

Orthopedic Surgeon, CT Surgeon, General Surgeon, Vascular Surgeon 

and other support specialists. 

 

The Hospital shall have dedicated round the clock Emergency theatre, 

surgical ICU, and post-operation setup with qualified staff. 

 

The Hospital shall provide necessary cashless diagnostic support 

round the clock, including specialized investigations such as CT, MRI 

and emergency biochemical investigations. 

 

The Hospital shall have in place all necessary infrastructure required 

for preauthorization round the clock. 

 

The Hospital shall agree to provide the services as per the packages 

and adhere to the treatment protocols, referred to in Annexure- 15. 

18. Specific criteria for Pediatric Congenital Malformations and Post 

Burns Contractures: 


The Hospital shall have services of qualified specialists in various fields‟ 

viz., pediatric surgeon, plastic surgeon with dedicated theatres, postoperation 

setup and staff. 

Note: 

a. In the absence of any one of the above, the offer will be treated as nonresponsive 

and summarily rejected. 

b. Relevant documents in support of the above criteria must be enclosed 

along with the Bid documents failing which the Bid will be liable to be 

rejected. 

c. The Financial Bids of the Bidders, unsuccessful in the technical 

evaluation shall not be considered for evaluation. 

Note: The qualifying requirements data shall be enclosed with the technical bid 

only. The bidders who do not qualify this criterion, will be disqualified 

immediately and their bids will not be considered. 

38. TECHNICAL BID 

The Technical Bid should be sealed in an envelope clearly marked in bold 

“TECHNICAL BID FOR EMPANELMENT UNDER MUKHYAMANTRI 

AMRUTUM (MA) YOJANA” written on the top of the envelope. 

If the Bidder fails to submit the supporting documents offline within time limit, 

he is liable for immediate disqualification. 

a. The online bid should be submitted on or before the time stipulated in 

the RFP notice at the web site http://www.nprocure.com 

b. The envelope should have the Bidder‟s name and address clearly written 

at the left bottom corner of the envelope. 

39. FINANCIAL BID: 

The Financial Bid should be compulsorily submitted through online 

only. 

(Please note that Anexture-5 should be attached to Financial Bid only) 

1. The Financial Bid shall take into account all costs associated with the 

assignment. 

2. No other information shall be provided along with the Financial Bid. 

3. The Financial Bid submission should be done on the website 

(electronic format) only on http://www.nprocure.com 

4. The online bids should be submitted on or before the time stipulated in 

RFP notice at the website http://www.nprocure.com. 


The envelopes (Technical Bid) should be sealed and duly super-scribed. 

“Technical Bid for empanelment under Mukhyamantri Amrutum (MA) 

Yojana”. 

The Technical Bid with supporting documents in physical form should be 

submitted at the following address before the due date and time. 

Dr. B. K. Patel, 

Additional Director (FW), 

Commissionerate of Health and Family Welfare, 

MS and ME, Block No. 5, Dr. Jivraj Mehta Bhavan, 

Gandhinagar, 

Gujarat 

Phone:079-232-53311 

Fax:079-232-56430, 

Email:mayojanagujarat@gmail.com. 

No Bid will be accepted after the prescribed closing time for submission of 

the same. The delay will not be condoned for any reason whatsoever 

including network/postal/transit delay. However, if the last date for 

submission of Bids is declared as a holiday by the Government, the last date 

for submission of Bids will be extended to the next working day. 

The Bids may be cancelled and not evaluated if the Bidder: 

1. Fails to submit the Financial Bid online; 

2. gives incomplete Bids; 

3. submits the technical and financial bids not as mentioned in the RFP 

Document; 

4. Makes additions or deletions in the packages of Financial Bid; 

5. If in the financial bid the Benefit Package rate does not includes the 

follow up charges. 

40. DEADLINE FOR SUBMISSION OF BID/PROPOSALS: 

Complete Bid document should be uploaded to 

http://www.nprocure.com by 12.00 hours on 19 th July, 2012 and 

physically submitted by 14.00 hours on 19 th July, 2012. The Bid 

documents received later than the prescribed date and time will not be 

considered for evaluation. 


IN NO CASES, RATES SHOULD BE QUOTED ANYWHERE EXCEPT 

ONLINE IN THE FINANCIAL BID PROPOSAL. 

41. AWARD OF CONTRACT: 

A Bidder in any Cluster with maximum number of lowest rate of 

packages will be given opportunity to match the lowest rate in remaining 

packages. 

If the Bidder with maximum number of L1 in the cluster does not agree 

to match L1 rate of other surgeries of that cluster then the Bidder with 

second highest number of lowest package rates in the Cluster will be 

given the choice to match remaining packages, and the process will be 

carried out till agreement is reached. 

If at the end of negotiations no agreement is arrived at about the package 

rates, the Financial Evaluation Committee may work out a formula for 

arriving at package rates based on the present bid rates or based on the 

advice of the Expert Committee. 

The rates finalized will be valid for next 3 years or as decided by the State 

Nodal Cell. 

The empanelled Hospitals who are registered under NABH/JCI(Joint 

Commission International)/ ACHS(Australia) or by any other 

accreditation body approved by International society for Quality in 

Healthcare(ISQua) will get 2.5% extra as quality incentive over and 

above the package rates. 


(DRAFT) SERVICE AGREEMENT BETWEEN IMPLEMENTATION SUPPORT 

AGENCY (ISA) AND THE SELECTED BIDDER / HOSPITAL 

This Agreement (hereinafter referred to as “Agreement”) made at ______ on this 

___________ day of ___________ 2012. 

BETWEEN 

Hospital______________________ Company Limited, a Company incorporated 

under the provisions of the Companies Act, 1956 and having its registered 

office at ___________________________________________________ (hereinafter 

referred to as “Implementation Support Agency‟ or “ISA” which expression 

shall, unless repugnant to the context or meaning thereof, be deemed to mean 

and include its successors, affiliates and assigns) as party of the FIRST PART. 

AND 

__________________________ a Company incorporated under the provisions of 

the Companies Act, 1956 and having its registered office at 

___________________________________________________ 

owning 

____________________(name of the Hospital)_______________________a Hospital 

located at __________________________________ (hereinafter referred to as 

“Hospital” or “Provider”, which expression shall, unless repugnant to the 

context or meaning thereof, be deemed to mean and include it's successors 

and permitted assigns) as party of the SECOND PART 

ISA and the Hospital are hereinafter individually referred to as "Party” or 

“party" and collectively as "Parties” or “parties") 

WHEREAS 

1. ISA is a company incorporated under the Companies Act, 1956 and has 

experience in the field of health schemes and in claim processing with a well 

established IT platform. ISA has entered into an agreement with the 

Government of Gujarat wherein it has agreed to provide the support in 

claim processing and hospital empanelment under Mukhyamantri 

Amrutum Yojana („MA‟ Yojana), and in identifying the Beneficiary families 

covered under Mukhyamantri Amrutum (MA) Yojana. 

2. Hospital is a health care provider duly recognized and authorized by 

appropriate authorities to impart heath care services to the public at large. 


3. Hospital has expressed its desire to join the Implementation Support 

Agency (ISA)‟s network of Hospitals and has represented that it has 

requisite facilities to extend medical facilities and treatment to Beneficiaries 

as covered under „MA‟ Yojana on the terms and conditions herein agreed. 

4. Implementation Support Agency (ISA) has on the basis of the Bid received 

from the Hospital and on its representation agreed to empanel the Hospital 

as empanelled provider for rendering complete health services to the 

Beneficieries as defined hereunder. 

NOW THIS AGREEMENT WITNESSETH and the Parties hereby agree as 

follows: 

Definitions: 

In this Agreement, unless inconsistent with, or otherwise indicated by the 

context, the following terms shall have the meanings assigned to them 

hereunder, namely: 

a. „AM‟ or „Arogya Mitra‟: means the first contact person for Mukhyamantri 

Amrutum (MA) Yojana patients at Network Hospital. 

b. „Bar-Coded Card‟ shall mean the Identification Card for BPL Beneficiaries 

issued under Mukhyamantri Amrutum (MA) Yojana. 

c. „Beneficiary‟ shall mean the personwho is covered under the „MA‟ Yojana 

health Scheme of the Government of Gujarat and who holds a valid Bar- 

Coded Card issued for „MA‟ Yojana, and „Beneficiaries‟ shall mean 

accordingly. 

d. „BPL‟: shall mean Below Poverty Line families as defined by the Rural 

Development Department and the Urban Development Department, 

Government of Gujarat. 

e. „Confidential Information‟ includes all information (whether proprietary or 

not and whether or not marked as „Confidential‟) pertaining to the business 

of the Hospital or any of its subsidiaries, affiliates, employees, companies, 

consultants or business associates to which the Hospital or its employees 

have access to, in any manner whatsoever. 


f. „HAM‟ or „Hospital Arogya Mitra‟ means the Mukhyamantri Amrutum (MA) 

Yojana Medical Coordinator of minimum MBBS qualification from the 

Network Hospital to coordinate with ISA. 

g. „Health Services‟ or „Services‟ shall mean all services necessary or 

required to be rendered by the Hospital under this Agreement with the 

Implementation Support Agency (ISA) in connection with “Mukhyamantri 

Amrutum (MA) Yojana” but does not include the business of the 

Implementation Support Agency (ISA) and or an intermediary or an agent. 

h. „IEC‟: means Information, Education & Communication. 

i. „ISA‟: means the Implementation Support Agency for the State Nodal Cell 

(SNC). 

j. „Institution‟ shall for all purpose mean the Hospital. 

k. „MOU‟: shall mean the Memorandum of Understanding between the 

Implementation Support Agency (ISA) and the empanelled Network Hospital. 

l. „Network Hospital‟ or „NWH‟: shall mean the Hospital (s) empanelled under 

Mukhyamantri Amrutum (MA) Yojana. 

m. „Scheme‟ shall mean the Mukhyamantri Amrutum (MA) Yojana of the 

Government of Gujarat. 

n. „State Nodal Cell‟: means the body constituted on behalf of Health and 

Family Welfare Department, Government of Gujarat for the Implementation 

of Mukhyamantri Amrutum (MA) Yojana. 

o. „Surgery/Surgeries‟: means cutting, abrading, suturing, laser or otherwise 

physically changing body tissues and organs by qualified medical doctors 

who are authorized to do so. 

p. „Therapy/Therapies‟: means the specific way of medical treatment to the 

patient before/after surgery. 

q. „Treatment‟: means medical management by qualified doctor/s in the 


Interpretations: 


In this Agreement, unless the context otherwise requires: 

(i)The masculine gender includes the other two genders and vice versa; 

(ii)The singular includes the plural and vice versa; 

(iii)The expressions „Person‟ or „Persons‟ include created entities (corporate 

or incorporate); 

(iv)Marginal notes or headings to clauses are for reference purposes only 

and do not bear upon the interpretation of this Agreement. 

(v)Should any condition contained herein, contain a substantive condition, 

then such substantive condition shall be valid and binding on the Parties 

notwithstanding the fact that it is embodied in the definitions clause. 

Article 1: 

Term of the Agreement 

1.1 This Agreement shall be in force for a period of one (1) years from the date 

of this Agreement. However, it is understood and agreed between the 

Parties that the term of this Agreement may be renewed yearly upon 

mutual consent of the Parties in writing, either by execution of a 

Supplementary Agreement or by exchange of letters. 

Article 2: 

Scope of services 

2.1 The Hospital shall provide the following Health Services to the 

Beneficiaries free of cost: - As per the attached Annexure 5. 

2.2 The Hospital undertakes to provide the services in a precise, reliable and 

professional manner to the satisfaction of Implementation Support Agency 

(ISA) and in accordance with additional instructions issued by 

Implementation Support Agency (ISA) in writing from time to time. 

2.3 The Hospital shall treat the Beneficiaries of „MA‟ Yojana according to good 

business practice. 

2.4 The Hospital will extend priority admission facilities to the Beneficiaries, 

whenever possible. 

2.5 The Hospital shall provide Packages for specified interventions/ treatment 

to the Beneficiaries as per the agreed rate between the ISA and the 

Hospital. It is agreed between the Parties that the Package will include: 


The charges for medical/ surgical procedures/ interventions under 

the Benefit Package, which will be no more than the Package charge 

agreed by the Parties, for that particular year. 

These Package rates will include: 

a) Registration charges 

b) Bed charges (General Ward in case of surgical) 

c) Nursing and Boarding charges 

d) Surgeons, Anesthetists, Medical Practitioner, Consultants fees etc. 

e) Anesthesia, Blood, Oxygen, O.T. Charges, Cost of Surgical 

Appliances etc. 

f) Medicines and Drugs 

g) Cost of Prosthetic Devices, implants 

h) X-Ray and other Diagnostic Tests etc 

i) Food to patients 

j) Expenses incurred for consultation, diagnostic tests and medicines 

up to 1 day before the admission of the patient and cost of 

diagnostic tests and medicines up to 10 days after the discharge of 

the patient from the Hospital for the same ailment / surgery 

k) Transportation Charge of Rs. 300/- (payable to the Beneficiary at 

the time of discharge in cash by the Hospital). 

l) Any other expenses related to the treatment of the patient in the 

Hospital. 

2.6 The Hospital shall ensure that medical treatment/facility under this 

agreement should be provided to the Beneficiaries with all due care and 

accepted standards. 

2.7 The cost of various tests conducted on BPL family members who 

ultimately do not undergo surgery, will not be included in the cost. 

However the Hospital will ensure that such tests are done free of cost to 

the patients. 

2.8 The Hospital shall allow the Implementation Support Agency‟s officials to 

visit the Beneficiaries. The Implementation Support Agency (ISA) shall not 

interfere with the medical teams of the Hospital, however, the 

Implementation Support Agency (ISA) reserves the right to discuss the 

treatment plan with treating doctor/s. Further access to medical 

treatment records and bills prepared in the Hospital will be allowed to the 

Implementation Support Agency (ISA) on a case to case basis by the 

Hospital. 


2.9 The Hospital shall also endeavor to comply with future requirements of 

Implementation Support Agency (ISA) to facilitate better services to the 

Beneficiaries e.g. providing for standardized billing, ICD coding etc and if 

mandatory by statutory requirement both Parties agree to review the 

same. 

2.10 The Hospital agrees to have its bills audited on a case to case basis as and 

when necessary through the Implementation Support Agency (ISA) audit 

team. This will be done on a pre agreed date and time and on a regular 

basis. 

2.11 The Hospital will convey to its medical consultants to keep the Beneficiary 

only for the required number of days of treatment and carry out only the 

required investigation and treatment for the ailment for which the 

Beneficiary is admitted. Any other incidental investigation required by the 

patient on his request needs to be approved separately by the 

Implementation Support Agency (ISA) and if it is not covered under MA 

Yojana, it will not be paid by the Implementation Support Agency (ISA) 

and the Hospital needs to recover it from the patient. 

Article 3: 

Identification of Beneficiaries 

3.1 Bar-Coded Cards would be the proof of the eligibility of BPL households 

for the purpose of the Scheme. The Beneficiaries will be identified by the 

Hospital on the basis of Bar-Coded Cards issued to them. The Bar-Coded 

Cards shall have the photographs and finger print details of the 

Beneficiaries. The Bar-Coded Card would be read by the Bar-Coded Card 

reader. The patients/ relative‟s finger prints would also be captured by the 

bio metric scanner. The POS machine will identify a person if the finger 

prints match with those stored on the card. In case the patient is not in a 

position to give fingerprint, any other member of the family who is 

enrolled under the Scheme can verify the patient‟s identity by giving his/ 

her fingerprint. 

3.2 The Hospital will set up a Help desk for „MA‟ Yojana Beneficiaries. The 

desk shall be easily accessible and will have all the necessary hardware 

and software required to identify the patients. 


3.3 For the ease of the Beneficiaries, the Hospital shall display the recognition 

and promotional material, network status, and procedures for admission 

as defined by the Implementation Support Agency (ISA) at prominent 

locations, including but not limited to outside the Hospital, at the 

reception and admission counter and Casualty/ Emergency departments. 

The format for the display sign outside the Hospital and at the reception 

counter will be defined by the ISA. 

3.4 It is agreed between the Parties that having implemented Bar-Coded 

Cards, in case of any technological issues arising, causing interruption in 

reading the Cards, thereby causing interruption in continuous servicing, 

there shall be a migration to manual heath cards, as provided by the 

Implementation Support Agency (ISA), and corresponding alternative 

servicing process, for which the Hospital shall extend all cooperation. 

Article 4: 

Hospital Services- Admission Procedure 

4.1 Planned Admission: It is agreed between the Parties that on receipt of 

request for hospitalization on behalf of the Beneficiary the process to be 

followed by the Hospital is prescribed in Article 27. 

4.2 Emergency Admission 

a) The Parties agree that the Hospital shall admit the Beneficiary (ies) 

without production of the Bar-coded Card in the case of emergency 

but the Bar-Coded Card will need to be produced and authenticated 

within 24 hours of the admission. 

b) The Hospital upon deciding to admit the Beneficiary should inform/ 

intimate over phone immediately to the 24 hours Implementation 

Support Agency (ISA)‟s helpdesk or the local/ nearest Implementation 

Support Agency (ISA) office. 

c) The data regarding admission shall be sent electronically to the 

server of the ISA. 

4.3 The Hospital will select the package only from the list approve under the 

MA Yojana (Annexure 5). For every patient covered under the scheme, pre 

authorization will be required from the ISA . 

4.4 On receipt of the preauthorization form for the Hospital giving the details 

of the ailments for admission with the package cost, which is to be 

forwarded within 12 hours of admission, the Implementation Support 


Agency (ISA) shall issue the confirmation letter within 24 hours of the 

receipt of the preauthorization form. 

4.5 In case the ailment is not covered under the Scheme or given medical data 

is not sufficient for the medical team to confirm the eligibility, 

Implementation Support Agency (ISA) can deny the guarantee of payment, 

which shall be addressed, to the Beneficiary under intimation to the 

Hospital. The Hospital will have to follow its normal practice in such 

cases. 

4.6 The Network Hospital will send the claim documents along with the 

electronic medical records or as directed by ISA via the ISA/MA web portal 

to the ISA. The ISA will scrutinize the claim documents at the initial stage 

from the stand point of non-medical and medical eligibility criteria. 

Deficiency of any documents shall be communicated to the Hospital within 

7 working days. A reminder for the same will again be forwarded to the 

Hospital once every 3 days of first intimation if the deficient documents 

are not received or are partially received. 

4.7 Denial of authorization/ guarantee of payment shall in no way mean 

denial of treatment. The Hospital shall deal with each case as per its 

normal rules and regulations. 

4.8 Authorization certificate will mention the amount guaranteed, class of 

admission, eligibility of the Beneficiary or various sub limits for rooms and 

board, surgical fees etc. wherever applicable. The Hospital must take care 

to ensure compliance. 

4.9 The guarantee of payment is given only for the necessary treatment cost of 

the ailment covered and mentioned in the request for hospitalization. Cost 

of any investigation carried out at the request of the patient but not 

forming the necessary part of the treatment also must be collected from 

the patient. 

4.10 In case the sum available of the coverage with the BPL family is considerably 

less than the estimated treatment cost, the Hospital should follow its 

normal norms of deposit/ running bills etc., to ensure that it realizes any 

excess sum payable by the Beneficiaries not provided for by indemnity 

under the scheme. 


Article 5: 

Checklist for the Hospital at the time of Patient Discharge 

5.1 Original discharge summary, counterfoil generated at the time of 

discharge, original investigation reports, all original prescriptions, 

pharmacy receipts etc. must not be given to the patient. These are to be 

forwarded to billing department of the Hospital who will compile and send 

it through registered AD to the Implementation Support Agency (ISA). A 

copy of the same shall be keep with the Hospital. 

5.2 The Discharge card/Summary must mention the duration of ailment and 

duration of other disorders like hypertension or diabetes and operative 

notes in case of surgeries. 

5.3 Signature or thumb impression of the patient/ Beneficiary on the final 

Hospital bill along with the patient‟s satisfaction letter must be obtained. 

5.4 The Hospital shall submit online claim report along with the discharge 

summary in accordance with the rates agreed with the ISA on a daily 

basis. 

5.5 The Hospital shall submit the original documents along with the 

discharge summary in accordance with the rates as agreed, to the ISA 

within 7 days of patient‟s discharge. 

Article 6: 

Payment Terms 

6.1 ISA agrees to pay to the Hospital all eligible bills within 15 working days, 

subject to submission of all supporting documents including postoperative 

investigations and reports as required online. Photocopies of 

daily progress reports and ICU charts should be sent by courier. 

6.2 The Hospital agrees to submit the core banking number and IFSC code of 

its bank account to the ISA to facilitate electronic fund transfer for settling 

the claims. (Refer Annexure–27). 

6.3 The Hospital agrees to submit all the claims for the surgeries/treatments 

performed within 7 days from the date of discharge of the Patient. 

6.4 The Hospital agrees that for all the claims for which preauthorization is 

obtained by the end of this Agreement period, surgeries/treatment will be 


done within 30 days of expiry of this Agreement and claim will be raised as 

per this Agreement 

6.5 The Implementation Support Agency (ISA) will have to take a decision 

regarding the claim settlement within 15 days of receiving it. The 

Implementation Support Agency (ISA) may decide to accept the claim, to 

reject it or to investigate it. In any of the cases, final settlement of the 

claim shall be done within 45 days from the date of receipt of such 

submission. 

6.6 However if required, Implementation Support Agency (ISA) can gather 

further documents from the Hospital related to the treatment, to process 

the case. 

6.7 Payment will be done by Electronic Fund Transfer as far as possible by 

the Sate Nodal Cell. 

6.8 In case of any patient‟s death during his/her stay at the Network Hospital 

(only after any surgical intervention), the Hospital will take preauthorization 

from the ISA for the hearse reimbursement. The 

reimbursement will be as per the MA rates and based on the shortest 

distance from the Network Hospital to the final destination. 

Article7 

Limitations of Liability and Indemnity: 

7.1 The Hospital will be responsible for all commissions and omissions in 

treating the patients referred under the Scheme and will also be 

responsible for all legal consequences that may arise. ISA will not be held 

responsible for the outcome of the treatment or quality of the care 

provided by the Hospital and should any legal complications arise and ISA 

is called upon to answer, the Hospital shall pay all legal expenses and 

consequent compensation, if any. 

7.2 The Hospital admits and agrees that if any claim arises out of` alleged 

deficiency in service on its part or on the part of its men or agents, then it 

will be the duty of the Hospital to answer such claim. In the event of ISA 

being proceeded against for such cause of action and any liability being 

imposed on ISA, only by virtue of its relationship with the Hospital, the 

Hospital shall step in and meet such liability on its own. 


7.3 Notwithstanding anything to the contrary in this Agreement, neither Party 

will be liable by reason of failure or delay in the performance of its duties 

and obligations under this Agreement if such failure or delay is caused by 

acts of God, strikes, lock-outs, embargoes, war, riots, civil commotion, any 

orders of Governmental, Quasi-Governmental or local authorities, or any 

other similar cause beyond its control and without its fault or negligence. 

Article 8: 

Declarations and Undertakings of the Hospital 

8.1 The Hospital undertakes that it has obtained all the registrations/ 

licenses/ approvals required by law in order to provide the Services 

pursuant to this Agreement and that it has the skills, knowledge and 

experience required to provide the Services as required in this Agreement. 

8.2 The Hospital undertakes to uphold all requirement of law in so far as they 

apply to it and in accordance with the provisions of the law and the 

regulations enacted from time to time, by the local bodies or by the 

Central Government or the State Government. 

8.3 The Hospital declares that it has never committed a criminal offence 

which prevents it from practicing medical care and no criminal charge has 

been established against it by a court of competent jurisdiction. 

Article 9: 

General responsibilities & obligations of the Hospital 

9.1 General Undertaking: The Hospital warrants that it has all the required 

facilities for performing the enlisted surgeries / procedures / therapies as 

specified in Annexures- 4, 5 and 15 to 22. 

9.2 Allocating minimum 25% of beds in the Network Hospital for 

Mukhyamantri Amrutum (MA) Yojana patients: The Hospital agrees to 

provide at least 25% of its available bed capacity for occupation by 

Mukhyamantri Amrutum (MA) Yojana patients for treatment under each 

specialty available in the Hospital and under which the procedures are 

covered in the Mukhyamantri Amrutum (MA) Yojana. 

9.3 Conduct of Outpatient Services: 


a) The Hospital agrees to provide separate Out Patient (OP) facilities for 

Mukhyamantri Amrutum (MA) Yojana patients, to be manned by the HAM 

of the Hospital and the Arogya Mitras recruited by the ISA. 

b) The Hospital agrees to do general counselling for all OP patients to 

ascertain their eligibility under Mukhyamantri Amrutum (MA) Yojana to 

avoid conversion into cash patients at a later date. 

9.4 Declaration by the patient regarding eligibility under the Scheme: The 

Hospital agrees to take a declaration from the patient at the time of 

admission on the applicability or otherwise of Mukhyamantri Amrutum 

(MA) Yojana in his / her case. In emergency/trauma cases, patients may 

be allowed 48 hours after stabilization of patients to claim applicability of 

Mukhyamantri Amrutum (MA) Yojana” 

9.5 Online Updation of Bed Occupancy: 

a) The Hospital agrees to upload the bed occupancy under each specialty for 

which the Hospital is empanelled as and when required. 

b) The first point of contact for all the patients (outpatients and inpatients) 

coming under the Scheme will be the Arogya mitra positioned at Network 

Hospital. 

c) The Hospital agrees to follow all the guidelines annexed hereto in 

rendering the services to Mukhyamantri Amrutum (MA) Yojana patients as 

part & parcel of this Agreement. The Hospital also agrees to follow and 

adhere to the guidelines issued by the ISA from time to time. 

d) The Hospital agrees to follow and adhere to the on-line workflow of the 

Mukhyamantri Amrutum (MA) Yojana in providing services to its patients. 

The do‟s and don‟ts for the Hospital are given in Annexure 13 hereto. 

e) Circulars / Notifications: All circulars / notifications issued by the ISA 

at a later date shall be deemed as part of this Agreement. 

f) The Hospital agrees to follow the guidelines issued by the ISA on specific 

specialties, as mentioned in Annexures-15,16,17,18,19, and 22. 

g) The Hospital hereby declares that it did not exclude any other specialty 

service deliberately from the Scheme in spite of having such facility and 

agrees to empanel for all the specialties for which adequate infrastructure 

is available with it. 

h) The Hospital shall provide free food for the patients and also provide 

transport / transportation charges for patients on discharge (Rs. 300/- 

with a ceiling of maximum Rs.3000/- per year) which will be the part of 

package rates. 


i) The Hospital shall ensure that no confidential information is shared or 

made available by the Hospital or any person associated with it to any 

person or entity not related to the Hospital without prior written consent 

of Implementation Support Agency (ISA). 

j) The Hospital shall provide cashless facility to the beneficiary in strict 

adherence to the provisions of this Agreement. 

k) The Hospital shall display its status of preferred service provider of „MA‟ 

Yojana at its reception/ admission desks along with the display and other 

materials supplied / defined by the Implementation Support Agency (ISA) 

whenever possible for the ease of the Beneficiaries. 

l) The Hospital shall at all times during the course of this Agreement 

maintain a help desk, preferably at the entrance of the Hospital, to manage all 

„MA‟ Yojana patients. This help desk would contain the following: 

Seating arrangement for Arogya Mitra 

Facility of telephone 

Facility of fax machine 

PC Computer 

Internet/ any other connectivity to the Implementation Support 

Agency Server 

PC enabled POS machine with a biometric scanner and Bar Code 

reader to read and manage Bar-Coded Card transactions, to be 

purchased at a pre negotiated price from the vendor specified by 

Implementation Support Agency (ISA). The maintenance of the 

same shall be the responsibility of the vendor specified by 

Implementation Support Agency (ISA). 

A person to man the helpdesk at all times. 

Designate one Medical officer as Hospital Arogya Mitra (HAM) 

Get two persons in the Hospital trained in Hospital software, claim 

processing and claim management. 

m) The Hospital shall use the IT platform developed by the ISA/SNC to conduct 

all transactions related to the Mukhyamantri Amrutum (MA) Yojana i.e. 

Planning schedules of medical camps, e-preauthorization, processing of 

claims and claims settlement etc. 

Article 10 

Compliance with Empanelment Criteria: 

10.1 The Hospital hereby declares that the bed capacity of the Hospital is equal 

to or more than 25, with adequate infrastructure and manpower as per 


criteria fixed for empanelment, and agrees to provide separate male and 

female wards with toilets and other basic amenities. 

10.2 The Hospital hereby declares that it has requisite infrastructure as per 

HEALTH AND FAMILY WELFARE DEPARTMENT guidelines in relation to 

specialty-wise services for which empanelment is done and agrees to 

provide quality diagnostic and treatment services as per the standard 

protocols. 

10.3 The Hospital declares that it has a well-equipped ICU to meet the 

emergency requirements of the patients belonging to all the categories 

empanelled for and agrees to facilitate round the clock diagnostic and 

specialist services as per the criteria fixed for empanelment and as 

mentioned in Annexure 2. 

10.4 The Hospital agrees not to refuse admission of Mukhyamantri Amrutum 

(MA) Yojana patient in any specialty where it has consultants and 

equipment. A minimum of 25% of overall bed capacity and of beds in each 

specialty have to be made available to Mukhyamantri Amrutum (MA) 

Yojana patients in the Network Hospital. 

10.5 Declaration by the Hospital about tied up diagnostic facilities: In case 

the Hospital is having tie up with an independent diagnostic center for 

advanced diagnostic facilities, the Hospital shall furnish an affidavit and a 

letter from tied up diagnostic center, in the formats provided in Annexures 

24 and 25, to ensure that the tests are conducted on cashless basis. 

10.6 Performance Security: 

a. The Hospital confirms having furnished a Performance Security in the 

form of a Bank Guarantee of Rs.10.00 Lakhs (Rupees Ten Lakhs only) 

valid for a period of one year in favour of State Health Society, 

Gandhinagar to ensure efficient service and to safeguard against any 

default. 

b. The Hospital agrees and undertakes that from the next year onward for 

every renewal year, it shall furnish Performance Security of an amount 

equivalent to 10% of the total claims occurred under „MA‟ Yojana in the 

previous year at the Hospital. 


c. The Performance Guarantee shall be discharged and released on 

submission of the Performance Security for the next year, as mentioned 

above. 

10.7 Liquidated Damages: 

a) The Hospital shall provide the Services as per the requirements specified 

by the „MA‟ Yojana and in terms of the provisions of this Agreement with 

ISA. In case of initial violation of the provisions of this Agreement by the 

Hospital such as refusal of service or direct charging from the „MA‟ 

Beneficiaries or defective service and negligence, an amount equivalent to 

50% of the amount of Performance Security will be charged as agreed 

Liquidated Damages by the ISA/SNC, The Liquidated Damages shall be 

adjusted against the amounts payable to the Network Hospital. In the 

event of the amount payable to the Network Hospital being less than the 

amount of Liquidated Damages, the balance amount shall be recovered 

by invoking the Performance Security. In such event, the Network 

Hospital shall replace the Performance Security by a fresh Bank 

Guarantee, for the full amount as required. 

b) In case of repeated defaults by the Hospital, the total amount of 

Performance Security shall be forfeited and action will be taken for 

removing the Hospital from the empanelment of „MA‟ Yojana as well as 

termination of this Agreement 

a) For over-billing and unnecessary procedures, the extra amount so 

charged will be deducted from the pending / future bills of the Hospital 

and the ISA/SNC shall have the right to issue a written warning to the 

Hospital not to do so in future. 

b) The recurrence, if any, of over-billing and unnecessary procedures, will 

lead to the stoppage of referral to the Hospital 

Article 11 

Infrastructure available for Empanelment: 

The Hospital agrees and undertakes to provide P.C, Printer, Scanner, Digital 

camera, Webcam, Barcode reader, Mike, Speakers, Stationary etc., at the 

Mukhyamantri Amrutum Yojana Counter/Kiosk which shall be exclusively for 

the use of the Arogya Mitra / Hospital Arogya Mitra, to ensure the smooth 

operation of the Scheme. 


Article 12 

Cashless Services under Package: 

12.1 The Hospital agrees to provide total cashless transaction to the 

Beneficiaries right from his reporting to discharge. 

12.2 The Hospital agrees to provide treatment as per the packages worked out 

by the ISA. The package includes consultation, medicine, diagnostics, 

implants, food, cost of transportation, hospital charges etc. In other words 

the package shall cover the entire cost of treatment of the patient from the 

date of reporting till the date of discharge from the Hospital and also post 

hospitalization cost up to 10 days, making the transaction truly cashless 

to the patient. Under any circumstances, the Hospital shall not charge any 

money within the treatment period as covered under the package. 

12.3The Hospital agrees to issue a test requisition slip to the patient which will 

empower the patient to approach the concerned diagnostic/test centers 

within the Hospital or otherwise, and have the tests done without any 

cash transaction. The details of the tests done and their results will be 

uploaded in the portal by the HAM of the Hospital. 

12.4 The Hospital agrees to keep all the Mukhyamantri Amrutum (MA) Yojana 

patients admitted till they are fit for discharge. 

12.5 The Hospital agrees to the package to be authorized even for those 

patients who were admitted as non-Mukhyamantri Amrutum (MA) Yojana 

patients out of ignorance but are subsequently identified as 

Mukhyamantri Amrutum (MA) Yojana beneficiaries during the course of 

stay in the Hospital. Any payment received from the patient in the mean 

while, shall be refunded immediately after getting preauthorization 

approval and before discharge of the patient from the Hospital, duly 

obtaining a receipt from the patient. 

12.6 The Hospital shall provide blood to the patients from its own blood bank 

subject to availability, within the package. In case of non-availability, the 

Hospital shall make efforts to procure blood from other blood banks, Red 

Cross, voluntary organizations etc. The Hospital shall also issue a copy of 

the request letter to the patient. Under any circumstances the patient 

shall not be charged for procurement of the compatible blood. 


12.7 In case of death of the Mukhyamantri Amrutum (MA) Yojana patient in the 

Hospital during the course of treatment, the Hospital shall make 

arrangements for ambulance to shift the dead body from the Hospital to 

the residence of the deceased. 

12.8 In-house death of the patient shall be intimated immediately on phone to 

the ISA with reasons. The death summary of the deceased should be sent 

within 48 hours to the ISA office. 

12.9 The acknowledgement letter for having received the ambulance services 

duly signed by the caretaker shall be enclosed along with the claim file 

submitted to ISA for the needful. 

Article 13 

Package Rates: 

13.1 The Package rates given in the Booklet (Mukhyamantri Amrutum (MA) 

Yojana Manual on Benefit Package for Cashless Treatment of BPL 

Population) shall form a part and parcel of this Agreement and it shall be 

the basis and binding for the treatment cost of various procedures. 

13.2 The package rates are the maximum rates indicated for each surgical 

procedure. However if the treatment cost is lesser than the package rate, 

settlement of the claims shall be made on the basis of actual bills 

submitted by the Hospital. 

13.3 The Hospital agrees to the continuation of the agreed tariff for the period 

of this Agreement. 

13.4 The Hospital under any circumstances shall not refuse to undertake any 

procedure on the ground of insufficient package. 

13.5 In all disputes related to package rates and technical approvals of 

preauthorization, the matter will be referred to ISA/SNC and the decision 

of the SNC shall be binding on the Hospital. 

Article 14: 

Cost of Evaluation of Patients: 

14.1 The cost of various treatments/tests conducted on the BPL family 

members who are evaluated but ultimately do not undergo Surgery or 


Therapies shall be borne by the Hospital and the Hospital shall not charge 

any fee for consultation and investigation from the Beneficiary. 

Article 15: 

Quality of Services: 

15.1 The Hospital agrees to provide separate and Free OPD consultation to the 

Beneficiaries. However, there should not be any discrimination to 

Mukhyamantri Amrutum (MA) Yojana patients vis-a-vis other paying 

patients in regard to quality of services. 

15.2 The Hospital shall treat Mukhyamantri Amrutum (MA) Yojana 

Beneficiaries in a courteous manner and according to good business 

practices. 

15.3 The Hospital shall extend admission facilities to the Beneficiaries round 

the clock. 

15.4 The Hospital shall have covered itself by proper professional indemnity 

insurance policy against errors and omissions and agrees to keep such 

policies in force during the entire tenure of this Agreement. 

15.5 The Hospital shall ensure that the best and complete diagnostic, 

therapeutic and follow-up services based on standard protocols and 

medical practices/recommendations are extended to the Beneficiaries. It is 

also mandatory for the Hospital to assess the appropriate need and 

subject the Beneficiaries for treatment/procedure. 

15.6The Hospital agrees to provide quality medicines, standard prostheses, 

implants and disposables while treating the Beneficiaries. 

15.7 The Hospital agrees to assist and cooperate with the medical auditing 

teams from the ISA and SNC, as and when required. 

15.8 The Hospital agrees to provide video recorded evidence of patient 

counseling before surgery in order to avoid legal complications / any 

adverse reaction by patients or patients‟ relatives or by public in the event 

of unacceptable outcome. 

15.9 The Hospital‟s morbidity and mortality cases will be subject to scrutiny by 

the ISA. 


Article 16 

Services of Mukhyamantri Amrutum (MA) Yojana 

„Hospital Arogya Mitra (HAM)‟: 

16.1 The Hospital shall have a Medical Officer/Medical Officers, designated as 

Mukhyamantri Amrutum (MA) Yojana Hospital Arogya Mitras, for the 

Scheme to coordinate with ISA through Arogya Mitras. The Hospital shall 

give the services of 

(i) Dr………………………………….as the HAM-1. 

His/ her contact details are as follows: 

Telephone:______________Mobile:______________and Email________________. 

(ii) Dr…………………………………….as the HAM-2. 

His/ her contact details are as follows: 

Telephone:________________Mobile:____________and Email________________. 

The Hospital should promptly inform the ISA about changes, if any, in the 

HAM (s) designated during the tenure of this Agreement. 

16.2 The following are the responsibilities of HAM (Mukhyamantri Amrutum 

(MA) Yojana Hospital Arogya Mitra): 

a) He shall guide the patient in all aspects. 

b) He shall ensure that all required evaluations including diagnostic tests 

are done free of cost for all Beneficiaries and the details of the same 

along with reports are captured in the ISA portal. 

c) He shall upload the OP/IP status of the patient. 

d) He shall sign the investigation request. 

e) He shall cross check whether diagnosis is covered under the Scheme. If 

doubtful about the plan of management, then he should coordinate with 

the treating specialist along with Package list as specified in Annexure 

5. 

f) He should facilitate the admission process of patients without any 

delay. 

g) After admission, he shall collect all the necessary investigation reports 

before sending for approval. 

h) He shall upload the admission notes and preoperative clinical notes of 

the patient. 

i) He shall ensure that preauthorization request is sent only for patients 

who are admitted. 

j) He shall ensure before sending preauthorization that all essential 

documents like MA card, Patient photo and also necessary reports as 


per the standard protocol, like CT Films, X-Ray films, Angio CD etc., are 

uploaded in the system. 

k) He shall coordinate with ISA doctors as need arises. 

l) Pre-authorizations kept pending from ISA shall be verified on a regular 

basis and necessary corrections shall be done by HAM. 

m) He shall furnish daily clinical notes (Pre-Operative and Post-Operative). 

n) He shall upload 3 photographs of the patient taken preoperative 

bedside, and immediate post-operative showing operation wound and at 

the time of discharge. 

o) He shall update surgery and discharge details and hand over signed 

copy of the summary along with follow-up advice in pre-printed 

stationary. 

p) He shall ensure free follow–up consultations, routine investigations and 

distribution of drugs to be supplied by the Hospital to the Beneficiaries. 

q) He shall ensure to update the details of on-bed status of patients time 

to time as per the format, as per Annexure-23 on the display board 

placed at the Arogya Mitra Kiosk / Reception desk. 

r) The roles and responsibilities of HAM are enumerated in Annexure – 11. 

16.3 The Hospital shall ensure that documentation of Mukhyamantri 

Amrutum (MA) Yojana patients is done using standard formats 

supplied/available online such as admission card, referral card, 

investigation slip, discharge summary etc. 

16.4 ISA reserves the right to visit the Beneficiary and check his medical data 

with or without intimation, as and when required. 

16.5 The Hospital shall allow the officials from the ISA and SNC to inspect the 

Hospital without obstruction and co-ordinate with them during surprise 

and regular inspections. 

16.6 The Hospital shall furnish periodical reports to ISA on the progress of the 

Scheme as per the formats prescribed for this purpose. 

16.7 The Hospital shall not give any document to facilitate the Mukhyamantri 

Amrutum (MA) Yojana patient to obtain any other relief like CMRF (Chief 

Minister Relief Fund) etc. The Hospital shall not claim any other relief for 

the procedures covered under the Scheme. Any deviation in this regard 

shall attract disciplinary action. 


16.8 The Hospital agrees to display availability of beds in the Hospital and 

also display specialty-wise bed occupancy under Mukhyamantri 

Amrutum (MA) Yojana at its reception/admission desks. 

16.9 The Hospital agrees to make available the list of diseases with package 

rates covered under Mukhyamantri Amrutum (MA) Yojana in the form of 

a booklet supplied by the ISA at its reception/admission desks. 

16.10 The Hospital agrees to display other materials supplied by ISA for the 

ease of the Beneficiaries. 

Article 17: 

Mukhyamantri Amrutum (MA) Yojana Kiosk and Arogya Mitra Services: 

17.1 The Hospital shall establish Mukhyamantri Amrutum (MA) Yojana 

Assistance Counter / Kiosk at the reception of the Hospital free of cost as 

per the design given by ISA for Arogya Mitras (Health Coordinators). 

(Photograph of the space provided for the Kiosk is annexed herewith as 

Anexure-28). 

17.2 the Hospital shall provide the following infrastructure and network facility 

at the counter: P.C, printer, scanner, digital camera, webcam, barcode 

reader, mike, speakers, stationary etc. The system and other peripherals 

should be provided exclusively for the use of Arogya Mitras who can use 

the resources at any point of time. 

17.3 The Hospital shall provide a dedicated 2 Mbps broadband connectivity to 

the computer to be exclusively used by the Arogya Mitras to access the 

web for online MIS, e-preauthorization etc. 

17.4 The Hospital shall allow Arogya Mitras access to the wards and patient‟s 

data to facilitate onward transmission to the ISA for preauthorization, 

claims, correct MIS etc. 17.4 The Hospital shall update the details like 

date of surgery, discharge of the Beneficiary, etc. in the ISA portal. 

17.5 The Hospital shall intimate Arogya Mitras and HAM regarding emergency 

admissions of Beneficiaries during non office hours. 

17.6 The Assistance Counter / Kiosk and other infrastructure / facilities as 

mentioned above should be installed within 10 days of signing of this 

Agreement. The Hospital also needs to inform and train personnel on the 


handling of POS machine and also on the process of obtaining 

authorization for conditions not covered under the list of packages, and 

have a manned help desk at its reception and admission facilities for 

aiding in the admission procedures for Beneficiaries of „MA‟ Yojana. 

17.7 The roles and responsibilities of Arogya Mitras are enumerated in 

Annexure-10. 

Article 18: 

General Responsibilities of Implementation Support Agency (ISA) 

18.1 Empanelment of Hospitals: 

The ISA shall sign MoU with the hospitals empanelled under the scheme. 

Institutions meeting the empanelment criteria set forth by the State 

Nodal Cell and having undergone satisfactory inspection by the 

Empanelment and Disciplinary Committee shall extend healthcare to the 

beneficiary under the scheme. A provision regarding non-compliance 

clause will be made in the hospital MoU. 

18.2 The Implementation Support Agency (ISA) has a right to avail similar 

services as contemplated herein from other hospitals / institutions for 

the health services covered under this Agreement. 

18.3 Implementation procedure: 

The entire scheme is intended to be implemented as cashless 

hospitalization arranged by the Network Hospitals. The procedure to be 

followed for availing treatment in the Network Hospitals is as follows: 

Step 1 

Beneficiaries approach nearby Sub District Hospitals/District 

Hospital/Medical College & Hospital/Network Hospital. Arogya 

mitras would facilitate the beneficiary. If beneficiary visits any other 

Government hospital other than the Network Hospital, the doctors 

will give him/her a referral card to the Network Hospital after 

preliminary diagnosis. The Beneficiary may also attend the Health 

Camps being conducted by the network hospitals and can get the 

referral card based on the diagnosis. 

Step 2 


The Arogya mitra engaged by the implementation support agency 

examines the referral card and bar coded plastic card and 

facilitates the beneficiary to undergo preliminary diagnosis and basic 

tests. 

Step 3 

The Network Hospital, based on the diagnosis, admits the patient and 

sends preauthorization request to the Implementation Support Agency. 

Step 4 

Doctors/Specialists of the Implementation Support Agency examine the 

preauthorization request and approve preauthorization within 24 hours on 

receiving the preauthorization request from the network hospitals, if all the 

conditions are satisfied. 

Step 5 

The Network Hospital extends cashless treatment and surgery to the 

beneficiary subject to the limits prescribed under the scheme. 

Step 6 

Network Hospital after discharge forwards the original bill, discharge 

summary with signature of the patient and other relevant documents to 

Implementation Support Agency for processing and settlement of the claim 

within one week (7 days) from the date of discharge of the patient. 

Step 7 

Implementation Support Agency scrutinizes the bills and forwards 

the payment request of the bill to the State Nodal Cell (SNC) within 

fifteen days (15 days) of the receipt of bills from the Network Hospital. 

Step 8 

The State Nodal Cell (SNC) after verification of the bills in lieu of the 

services provided will directly make the payment by way of electronic 


transfer to the Network Hospital(s) within 30-days of receiving the bills 

from the Implementation Support Agency. 

The Implementation Support Agency will provide an IT platform developed by 

the State Nodal Cell / ISA to conduct all transactions related to the 

Mukhyamantri Amrutum (MA) Yojana. Transactions including planning and 

schedules of medical camps, E-preauthorization, processing of claims and 

claims settlement. 

The Implementation Support Agency will have district level monitoring staff 

with district coordinators. The ISA is responsible for identifying, engaging, 

training and positioning the Arogya Mitras and the District Coordinators. 

Article 19: 

Relationship of the Parties 

19.1 Nothing contained herein shall be deemed to create between the Parties 

any partnership, joint venture or relationship of principal and agent or 

master and servant or employer and employee or any affiliate or 

subsidiaries. Each of the Parties hereto agrees not to hold itself or allow 

its directors employees/agents/representatives to hold out to be a 

principal or an agent, employee or any subsidiary or affiliate of the other. 

Article 20: 

Reporting 

20.1 In the first week of each month, beginning from the first month of the 

commencement of this Agreement, the Hospital and Implementation 

Support Agency (ISA) shall exchange information on their experiences 

during the month and review the functioning of the process and make 

suitable changes whenever required. However, all such changes have to 

be in writing and by way of suitable supplementary agreements or by 

way of exchange of letters. 

20.2 All official correspondence, reporting, etc pertaining to this Agreement 

shall be conducted with the Implementation Support Agency (ISA) at its 

corporate office at the address _______________________________. 

Article 21: 

Termination 

21.1 The Implementation Support Agency (ISA) reserves the right to terminate 

this Agreement as per the guidelines issued by State Nodal Cell, Health 


and Family Welfare Department, Government of Gujarat as given in 

Annexure 9. 

21.2 This Agreement may be terminated by either party by giving one month‟s 

prior written notice by means of registered letter or a letter delivered at 

the office and duly acknowledged by the other, provided that this 

Agreement shall remain effective thereafter with respect to all rights and 

obligations incurred or committed by the Parties hereto prior to such 

termination. 

21.3 Either party reserves the right to inform the public at large along with 

the reasons of termination of the Agreement by the method which they 

deem fit. 

Article 22: 

Confidentiality 

22.1 Each Party shall maintain confidentiality relating to all matters and issues 

dealt with by the Parties in the course of the business contemplated by 

and relating to this Agreement. The Hospital shall not disclose to any 

third party, and shall use its best efforts to ensure that its officers and 

employees keep secret all information disclosed, including without 

limitation, documents marked confidential, medical reports, personal 

information relating to the Beneficiaries, and other unpublished 

information except as may be authorized in writing by Implementation 

Support Agency (ISA). The Implementation Support Agency (ISA) shall not 

disclose to any third party and shall use its best efforts to ensure that its 

directors, officers, employees, sub-contractors and affiliates keep secret all 

information relating to the Hospital including without limitation to the 

Hospital‟s proprietary information, process flows, and other details. 

22.2 In Particular the Hospital agrees to: 

a) Maintain confidentiality and endeavour to maintain confidentiality of any 

persons directly employed or associated with health services under this 

agreement and of all information received by the Hospital or such other 

medical practitioner or such other person by virtue of this Agreement or 

otherwise, including Implementation Support Agency (ISA)‟s proprietary 

information, confidential information relating to the Beneficiaries and 

medicals test reports whether created/ handled/ delivered by the 

Hospital. Any personal information relating to a Beneficiary received by 

the Hospital shall be used only for the purpose of 


inclusion/preparation/finalization of medical reports/ test reports for 

transmission to Implementation Support Agency (ISA) only and the 

Hospital shall not give or make available such information/ any 

documents to any third party whatsoever. 

b) Keep confidential and endeavour to maintain confidentiality by its 

medical officers, employees, medical staff, or such other persons, of 

medical reports relating to the Beneficiaries, and ensure that the 

information contained in these reports remains confidential and the 

reports or any part of reports is not disclosed/ informed to any 

Insurance Agent / Advisor under any circumstances. 

c) Keep confidential and endeavour to maintain confidentiality of any 

information relating to the Beneficiaries, and shall not use the said 

confidential information for research, creating comparative database, 

statistical analysis, or any other studies without appropriate previous 

authorization from Implementation Support Agency (ISA) and through 

Implementation Support Agency (ISA) from the Beneficiary. 

22.3 This Article shall survive the termination/expiry of this Agreement. 

Article 23: 

Indemnities and other Provisions 

23.1 Implementation Support Agency (ISA) will not interfere in the treatment 

and medical care provided to its Beneficiaries. Implementation Support 

Agency (ISA) will not be in any way held responsible for the outcome of 

treatment or quality of care provided by the Hospital. 

23.2 Implementation Support Agency (ISA) shall not be liable or responsible for 

any acts, omission or commission of the doctors and other medical staff of 

the Hospital and the Hospital shall obtain professional indemnity policy at 

its own cost for this purpose. The Hospital agrees that ISA shall not be 

responsible in any manner whatsoever for the claims, arising from any 

deficiency in the services or any failure to provide identified services. 

23.3 Notwithstanding anything to the contrary in this agreement neither Party 

shall be liable by reason of failure or delay in the performance of its duties 

and obligations under this Agreement if such failure or delay is caused by 

acts of God, strikes, lock-outs, embargoes, war, riots, civil commotion, any 

orders of governmental, quasi-governmental or local authorities, or any 

other similar cause beyond its control and without its fault or negligence. 


23.4 The Hospital will indemnify, defend and hold harmless the 

Implementation Support Agency (ISA) against any claims, demands, 

proceedings, actions, damages, costs, and expenses which ISA may incur 

as a consequence of the negligence of the Hospital in fulfilling obligations 

under this Agreement or as a result of the breach of the terms of this 

Agreement by the Hospital or any of its employees or doctors or medical 

staff. 

Article 24: 

Notices 

24.1All notices, demands or other communications to be given or delivered 

under or by reason of the provisions of this Agreement shall be in writing 

and delivered to the other Party: 

a. By registered mail; or 

b. By courier; or 

c. By facsimile; 

24.2 In the absence of evidence of earlier receipt, a demand or other 

communication to the other Party is deemed given 

if sent by registered mail, seven working days after posting it; and 

if sent by courier, seven working days after posting it; and 

if sent by facsimile, two working days after transmission. In this case, 

further confirmation has to be done via telephone and e-mail. 

24.3 The notices shall be sent to the other Party to the addresses given below 

(or to the addresses which may be provided by way of notices made in the 

above said manner): 

If to the Hospital: 

Address : 

Attn: ………………… 

Tel : ……………. 

Fax: …………… 

E-mail: 

If to the Implementation Support Agency (ISA) 


Address : 

Attn: ………………… 

Tel : ……………. 

Fax: …………… 

E-mail: 

Article 25 

Hospital Services- Admission Procedure 

25.1 The Hospital agrees not to deny admission to any Beneficiary for want of 

preauthorization. 

25.2 The Hospital agrees to provide a separate ward for Mukhyamantri 

Amrutum (MA) Yojana Beneficiaries. 

25.3 The Hospital agrees to provide separate operation theatre days and weekly 

schedules for the surgeries/ therapies to be performed for the 

Beneficiaries. 

25.4 The Hospital agrees to handle a minimum number of cases in each 

specialty including trauma cases based on their available infrastructure 

as under. 

25.5 The Hospital agrees to submit the vacancy level in preoperative wards, ICU 

and post operative wards and also upload the same in the ISA portal on a 

daily basis. 

Capacity to admit number of 

SPECIALTY 

patients/Day (Bed Strength) 

Burns and Plastic Surgery 

ENT 

Gynecology and Obstetrics 

Cardiac Interventions 

Cardiothoracic Surgery 

Surgical Gastroenterology 

Genitourinary Surgery 

Neurosurgery 

Pediatric Surgery 

SPECIAL SERVICES 

Cancer 

Medical Oncology 


Surgical Oncology 

Radiation Oncology 

25.6 Request for examination and if necessary hospitalization for surgical 

procedures on behalf of the Beneficiaries shall be made by the 

“Mukhyamantri Amrutum (MA) Yojana Help Desk” at any Government 

Hospital or by the “Mukhyamantri Amrutum (MA) Yojana Assistance 

Counter/ Kiosk” at the Network Hospital. 

25.7 Arogya Mitras at Mukhyamantri Amrutum (MA) Yojana Assistance 

Counter/ Kiosk at the Network Hospital will coordinate with the Hospital 

from the time of admission till discharge after the surgical procedure. 

E-Pre-authorization: 

25.8 Pre-authorization request shall be sent only after admission and the 

patient shall be admitted as inpatient till final decision on the 

preauthorization is made. 

25.9 The Hospital shall submit the e-pre-authorization, after admitting the 

patient as inpatient, on the ISA Portal complete in all aspects including 

the signed copy of consent of the patient. All relevant test reports along 

with digital photograph of the Beneficiary taken in the Hospital shall also 

be uploaded. The Catheterization CD, MRI films, X-rays, cytology and 

biopsy reports / slides should be submitted. 

25.10 ISA undertakes to approve the preauthorization indicating the relevant 

package rates within 12 working hours of the receipt of the request for 

pre-authorization form as well as the required data and information 

online. The Hospital agrees to update the surgery online immediately 

after performing the surgery. However, the validity period of the 

preauthorization is 14 days from the date of approval. The Hospital 

agrees to update clinical notes of all cases (both pre & post preauthorization 

notes) in the website on daily basis. If the surgery / 

therapy is not updated within 14 days after approval of preauthorization, 

then preauthorization will automatically get cancelled in the ISA portal. 

In such cases the Hospital should obtain fresh approval for the cancelled 

pre-authorizations by mentioning valid reasons and the ISA reserves the 

right to approve the request of pre-authorization. 


25.11 After approval of pre-authorization, if the patient is not found on bed at 

the time of routine check by officials of ISA / SNC and in case the 

Hospital is unable to present the patient during the routine check by 

officials of ISA / SNC, the ISA reserves the right to cancel the 

preauthorization immediately without any intimation. 

25.12 If the Hospital is not able to conduct the operation within a reasonable 

time for any reason other than medical, such as non availability of beds 

or specialists, the Hospital shall arrange for the operation to be 

conducted at any other appropriate Network Hospital in consultation 

with ISA. 

25.13 Pre-authorization preferably shall be given to whichever Network Hospital 

does the preliminary screening either at the medical camp or at the 

Hospital. Second preauthorization for the same patient from different 

Network Hospital shall not be entertained for the same procedure unless 

medically warranted or surgical procedure is unduly delayed by the first 

Hospital without proper medical grounds. 

25.14 ISA reserves the right to disallow the claim if the surgery/therapy is 

performed before any approval from the ISA and pre-authorization is 

obtained at a later date while keeping the ISA in dark about the surgery / 

therapy. 

25.15 The Hospital agrees to obtain emergency telephonic approval for 

emergency cases only. The ISA reserves the right to cancel the 

emergency telephonic approval, if the Hospital fails to update the preauthorization 

online within 72 hours of emergency telephonic approval. 

The Hospital also agrees to perform the surgery / therapy obtained 

through telephonic intimation within 24 hours from the date and time of 

telephonic approval. The Hospital also agrees to update the surgery / 

therapy details online for telephonic approvals, mentioning the date and 

time along with specific remarks and photographic evidences, starting 

from the telephonic intimations. 

Article 26 

Discharge and Follow-up: 

26.1 Intimation of the impending discharge of the Beneficiary needs to be 

advised to Mukhyamantri Amrutum (MA) Yojana Assistance Counter at 

least one day before the discharge of the patient. 


26.2 The discharge has to be done in the presence of concerned HAM and 

Arogya Mitra. 

26.3 At the time of discharge the transportation cost has to be reimbursed to 

the patient. The acknowledgement of receiving the amount for 

transportation has to be generated from the ISA portal and the signed 

copy has to be uploaded. 

26.4 Discharge summary will be generated from the ISA portal in a pre-printed 

stationary. The discharge summary will consist of all the treatment details 

of the patient at the Hospital and the follow-up regime for the patient 

including consultation and medication. 

26.5 All the patients must be provided with follow-up medicines after discharge 

by the Hospital, as part of the package. 

26.6 If the same patient is coming back to the Hospital, the follow-up details 

have to be uploaded in the ISA Portal. 

26.7 Satisfaction letter of the Patient has to be generated from the ISA Portal 

and the signed copy has to be uploaded. 

26.8 The HAM & Arogya Mitra should counsel the patient for all the 

precautions to be taken for the post-operative care. 

26.9 All patients who require follow-up medicines will be advised by the 

Hospital to come back on the 11 th day of discharge for first mandatory 

follow-up. The date of first follow-up will be generated by the ISA portal 

along with the discharge summary. 

26.10 The subsequent follow-ups for the above cases will be as per the followup 

guidelines Given in Annexure-8. 

26.11 The Hospital shall provide follow-up services to the Beneficiaries for a 

period of one year after discharge, under the Scheme. 

26.12 The Hospital shall provide free post surgical physiotherapy services, 

wherever required during the tenure of this Agreement. 


Article 27 

Billing Procedure/Checklist for the Hospital at the time of Patient‟s 

Discharge: 

27.1 It is admitted and agreed that the Hospital is aware that this Agreement 

has been entered into for the purpose of implementation of the 

Mukhyamantri Amrutum (MA) Yojana intended for Below Poverty Line 

families of Gujarat. Accordingly, the Hospital under any circumstances 

shall not charge or seek any payment from the Beneficiaries but will look 

only for indemnity, and that too only to the limits/schedule of fees in 

respect of procedures referred to earlier and agreed to under this 

Agreement. 

27.2 Signature or the left thumb impression of the patient / Beneficiary will be 

obtained on final Hospital bills and the discharge form. 

27.3 The Hospital will submit the following along with its bills: original 

discharge summary, original investigation reports, all original 

prescriptions, procedure CD‟s, MRI films, X-rays, post operative slides 

with biopsy report, 3 photographs of the patient taken preoperative 

bedside, immediate post-operative showing operation wound and at the 

time of discharge, case sheet with operation notes, breakup of the bills 

(room rent, investigations, procedure charges & pharmacy receipts) etc. 

These documents are required while submitting the bills, for settlement of 

claims. The copies of the discharge summary signed by the Beneficiary 

will be uploaded in the ISA portal. A summary of the bills raised will also 

be uploaded. 

27.4 Letter of satisfaction from the patient should also be obtained and sent 

along with the bills in prescribed format. 

27.5 The Hospital should ensure that chemo therapy drugs are physically 

administered to the patients. The Hospital should produce bills by quoting 

batch no. and attaching empty vials & ampoules with intact labels. 

Case 1: In case of Package covered under the Scheme and sufficient funds 

available 

1.1. The Beneficiary approaches the „MA‟ Yojana help desk at the Network 

Hospital of Implementation Support Agency (ISA). 


1.2. The Help desk verifies that the Beneficiary has genuine card issued 

under „MA‟ Yojana (key authentication) and that the person carrying 

the card is enrolled (fingerprint matching). 

1.3. After verification, a slip shall be printed giving the person‟s name, age 

and amount of cover available. 

1.4. The Beneficiary is then directed to a doctor for diagnosis. 

1.5. The doctor shall issue a diagnosis sheet after examination, specifying 

the problem, examination carried out and line of treatment prescribed. 

1.6. The Beneficiary approaches the „MA‟ Yojana help desk along with the 

diagnostic sheet. 

1.7. The help desk shall re-verify the card and the Beneficiary and select 

the package under which treatment is to be carried out. Verification is 

to be done preferably using patient fingerprint, only in situations 

where it is not possible for the patient to be verified, it can be done by 

any family member enrolled in the card. 

1.8. The terminal shall automatically block the corresponding approximate 

amount on the card. 

1.9. At the same time the Hospital shall take authorization from 

Implementation Support Agency (ISA). 

1.10. The Hospital shall fax or send through online to Implementation 

Support Agency (ISA) a pre-authorization request. 

1.11. Implementation Support Agency (ISA) shall either approve or reject the 

request. In case Implementation Support Agency (ISA) approves, it will 

also provide the AL (authorization letter) number and package amount 

authorized to the Hospital via return fax or through online. 

1.12. On receipt of approval the „MA‟ Yojana help desk would manually enter 

the patient‟s details (as defined by the ISA) into the help desk device. 

The device would connect to the server on-line. The server would also 

send the confirmation (denial/approval) to the help desk device. 

1.13. In case during treatment, requirement is felt for extension of package 

or addition of package due to complications, the patient or any other 

family member would be verified and required package would be 

selected. This would ensure that the Implementation Support Agency 

is appraised of change in claim. The availability of sufficient funds is 

also confirmed thereby avoiding any confusion at time of discharge. 

1.14. Thereafter, once the Beneficiary is discharged, the Beneficiary shall 

again approach the help desk with the discharge summary. 

1.15. After card and Beneficiary verification, the discharge details shall be 

entered into the terminal. 


1.16. In case the treatment is covered, the Beneficiary may claim the 

transport cost Rs.300/- from the help desk. 

1.17. In case treatment of one family member is under way when the card is 

required for treatment of another member, the software shall consider 

the cover available after deducting the amount blocked against the 

package. 

1.18. Due to any reason if the Beneficiary does not avail treatment at the 

Hospital after the amount is blocked the „MA‟ Yojana help desk would 

need to unblock the amount. 

Case 2: In case of packages not covered under the Scheme 

2.1. In case the line of treatment prescribed is not covered under „MA‟ 

Yojana, the help desk shall advise the Beneficiary accordingly and the 

Hospital shall follow the norms of deposit / running bills. 

Case 3: In case of in-sufficient funds 

3.1 In case the amount available is less than the package cost, the 

Hospital shall follow the norms of deposit / running bills. 

3.2 In case of insufficient funds the balance amount of the coverage with 

the BPL family could be utilized and the rest of the amount would be 

paid by the Beneficiary after the consent taken from the Beneficiary. 

3.3 The terminal would have a provision to capture the amount collected 

from the Beneficiary. 

Article 28 

Medical / Health Camps: 

28.1 The Hospital shall conduct free medical camps at least once in a month 

at the place specified by the ISA to identify the members of the MA 

Yojana who may require surgeries covered under the Scheme as per the 

schedule given by the ISA for such surgeries. The Health Camp 

Guidelines as given in Annexure-26 shall be scrupulously followed. 

28.2 The Hospital shall carry necessary diagnostic equipment such as ECG, 

Echo, Ultrasound etc. to these free medical camps. 

28.3 The Hospital shall provide services of concerned specialists namely 

Cardiologists, CT Surgeon, Neurosurgeons, Urologists, Oncologists, 

Gynecologists, Plastic Surgeon, Pediatric Surgeon, General Physicians 

etc. at the camps to facilitate proper evaluation of the patients. 


28.4 The Hospital shall submit the camp confirmation online as given in the 

guidelines in the prescribed format to ISA at least one week in advance 

of the stipulated date. 

28.5 The Hospital shall inform all the stakeholders such as District 

Administration, concerned public representatives, PHC (Primary Health 

Center)/TH (Taluka Hospital)/ DH (District Hospital) staff etc well in 

advance for successful conduct of the camp. 

28.6 The Hospital shall spread awareness about the camp through publicity 

in coordination with district health authorities and Arogya Mitras. 

28.7 The Hospital shall provide patient data to ISA in the prescribed form at 

the end of the camp. 

28.8 The Hospital shall enter the details of the patients screened and referred 

at the camps on the ISA portal on the same day of the camp. 

28.9 The Hospital shall coordinate constantly with the Medical Camps Cell of 

the ISA in all matters related to the medical camps. 

28.10 The patient referred from the camp shall be followed up and transported 

to the Hospital within 10 days of the camp unless the patient is not 

willing, in which case the same should be recorded and updated on the 

ISA Portal. 

28.11 The Hospital shall have an officer, designated as Mukhyamantri 

Amrutum (MA) Yojana Hospital Arogya Mitra who will act as the Medical 

Camp Coordinator for the Scheme to coordinate with ISA through 

Arogya Mitras. 

28.12 The Hospital shall give the full-time services of HAM to coordinate all 

activities related to camps and patient follow-up from camps. 

The following are the responsibilities of Mukhyamantri Amrutum (MA) 

Yojana Hospital Arogya Mitra during the Medical Camp: 

o Confirmation of camps online and indenting online 

o Carrying out the IEC (Information, Education and Communication) 

activities within camp area at least 7 days before the camp date. 

o Providing facilities like shamianas, chairs, screening enclosures. 

o Providing common medicines in the camps. 


o Arranging health education exhibits and pamphlets etc., in the camp. 

o Coordinating and ensuring participation of specialists. 

o Arranging the diagnostic equipment 

o Coordinating with PHC (Primary Health Centre) doctors/Government 

doctors, public representatives, SHG groups (Self Help Group) and 

Local Administration. 

o Raising claims online for the camps conducted. 

o Follow – up of patients referred from Camps 

o Any other responsibilities assigned by the ISA with regard to the 

Hospital claims. 

Article 29 

PROCESS NOTE FOR DE-EMPANELMENT OF HOSPITALS 

The operational guidelines regarding de-empanelment of guidelines which are 

empanelled under Mukhyamantri Amrutum (MA) Yojana are given in 

Annexure-9 

Article 30 

LAW AND ARBITRATION 

30.1 The provisions of this Agreement shall be governed by, and construed in 

accordance with India law. 

30.2 Any dispute, controversy or claims arising out of or relation to this 

Agreement or the breach, termination or invalidity thereof, shall be settled 

by arbitration in accordance with the provisions of the Arbitration and 

Conciliation Act, 1996. 

30.3 The arbitral tribunal shall be composed of three arbitrators, one arbitrator 

appointed by each Party and one another arbitrator appointed by the 

mutual consent of the arbitrators so appointed. 

30.4 The place of arbitration shall be Gandhinagar and any award whether 

interim or final, shall be made, and shall be deemed for all purposes 

between the parties to be made, in English. 

30.5 The arbitral procedure shall be conducted in the English language and 

any award or awards shall be rendered in English. The procedural law of 

the arbitration shall be India law. 


The award of the arbitrator shall be final and conclusive and binding upon 

the Parties, and the Parties shall be entitled (but not obliged) to enter 

judgement thereon in any one or more of the highest courts having 

jurisdiction. 

30.6 The rights and obligations of the Parties under, or pursuant to, this 

Clause including the arbitration agreement in this Clause, shall be 

governed by and subject to India law. 

30.7 The cost of the arbitration proceeding would be born by the parties on 

equal sharing basis. 

Article 31 

Miscellaneous 

31.1 This Agreement together with the Annexures attached hereto constitutes 

the entire agreement between the Parties and supersedes, with respect to 

the matters regulated herein, all other mutual understandings, accords 

and agreements between the Parties, irrespective of their form. The 

Annexures to this Agreement shall constitute an integral part of this 

Agreement. 

31.2 Except as otherwise provided herein, no modification, amendment or 

waiver of any provision of this Agreement will be effective unless such 

modification, amendment or waiver is approved in writing by the Parties 

hereto. 

31.3 Should any specific provision of this Agreement be wholly or partially not 

legally effective or unenforceable or later lose its legal effectiveness or 

enforceability, the validity of the remaining provisions of this Agreement 

shall not be affected thereby. 

31.4 The Hospital may not assign, transfer, encumber or otherwise dispose of 

this Agreement or any interest herein without the prior written consent of 

Implementation Support Agency (ISA), provided however, that the 

Implementation Support Agency (ISA) may assign this Agreement or any 

rights, title or interest herein to an Affiliate without requiring the consent 

of the Hospital. 

31.5 The failure of any of the Parties to insist, in any one or more instances, 

upon a strict performance of any of the provisions of this Agreement or to 


exercise any option herein contained, shall not be construed as a waiver 

or relinquishment of such provision, but the same shall continue and 

remain in full force and effect. 

31.6 The Hospital shall indemnify, defend and hold harmless the 

Implementation Support Agency (ISA) against any claims, demands, 

proceedings, actions, damages, costs, and expenses which the latter may 

incur as a consequence of the negligence of the Hospital in fulfilling the 

obligations under this Agreement or as a result of the breach of the terms 

of this Agreement by the Hospital or any of its employees/doctors/other 

medical staff. 

31.7 The invalidity or unenforceability of any provisions of this Agreement in 

any jurisdiction shall not affect the validity, legality or enforceability of the 

remainder of this Agreement in such jurisdiction or the validity, legality or 

enforceability of this Agreement, including any such provision, in any 

other jurisdiction, it being intended that all rights and obligations of the 

Parties hereunder shall be enforceable to the fullest extent permitted by 

law. 

31.8 The captions in this Agreement are included for convenience of reference 

only and shall be ignored in the construction or interpretation hereof. 

SIGNED AND DELIVERED BY 

______________________ Company Limited, 

the within named 

Implementation Support Agency_____________________, 

by the hand of ___________ 

it‟s Authorised Signatory In the presence of: 

SIGNED AND DELIVERED BY_________________ 

The within named Hospital__________________. 

by the Hand of _____________________ 

its Authorised Signatory, 

In the presence of: 


INSTRUCTIONS 

Paragraph Reference 

ANNEXURE - 1 

1 

1 

Name and Address of the State Nodal Cell: Department of Health & Family Welfare, 

Gandhinagar. 

Address: Commissionerate of Health and Family Welfare, MS and ME, Block No. 5, 

Dr. Jivraj Mehta Bhavan, Gandhinagar, Gujarat. 

Telephone: 079-232-53311, Fax: 079-232-56430,Email:mayojanagujarat@gmail.com 

22 2 The physical submission of the technical bid document address is: 

Dr. B. K. Patel, Additional Director (FW), Commissionerate of Health and Family 

Welfare, MS and ME, Block No. 5, Dr. Jivraj Mehta Bhavan, Gandhinagar, 

Gujarat.Phone:079-232-53311, Fax: 079-232-56430. 

3 Proposals must remain valid 180 days after the submission date 

4 Clarifications may be requested not later than 3 days before the submission date. 

5 5 Proposals shall be submitted in the following language:- English 

6 The format of the Technical Proposal to be submitted: As per the Annexure 2 

7 Please indicate [√] against the cluster for which the Hospital is Bidding (main 

speciality); 

1 Burns 

2 Cardiology 

3 Cardiothoracic Surgery 

4 Cardiovascular Surgery 

5 Genito Urinary Surgery 

6 Neuro Surgery 

7 Paediatric Surgeries 

8 Poly Trauma 

9 Medical Oncology 

10 Radiation Oncology 

11 Surgical Oncology 

12 Combined Oncology 

Note: The benefit packages should includes the follow up package charges 

8 Attach signed copy of Annexure-14 

9 Attach filled and signed copy of Annexure-24 

10 Attach filled and signed copy of Annexure-25 

11 Ensure that documents mentioned in Annexure-31 are attached with technical Bid. 


ANNEXURE - 2 

DETAILS OF THE TECHNICAL PROPOSAL 

Application for empanelment of private health care organisation under 

Mukhyamantri Amrutum (MA) Yojana state of Gujarat 

Application Form & Self Assessment Guide- Gujarat 

1. Name of the Health Care Organization:____________________________ 

2. Address:_____________________________________________________________ 

3. Ownership:______________________________________________________________ 

4. Year in which Established:________________________________________ 

5. Contact person(s):(Please indicate [√] with whom correspondence to be 

made) 

 

 

Chief Executive Officer: (or equivalent) 

Mr./Ms./Dr.___________________________________________________________ 

Designation: __________________________________________________________ 

Tel: ___________________________ Mobile: _______________________________ 

Fax: _________________________________________________________________ 

E-mail: _______________________________________________________________ 

Empanelment Coordinator (if different from:5 above) 

Mr./Ms./Dr.___________________________________________________________ 

Designation: __________________________________________________________ 

Tel: ___________________________ Mobile: _______________________________ 

Fax: _________________________________________________________________ 

E-mail: _______________________________________________________________ 

6. Is the Health Care Organisation registered with Gujarat Pollution 

Control Board:________________ 

7. Number of Inpatient Beds: (number currently in operation) 

(Please exclude emergency, day-care, recovery room beds 

etc.)_______________________________________________________ 


8. OPD & IPD data (Last three years) including Day Care cases: 

OPD Data (Last three years) 

Period 

Number of Patients Admitted 

IPD DATA (Last three years) 

Period 

Number of Patients Admitted 

9. Scope of Empanelment (Clinical services being provided by the 

Hospital). Application is made as a (strike out which is not applicable). 

Type of Hospital; 

a. Type-1: Multi Specialty (General Purpose Hospital) 

a) Having more than 100 beds 

b) Having more than 75 beds but less than or equal to 100 beds 

c) Having more than 50 beds but less than or equal to 75 beds 

d) Having more than 25 beds but less than or equal to 50 beds 

b. Type-2: Single Super specialty Hospital (Indicate specialty from list 

below) 

a) Having more than 50 beds 

b) Having more than 25 beds but less than or equal to 50 beds 

10 Infrastructure Conditions: 

The Hospital should comply with the following criteria at least under 

once specialty. Further if the Hospital is Multi-Specialty and fulfils the 

criteria under various specialities, then Hospital shall provide its 

services under all specialities empanelled under the Scheme. 


11. Functional Services available with the bidder (Please tick as per the 

availability): 

A. Surgical Specialties Please 

tick 

mark 

1 General Surgery 

1.1 Qualified General Surgeon with post graduate degree in General 

Surgery 

1.2 Well Equipped theatre facility with trained staff 

1.3 Post-op with Ventilator Support 

1.4 SICU Facility 

1.5 Availability of support speciality of General Medicine, Pediatrics 

1.6 The surgeon should have performed at least 100 cases 

1.7 For Laparoscopic Surgeries 

1.8 Surgeon having requisite training and having performed at least 100 

procedures for laparoscopic surgery (documentary evidence to be 

produced) 

2 Orthopedic Surgery 

2.1 Qualified Orthopedic Surgeon 

2.2 Well equipped theatre with C-Arm facility 

2.3 Trained paramedics 

2.4 Well equipped Post- op facility with ventilator Support 

2.5 Round the clock lab support with CT, MRI 

3 Gynecology and Obstetrics 

3.1 Qualified Gynecologist 

3.2 Expertise trained in laparoscopic procedure with minimum 100 

performances 

3.3 Well equipped theatre 

3.4 Post-op Ventilator & Pediatric reconstruction facility Support 

3.5 Support services of Pediatrician 

4 Opthalmology 

4.1 Qualified Optholomologist, trained Vitreo Renal and Corneal surgeon 

4.2 Optometry facility 

4.3 Well equipped theatre facility 

5 ENT 

5.1 Qualified ENT surgeon 


5.3 Post-op Ventilator Support 

5.4 Audiology support, furnish the audiologist name, qualification and 

infrastructure available along with photograph of the equipment. 

6 Cardio-thoracic surgery 

6.1 CT Surgeon 


6.2 CT theatre facility 

6.3 Cathlab 

6.4 Cardiologist support 

6.5 Post-op with ventilator support 

6.7 ICCU 

6.8 Other cardiac infrastructure 

7 Plastic Surgery 

7.1 Qualified Plastic Surgeon with Mch in plastic surgery or other 

equivalent degree recognised by MCI 

7.2 Well Equipped Theatre 

7.3 SICU 

7.4 Post-op with Ventilator support 

7.5 Trained Paramedics 

7.6 Post-op rehab/Physiotherapy support 

8 Neurosurgery 

8.1 Qualified Neuro-Surgeon (M.Ch Neurosurgery/DNB Neurosurgery) 

8.2 Well Equipped Theatre with qualified paramedical staff, C-Arm, 

Microscope, neurosurgery compatible OT table with head holding 

frame (horse shoe, Mayfield /sugita or equivalent frame). 

8.3 Neuro ICU facilitywith minimum 6 beds 


8.5 Step down ICU facility 

8.6 Facilitation for round the clock MRI, CT and other support biochemical 

investigations 

9 Urology 

9.1 Qualified urologist 

9.2 Well equipped theatre with C-ARM 

9.3 Endoscopic investigation support 


9.5 Esw lithotripsy equipment 

10 Pediatric Surgery 

10.1 Qualified pediatric surgeon 


10.3 Pediatric and Neonatal ICU support 

10.4 Post –op with ventilator and pediatric resuscitator facility 

10.5 Support services of paediatrician 

11 Surgical Gastroenterology 

11.1 Qualified Surgical Gastroenterologist 

11.2 Well Equipped Theatre 

11.3 Endoscope equipment 


11.5 The Hospital must have done at least 100 Endoscopic Surgeries 


11.6 SICU 

12 Burns Unit 

12.1 Qualified Plastic Surgeon with Mch in plastic surgery or other 

equivalent degree recognised by MCI 

12.2 Isolation ward having monitor, defibrillator, central oxygen line and all 

OT equipment. 

12.3 No touch method of wound dressing 

12.4 Support of General Surgeon 

B. Medical Specialties 

1 General Medicine 

1.1 Qualified General Physician with post graduate degree in General 

Medicine or equal 

1.2 AMC with Ventilator support 

2 Pediatrics 

2.1 Neo-natal services: 

1.1 Neonatal Surgical ICU- Infrastructure: 

1.1.1 Minimum 10 beds (thermo controlled overhead radiant warmer with 

inbuilt light and suction) of level III NICU. 

1.1.2 NICU should be divided into 2 portions, one for clean babies and other 

for septic babies. 

1.1.3 Minimum floor space of 60 sq.ft / neonate & total area three times of 

the area allotted for beds. 

1.1.4 Each cot equipped with –Oxygen point, Compressed air point, 

Vacuum point, 4-6 Electric points, Monitors, Infusion pump, Suction 

machine. 

1.1.5 Central air conditioning with min. six changes of room air per hour 

with air filters. Two outside air changes. 

1.1.6 Temp. (72-78 o F) & humidity(30-60%) control 

1.1.7 Illumination with bright cool white fluorescent light (1-60 foot candles) 

24 X 7 with diurnal variation 

1.1.8 Sound proof 

1.1.9 NICU should be Equipped with Ventilators, Phototherapy Units, 

Transport incubators, Nebulizer, Pulse oxymeter, Multi-para-monitors, 

Syringe pumps, Infusion pumps, Resuscitation trolley. 

Availability of mother rooms and feeding area. 

Availability of radiological services(including IITV), Laboratory services 

and Blood bank 

1.2 Neonatal Surgical ICU- Manpower: 

1.2.1 NICU should be under the charge of accredited Paediatrician 

adequately trained in neonatal intensive care. 

1.2.2 Round the clock resident doctor/ paediatrician 24X7 


1.2.3 On call Paediatric Surgeon 24X 7. 

1.2.4 1:1 to 1:1.5 is required ratio of qualified nursing staff to neonate. 

At least 50% of on duty nursing staff should have a proper training in 

neonatal care. 

1.3 Neonatal Surgical PICU- Infrastructure: 

1.3.1 Minimum 5 beds of PICU well equipped with Central Oxygen supply, 

Ventilator, Defibrillator, Monitors, Resuscitation trolley, Pulse 

oxymeters, Infusion pump, Suction machine. 

1.4 Neonatal Surgical PICU- Manpower: 

1.4.1 1:1 to 1.5 qualified nurse to patient ratio 

1.4.2 Round the clock availability of duty doctor 

1.4.3 On call paediatric surgeon 

1.5 Neonatal General Ward 

1.5.1 Minimum 5 bedded general ward with min. space of 5 ft between 2 

beds 

1.5.2 Availability of qualified nursing staff and duty doctor 

1.6 Neonatal Operation Theater 

1.6.1 In Hospital premises only 

1.6.2 Well equipped Operation Theater with high quality anesthesia trolley 

1.6.3 Multipara monitors 

1.6.4 Infusion and syringe pumps 

1.6.5 Heating mattresses 

1.6.6 Proper OT table and shadow less OT lights 

1.6.7 Good quality electrocautry with mono and bipolar wires 

1.6.8 Central supply of gases 

1.6.9 Suction apparatus 

1.6.10 Pediatric instrument set with autoclave facilities 24*7 

1.6.11 OT fumigation facilities 

3 Cardiology 

3.1 Qualified Cardiologist with DM or Equivalent Degree 

3.2 ICU Facility with cardiac monitoring and ventilator support 

3.3 Hospital should facilitate Round the clock cardiologist services 

3.4 Availability of support speciality of General Physician, & Pediatrician 

3.5 Cardiac Intervention and Procedures 

3.6 Qualified Cardiologist with experience in interventions and procedures 

3.7 Fully equipped Cathlab Unit with qualified and trained Pediatrician 

3.8 Must have Backup CT Surgery Unit to perform Cardiac Surgeries 

3.9 The Hospital should have done at least 100 interventions 

4 Nephrology 

4.1 Qualified Nephrologists with DM or Equivalent Degree 

4.2 Haemodialysis facility 

4.3 AMC and physician Support 


5 Medical-Gatro Enterology 

5.1 Qualified Gastro Enterologist with DM or Equivalent Degree 

5.2 Endoscopy facility 

5.3 AMC and Physician Support 

5.4 Centre Must have done at least 100 Endoscopic Procedures 

6 Endocrinology 

6.1 Qualified Endocrinologist with DM or Equivalent Degree 

6.2 AMC with ventilator and Physician Support 

7 Neurology 

7.1 Qualified Neurologist with DM or Equivalent Degree 

7.2 EEG, ENMG, Angio-CT facility for Neurological study 

7.3 Neuro ICU Facility with ventilator support 

7.4 Physician Support 

8 Dermatology 

8.1 Qualified Dermatologist with MD or Equivalent Degree 

8.2 AMC and physician support 

9 Pulmonology 

9.1 Qualified Pulmonologist 

9.2 RICU facility 

9.3 Spirometer and Bronchoscopy facility 

9.4 Physician Support 

10 Rheumatology 

10.1 Qualified Rheumatologist 

10.2 MICU facility 

10.3 Physician and Orthopedic Support 

10.4 Physiotherapy Support 

C. Combined Services For Cancer Therapy 

11 Cancer 

11.1 Services of qualified Medical Oncologist 

11.2 Services of qualified Surgical Oncologist 

11.3 Services of qualified Radiation Oncologist 

11.4 Fully equipped Radiotherapy Unit 

11.5 SICU 


12. Details of Specialties Available/ Clinical Services provided by the 

Hospital: 

Sr. 

No 

Clinical Service Service 

Provide 

Total 

Number 

Beds 

availabl 

Beds 

availabl 

Beds 

availabl 

Comment 

s 

. 

d of Beds e in e in e in (during 

(Yes/ 

No) 

Availabl 

e 

ICU Post Op 

facility 

step 

down 

ICU 

onsite 

verificatio 

n ) 

1 Cardiology 

2 Cardiothoracic 

Surgery 

3 Coronary Care 

Unit 

4 Day Care 

Treatment 

Endoscopy 

(Diagnostic & 

Therapeutic) 

5 Dermatology 

6 Dentistry & 

Oral Surgery 

7 Dialysis 

8 Emergency 

Medicine & 

Surgery 

9 Ear Nose and 

Throat 

10 Fertility 

Regulation 

11 Gastroenterolo 

gy 

12 General 

Medicine 

13 General 

Surgery 

14 Gynecology 

15 Intensive Care 

Unit adult 


Unit pediatric 


Unit neonatal 


18 Laser 

treatment 

19 Nephrology 

20 Neurology 


22 Nuclear 

Medicine 

23 Obstetrics 

24 Oncology 

1.Medical 

Oncology 

2.Radiation 

Oncology 

3.Surgical 

Oncology 

25 Ophthalmology 

26 Orthopedic 

Surgery 

27 Pediatric 

Surgery 

28 Plastic & 

Cosmetic 

Surgery 

29 Physiotherapy 

& 

Rehabilitation 

30 Medicine 

31 Respiratory 

Medicine 

32 Surgical ICU 

33 Transplantatio 

n Services 

34 Day care 

Treatment 

Bronchoscopy 


36 Gastrointestina 

l (GI) Surgery 

37 Genito Urinary 

Surgery 

38 Infectious 

Diseases 


39 Oral Surgery 

40 Palliative Care 

41 Prosthesis 

42 Polytrauma 

43 Pulmonology 

44 Urology 


46 Burns Unit 

13. Specialty wise infrastructure available: 

Sr Clinical Cases Overall 

. Service handled in % of 

No 

last two occupan 

. 

years cy 

201 201 

0-11 1-12 

Anestheti 

st round 

the clock 

[Yes/No] 

OT 

facilit 

y 

Sterili 

ty 

Unit 

Commen 

ts 

(during 

onsite 

verificati 

on ) 

1 Cardiology 

2 Cardiothoraci 

c Surgery 

3 Coronary 

Care Unit 


Throat 

5 Gastroenterol 

ogy 

6 General 

Medicine 

7 General 

Surgery 

8 Laser 

treatment 

9 Nephrology 

10 Neurology 


12 Nuclear 

Medicine 

13 OBG 

14 Medical 

Oncology 

15 Radiation 


Oncology 

16 Surgical 

Oncology 

17 Ophthalmolog 

y 

18 Orthopedic 

Surgery 

19 Pediatric 

Surgery 

20 Plastic & 

Cosmetic 

Surgery 


Medicine 

22 Transplantati 

on Services 


24 Gastrointesti 

nal (GI) 

Surgery 

25 Genito 

Urinary 

Surgery 

26 Infectious 

Diseases 


28 Polytrauma 


30 Urology 


32 Burns Unit 

Note: 

1. Please furnish the separate list mentioning name of the anesthetists, 

registration no., qualification, no. of years of experience, university name 

and mobile no. 

2. Further furnish the photograph (post card sized duly attested by the 

authorized signatory with seal and signature) of the equipments available in 

OT along with equipment make details. 


14. Specialists Information: Note: Provide information only about cases 

handled in your Hospital. 

Sr. 

No 

Clinical Service 

Qualificati 

on 

Reg. 

no. 

Year 

of 

No. 

cases 

of 

. 

Exp. 

handled 

1 Cardiology 

2 Cardiothoracic 

Surgery 

3 Coronary Care 

Unit 

4 Day Care 

Treatment 

Endoscopy 

(Diagnostic 

&Therapeutic) 

5 Dermatology 

6 Dentistry & Oral 

Surgery 

7 Dialysis 

8 Emergency 

Medicine & 

Surgery 


Throat 

10 Fertility 

Regulation 

11 Gastroenterology 

12 General Medicine 

13 General Surgery 

14 Gynecology 


Unit adult 


Unit pediatric 


Unit neonatal 

18 Laser treatment 

19 Nephrology 

20 Neurology 

Name of 

the 

speciali 

st 

Full 

time/ 

on 

call 

Comment 

s 

(during 

onsite 

verificatio 

n ) 



22 Nuclear Medicine 

23 Obstetrics 

24 Oncology 

1.Medical 

Oncology 

2.Radiation 

Oncology 

3.Surgical 

Oncology 

25 Ophthalmology 

26 Orthopedic 

Surgery 

27 Pediatric Surgery 

28 Plastic & 

Cosmetic Surgery 

29 Physiotherapy & 

Rehabilitation 

30 Medicine 


Medicine 

32 Surgical ICU 

33 Transplantation 

Services 

34 Day care 

Treatment 

Bronchoscopy 


36 Gastrointestinal 

(GI) Surgery 

37 Genito Urinary 

Surgery 

38 Infectious 

Diseases 


40 Palliative Care 

41 Prosthesis 

42 Polytrauma 


44 Urology 


46 Burns Unit 


15. Diagnostic Services: 

A. Diagnostic Service: 

Sr. Diagnostic Service 

No. 

1 Diagnostic Imaging: 

2 CT Scan 

3 DSA Lab 

4 Gamma Camera 

5 MRI Scan 

6 PET Scan 

7 Ultrasound 

8 X-Ray- conventional 

9 X-Ray- digital 

17 ECHO 

18 ECG 

19 Others 

In 

House 

[Yes/No] 

Out 

Sourced 

[Yes/No] 

Comments 

(during onsite 

verification ) 

B. Laboratory Services: 

Sr. Laboratory Services 

No. 

1 Clinical Bio-chemistry 

2 Clinical Immunology 

3 Clinical Microbiology & Serology 

4 Clinical Pathology 

5 Molecular Diagnostics 

6 Blood Transfusion services 

7 Blood Bank 

8 Genetics 

9 Cytopathology 

10 Histopathology 

11 Others 

In 

House 

[Yes/No] 

Out 

Sourced 

[Yes/No] 

Comments 



[Please enclose photographs of basic pathological, Biochemical, Microbiology & 

Serology and Hematology investigations] 


[Please enclose photographs of USG Scan, ECG, ECHO and X-Ray with make 

details] 

[For outsourced diagnostic facilities and ambulance service furnish the 

affidavit] 

16. Pharmacy 

Pharmacy available round the 

clock 

17. Professions allied to Medicine 

1 Dietetics 

2 Physiotherapy 

3 Occupational Therapy 

4 Speech and Language 

Therapy 

5 Ambulance Service 

18. List Inpatient Care Units/ Wards and the Number of each Unit/ 

Ward. 

Sr. Name of Unit/ Ward Number Numb Floor/ Comments 

No 

of Wards er of Location (during 

. 

Beds 

onsite 


1 Private Wards (Single 

occupancy) 

2 Semi Private Wards (2-3 

patients occupancy)- AC 

3 Semi Private Wards (2-3 

patients occupancy)- non 

AC 

4 General Wards(4-10 

patients occupancy) AC 

5 General Wards(4-10 

patients occupancy) non AC 

6 ICU 

7 NICU 


8 PICU 

9 ITU 

10 HDU 

11 Any others 

19. Non clinical and Administrative Departments (tick any one) 

Sr. 

No. 

Support service In 

House 

Out 

sourced 

1 Catering 

2 Cleaning services 

3 General 

Administration 

4 Medical Records 

5 Keeping 

6 Laundry 

7 Pharmacy 

Services 

8 Management of 

clinical waste 

9 Management of 

nonclinical 

Waste 

10 Mortuary 

Services 

11 Security Services 

12 Technical 

Department and 

Equipment 

Management 

12 Other, please 

specify 

Out sourced to 

(name of the 

agency/company) 

Comments 



20. Staff Information (attach a separate sheet with details) 

Sr. 

No. 

Group 

Numb 

er 

Comments 



1 Managerial 

2 Doctors 


2.1 Resident Doctors- regular appointment 

2.1 Resident Doctors contractual 

2.3 Resident Doctors- part time 

2.4 Consultants (specialty wise) 

a) Full Time 5 

b) Part Time 

3 Nurses 

4 Technicians 

5 Paramedical 

6 Others 

21. For Indoor Services: Essential Infrastructure Assessment Checklist. 

Sr. 

No. 

Paramet 

er 

Objective Element Yes No Comments 

(during 

onsite 


1 Physical 

facility 

2 Equipme 

nts 

More than 

a. 100 bedded for multi specialty 

b. 25 to 100 beds 

c. 25 bedded for single specialty,10 

for day care 

Provision of 24 X 7 emergency 

Services 

Provision of 

a. Private Room 

b. Semi Private room 

c. General Ward 

Provision of round the clock 

potable water and electricity 

supply with back up facility 

Provision of toilets and wash 

rooms. 

Adequately equipped emergency 

room with drugs, equipment, 

personnel 

All patient areas equipped with 

drugs, equipment, personnel 

Ventilator, cardiac monitor, 


3 Imaging 

& 

laborato 

ry 

services 

4 Certified 

copies of 

license 

(*as 

applicab 

le) 

5 Certified 

copies of 

Licenses 

(*As 

applicab 

le) 

defibrillator, pulse oximeter, 

Central AC in OT 

ICU/ITU 

Equipment & medicines available 

for resuscitation of patient & CPR 

in all patient areas 

Equipment for fire safety available 

as required 

CTG & Radiant warmer in labour 

room 

In house or Formal tie up with 

large empanelled laboratory, BARC 

approved imaging centre 

Trade License Building permit* 

PNDT License* 

AERB approvals and BARC 

Radiation Protection Certificate for 

imaging equipment* 

NOC from Fire Dept 

Explosives License for storage of 

Medical gases 

License for lifts and elevators* 

Drugs & Cosmetics License 

Narcotic & Psychotic 

Substances License 

Blood Bank License* 

Excise permit to store spirit 

License under Bio Medical Waste 

Management & Handling Rules 

NOC under Pollution Control Act 

Vehicle Registration Certificates 

Building Plan 

Audited Balance Sheet for last 3 

years with profit and loss account 

PAN Card 

Income Tax clearance 

Sales Tax Clearance 


Partnership Deed 

Accreditation Certificate 

Certificates of empanelment under 

any other State/Central Govt. 

Health Schemes. 

22. Any punitive measures taken against the Hospital / Diagnostic Labs or 

major partners within last five years by any statutory authority. If yes, 

please give details. 

23. Whether the institution is empanelled under any other State/Central 

Government‟s Health Scheme? Yes / No 

If Yes then Notification No. & Date of Empanelment under CGHS/ RSBY/ 

Chiranjivi Yojana/Balsakha Yojana/School Health Programme (duly 

supported by the documentary proof in this 

regard):______________________________________________________ 

24. Litigation, if any:______________________________________________________ 

25. Any punitive measures taken against the HCO or major partners within 

last five years by any statutory authority. If yes, please give details. 

I, ____________________, son/ daughter of________________________________ 

of_______________________________________do hereby affirm that the facts 

given above are true and if any discrepancy is detected at a later date, the 

application form/ empanelment of my Hospital may be rejected without any 

further reference to me or my organisation. 

Authorised Signatory 

Name: _________________________ 

Designation:____________________ 


RECOMMENDATION OF THE INSPECTION COMMITTEE: 

 

 

Whether the Hospital has sufficient facilities to cater the services to MA 

Beneficiaries (In Yes or No only): 

Whether the Hospital is eligible for empanelment under MA Yojana (In Yes 

or No only): 

Other recommendations of the Committee;___________________________________ 

______________________________________________________________________________ 

SIGNATURE, NAME & DESIGNATION OF COMMITTEE MEMBERS : 

1____________________________________________________________________________ 

2____________________________________________________________________________ 

3……________________________________________________________________________ 


EVALUATION OF TECHNICAL BID PROCESS 

ANNEXURE-3 

Technical Evaluation (Total Marks -100) 

Based on the submitted proposals onsite evaluation by an Inspection team 

constituted by State Nodal Cell will evaluate the technical bid on following 

parameters: 

Criteria, Sub- Criteria and point system for evaluation of full Points 

Technical Proposal 

A. Common points for all Specialty Hospitals: 

1. Type of Hospital 

Type-1: Multi Specialty (General Purpose Hospital) 

e) Having more than 100 beds 

f) Having more than 75 beds but less than or equal to 100 

beds 

g) Having more than 50 beds but less than or equal to 75 beds 

h) Having more than 25 beds but less than or equal to 50 beds 

20 

20 

15 

10 

5 

Type-2: Single Super specialty Hospital (Indicate specialty from 

list below) 

c) Having more than 50 beds 

d) Having more than 25 beds but less than or equal to 50 beds 

2. General Ward: 

1 Nurse: 10 patients with 24hrs services in 3 shifts in a day 

1duty doctor: 10 patients with 24hrs service in 3 shifts in a 

day 

The space between two beds should be at least 5 feet 

The provider should have separate male and female wards 

3. ICU Beds: 

The Hospital should have at least 3 beds. 

1 Nurse: 1 patient with 24hrs service in 3 shifts. 

1 duty doctor: 4 to 5 patients with 24hrs service in 3 shifts. 

The ICU ward should be equipped with ventilators, 

defibrillators, monitors, central oxygen line, suction 

apparatus and pulse oxymeter. 

4. The Step down ICU ward: 

The Hospital should have at least 2 beds 

1 Nurse: 3 patients with 24hrs service in 3 shifts. 

20 

10 

8 

2 

2 

2 

2 

20 

2 

2 

2 

14 

8 

1 

1 


1 duty doctor: 4 to 5 patients with 24 hrs services in 3 shifts 

The Step down ICU ward should be equipped with 



5. The post operative ward: 

The Hospital should have at least 2 beds 

1 Nurse: 1 patient with 24hrs service in 3 shifts. 

1 duty doctor: 4 to 5 patients with 24 hrs services in 3 shifts. 

The post operative ward should be equipped with ventilators, 



6. IPD data (Last three years) including Day Care cases: 

Number of Patients Admitted: 

Total patients more than 2,000 but less than 10,000 patients 

Total patients above 10,001 patients 

7. Whether the institution is empanelled under any other 

State/Central Government‟s Health Scheme; 

7.1 Rashtriya Swasthya Bima Yojana (RSBY) 

7.2 Chiranjivi Yojana 

7.3 CGHS 

7.4 Balsakha Yojana 

7.5 School Health programme 

8. Whether the institution is using Software base HMIS in 

Hospital; 

Total of 1 to 8 (out of the total 100 marks) 

1 

5 

9 

1 

1 

1 

6 

20 

10 

20 

10 

2 

2 

2 

2 

2 

5 

Note: 

 

Out of the total 100 marks, minimum 70 marks are required for the 

inspection team to visit the Hospital. The bidders who do not fulfill 

these criteria, will be disqualified immediately and their bids will not 

be considered. 

 

Only the recommendation of the Inspection Team i.e. in „YES‟ will 

qualify the technical bid. 


ANNEXURE- 4 

SPECIFICATIONS FOR THE HARDWARE AND SOFTWARE FOR 

EMPANELLED HOSPITALS 

HARDWARE: 

One Bar Code reader: 

ONE Biometric finger print recognition device with following configuration: 

5v DC 500mA (Supplied via USB port) 

Operating temperature range: 0c to 40c 

Operating humidity range: 10% to 80% 

Compliance: FCC Home or Office Use, CE and C-Tick 

500 dpi optical fingerprint scanner (22 x 24mm) 

USB 1.1 Interface 

Drivers for the device should be available on Windows or Linux platform 

High quality computer based fingerprint capture (enrolment) 

Capable of converting Fingerprint image to RBI approved ISO 19794 

template. 

SOFTWARE: 

Transaction software for Hospitals approved by State Nodal Cell for MA 

Yojana 

MAINTENANCE SUPPORT: 

ONE year warranty for all hardware devices supplied 

Free Service Calls for Software maintenance for 1 years 

Unlimited Telephonic Support 


FINANCIAL BID 

ANNEXURE-5 

Name of Bidder Agency/Organization with permanent address: _ _ _ _ _ _ _ _ _ _ 

FINANCIAL BID 

These package rates will include bed charges (general ward), Nursing and boarding charges, Surgeons, 

Anesthetists, Medical Practitioner, Consultants fees, Anesthesia, Blood, Oxygen, O.T. Charges, Cost of 

Surgical Appliances, Medicines and Drugs, Cost of Prosthetic Devices (FDCA approved only, implants, X-Ray 

and Diagnostic Tests, food to patient etc. Expenses incurred for diagnostic test and medicines up to 1 day 

before the admission of the patient and cost of diagnostic test and medicine up to 10 days of the discharge 

from the Hospital for the same ailment / surgery and transport expenses will also be the part of package. The 

package should cover the entire cost of patient from date of reporting to his discharge from Hospital, making the 

transaction truly cashless to the patient. 

In case of any patient‟s death during his/her stay at the network Hospital (only after any surgical 

intervention). The Hospital will take pre authorization from the ISA for the hearse reimbursement. The 

reimbursement will be as per the MA rates and based on the shortest distance from the network Hospital to 

the final destination. 

Instructions for financial Bidding: For the purpose of this RFP the packages have been divided into specialty 

wise clusters. The package rates must include the follow up package charges also. The bidders are also 

required to mention the follow-up package charges considered under the Benefit package separately. The 

bidders are not allowed to add or delete any of the packages/follow up packages from the financial bid. The 

documents which are necessary for the claim processing along with other documents are mentioned under 

pre and post operative Investigation. The packages and their distribution are as follows: 


GOVERNMENT OF GUJARAT 

MUKHYAMANTRI AMRUTUM (MA) YOJANA 

Benefit Packages 

Cluster 1- BURNS 

Main Specialty- Burns 

Sr. 

No. 

Subspecialty 

Procedure Name 

Package 

Rates (in 

Rs.) 

Pre-operative 

Investigation 

Post-operative 

Investigation 

Follow 

up 

1.1 Burns 

20% burns or scalds/burns over face 

(with or without grafting) 

Clinical 

Photograph 

Clinical 

Photograph 

3 

1.2 Burns Up to 30% (with grafting) 

Clinical 

Photograph 

Clinical 

Photograph 

3 

1.3 Burns 

upto-40% with Scalds (Conservative/ 

without grafting) 

Clinical 

Photograph 

Clinical 

Photograph 

3 

1.4 Burns upto-40% Mixed Burns (with grafting) 

Clinical 

Photograph 

Clinical 

Photograph 

3 

1.5 Burns upto-50% with Scalds (Conservative) 

Clinical 

Photograph 

Clinical 

Photograph 

3 

1.6 Burns 

upto-50% Mixed Burns (with surgery 

grafting) 

Clinical 

Photograph 

Clinical 

Photograph 

3 

1.7 Burns upto-60% with Scalds (Conservative) 

Clinical 

Photograph 

Clinical 

Photograph 

3 

1.8 Burns Up to-60% Mixed Burns (with Surgeries) 

Clinical 

Photograph 

Clinical 

Photograph 

3 

1.9 Burns 

Above 60% Mixed Burns (with 

Surgeries) 

Clinical 

Photograph 

Clinical 

Photograph 

3 

1.10 Burns 

Post Burn Contracture surgeries for 

Functional Improvement(Package 

including splints, pressure garments 

and physiotherapy), Mild 

Clinical 

Photograph 

Clinical 

Photograph 

3 


1.11 Burns 




and physiotherapy), Moderate 


1.12 Burns 



and physiotherapy), Severe 

Total of cluster 1 (1 to 12) in Rs. 

Clinical 

Photograph 

Clinical 

Photograph 

Clinical 

Photograph 

Clinical 

Photograph 

3 

3 

The above package rate should include minimum 3 follow up at an interval of 2 months from the patients 

discharge date. 

Note:- 

The specifications for pressure garments to be used are as below; 

1. The fabric should be intricately woven meshwork of spandex, interwoven with cotton yarn 

2. The meshwork should have a fine uniform network of wefts and wharfs , finely knit , to provide 

elasticity 

3. Fabric should have a recoil strength of 15%, and provide elasticity. 

4. Should be a breathable fabric 

5. The terminal ends be flat locked to prevent the elastic from slipping 

6. The designs should be to suite the body contour 

7. The fabric should be washable 

8. The seams and joints should be soft ,to prevent biting into the folds 


Benefits and Quality Parameters of Soft Tissue Expanders 

Tissue expansion is a mechanical process that increases the surface area of local tissue, representing a new alternative in 

plastic surgery. Tissue expanders is widely used in case of reconstruction of post burns, extreme birth defects and trauma 

wherein the available skin is limited and reconstruction requires expansion of the available skin in the vicinity. The 

expanders are available in various sizes and shape depending upon the need. Ensuring successful outcomes for patients 

is extremely important. 

A substandard tissue expander for patients can lead to complications such as infection, product failure, implant exposure, 

trauma, lost port, leaking, and the compromise of adjacent structures. Long-term complications essentially consist of 

persistent oedema, widening of scars, loss of sensitivity, and occasionally bone deformities induced by compression. These 

are not only a burden on the patient but can also become an added cost for insurer in terms of future claims and a 

productivity loss for the state. Hence it is important to identify the critical factors for successful patient outcome and 

design insurance coverage criteria which will ensure only those products are used which will provide optimal outcomes. 

Therefore, it is very important to use tissue expanders of the highest safety standards. 

These factors can be grouped into two categories: 

1. Quality Certification 

2. Design of Tissue Expanders 

Factors affecting 

# 

Recommendations 

successful outcomes 

1 Quality Certification Tissue expanders should be US FDA approved and if it is a CE marked products should 

have certificates from other notified conforments assessment bodies such as BSI Group. 

This ensures that they are of the highest standard. 

2 Design of Tissue 

Expanders 

a Safety and strength of 

Dacron Base, Dimethyl 

Shell and Injection Port 

b Leakage Prevention 

Dacron Base should be designed to ensure unidirectional expansion of the tissue 

expanders. The Shell of tissue expanders should be strong enough to resist over 

expansion. This can be achieved through effective dipping of expanders in medical grade 

silicon at the time of manufacturing. The injection port should be strong enough to 

withstand frequent incisions. 

Design should ensure bottom base loading of silicon so that the expander expands 

equally. This ensures prevention from leakage. 


Sr. 

No. 

Subspecialty 

Cluster 1A- BURNS FOLLOW UP PACKAGES 

(Mention Follow-up Packages as included in above package) 

Follow 


up 

20% burns or scalds/burns over face (with or 

without grafting) 3 

1A.1 Burns 

1A.2 Burns Up to 30% (with grafting) 3 

upto-40% with Scalds (Conservative/ without 

1A.3 Burns grafting) 3 

1A.4 Burns upto-40% Mixed Burns (with grafting) 3 

1A.5 Burns upto-50% with Scalds (Conservative) 3 

1A.6 Burns upto-50% Mixed Burns (with surgery grafting) 3 

1A.7 Burns upto-60% with Scalds (Conservative) 3 

1A.8 Burns Up to-60% Mixed Burns (with Surgeries) 3 

1A.9 Burns Above 60% Mixed Burns (with Surgeries) 3 

1A.10 Burns 

1A.11 Burns 

1A.12 Burns 

Post Burn Contracture surgeries for Functional 

Improvement(Package including splints, 

pressure garments and physiotherapy), Mild 3 



pressure garments and physiotherapy), 

Moderate 3 



pressure garments and physiotherapy), Severe 3 

Rates per 

Follow up 

(in Rs.) 

Total Follow up 

package rate (as 

included in above 

package) in Rs. 


Cluster- 2 CARDIOLOGY 

Main Specialty- Cardiology 

Package 

Sl. 

No. Sub-specialty Procedure Name 

Rates (in 

Rs.) 

Pre-operative 

Investigation 


Investigation 

CAG (Coronary 

2.1 Cardiology Angiography) 2D ECHO - 

Peripheral/ Renal 

2.2 Cardiology Angiography 2D ECHO - 

Follow 

up 

2.3 Cardiology 

Coronary Ballon 

Angioplasty CAG - 5 visits 

2.4 Cardiology Cath with Oxymetry 2D ECHO - 

2.5 Cardiology Cath without Oxymetry 2D ECHO - 

2.6 Cardiology Check Angiography 2D ECHO - 


Coronary Angiography + 

Peripheral/ Renal 

Angiography 2D ECHO - 


Renal/ Carotid Plasty – 

Unilateral CAG - 5 visits 


Renal/ Carotid Plasty – 

Bilateral PAG - 5 visits 

2.10 Cardiology Peripheral Ballon Plasty PAG - 5 visits 

2.11 Cardiology Aortic Stenting PAG - 5 visits 


Ballon Atrial Septectomy – 

BAS 2D ECHO - 

2.13 Cardiology IVC filter - 

2.14 Cardiology Bi Ventricular Pacing - CRT - 


AICD - Automatic 

Implantable Cardiac 

Defibrillator - 


Combo: AICD+Bi 

ventricular pacemaker - 







PTCA - one stent (nonmedicated) 

CAG X-Ray 5 visits 

PTCA - 2 stent (nonmedicated) 

CAG X-Ray 5 visits 

Balloon Mitral Valvotomy – 

BMV 2D ECHO 2D ECHO 

Coarctation dilatation – 

BDC 2D ECHO 2D ECHO, x-RAY 

Balloon Pulmonary 

Valvotomy – BPV 2D ECHO 2D ECHO 

Balloon Aortic Valvotomy – 

2.22 Cardiology BAV 2D ECHO 2D ECHO 

Peripheral Angioplasty 

2D ECHO , 

2.23 Cardiology withstent (non-medicated) 

ANGIOGRAM DOPPLER 5 visits 

Renal Angioplasty withstent 

2.24 Cardiology (non-medicated) ANGIOGRAM DOPPLER , X-RAY 5 visits 

Both side renal Angioplasty 

2.25 Cardiology withstent (non-medicated) ANGIOGRAM DOPPLER , X-RAY 5 visits 

2.26 Cardiology Vertebral Angioplasty ANGIOGRAM DOPPLER 5 visits 

Pacemaker Temporary Pacemaker 

2.27 Implantation implantation CAG , ECG ECHO , X-RAY 

Permanent pacemaker 

implantation (only VVI) 

including Pacemaker value CAG , ECG ECHO , X-RAY 

Pacemaker 

2.28 Implantation 

2.29 Cardiology Pericardiocentesis 2D ECHO 2D ECHO 

2.30 Device Closure PDA Device Closure 2D ECHO 2D ECHO 

2.31 Device Closure ASD Device Closure 2D ECHO 2D ECHO , X-RAY 

2.32 Device Closure VSD Device Closure 2D ECHO 2D ECHO , X-RAY 

2.33 Coil Closure PDA Coil (one) insertion 2D ECHO 2D ECHO , X-RAY 

2.34 Coil Closure PDA Multiple coil insertion 2D ECHO 2D ECHO , X-RAY 

2.35 Cardiology IVUS angiogram IVUS report 

2.36 Cardiology EP study ECG, 2D Echo Clinical Photograph 

2.37 Cardiology RF Ablation ECG, 2D Echo Clinical Photograph 


2.38 Cardiology 3D Maping + Ablation ECG, 2D Echo Clinical Photograph 


Medical treatment of Acute 

MI with Thrombolysis 

2D ECHO, 

CPKMB,CAG, ECG, 

TROPONINE-T 

2D ECHO, ECG, 

LAB 

INVESTIGATION 


Thrombolysis for peripheral 

ischemia 

ECG, 2D Echo 

2.41 Cardiology Rotablation+ PTCA CAG X-Ray 5 visits 

2.42 Cardiology Rotablation+ PTCA+ Stent CAG X-Ray 5 visits 


Cluster- 2A CARDIOLOGY FOLLOW UP PACKAGE 

(Mention Follow-up Packages included in above package) 

Rates per 

Follow up 

Sr. No Sub Specialty Procedure Name Follow up (Rs.) 

Coronary Ballon 

2A.1 Cardiology 

Angioplasty 5 

Total Follow up package 

(as included in above 


2A.2 Cardiology Cath with Oxymetry 5 


Renal/ Carotid Plasty - 

Unilateral 5 


Renal/ Carotid Plasty - 

Bilateral 5 


Peripheral Ballon 

Plasty 5 

2A.6 Cardiology Aortic Stenting 5 




PTCA - one stent (nonmedicated) 

5 

PTCA - 2 stent (nonmedicated) 

5 

Peripheral Angioplasty 

withstent (nonmedicated) 

5 




Renal Angioplasty 

withstent (nonmedicated) 

5 

Both side renal 

Angioplasty withstent 

(non-medicated) 5 

2A.12 Cardiology Vertebral Angioplasty 5 

2A.13 Cardiology Rotablation+ PTCA 5 

Rotablation+ PTCA+ 


Stent 5 

Sl. 

No. 

Subspecialty 


Cluster 3, CARDIOLOGY 

Main Specialty- Cardiothoracic Surgery 

Package 

Pre-operative 

rates (in 

Investigation 

Rs.) 


Investigation 

Follow 

up 

3.1 CABG CABG CAG Clinical Photograph 5 visits 

3.2 CABG Re DO CABG CAG Clinical Photograph 5 visits 

3.3 CABG CABG with IABP 2D ECHO , CAG Clinical Photograph 5 visits 

3.4 CABG CABG with Aneurismal repair CAG Clinical Photograph 5 visits 

3.5 CABG CABG with MV repair 2D ECHO , CAG Clinical Photograph 5 visits 

3.6 CABG 

CABG with post MI VSD 

repair 

2D ECHO , CAG Clinical Photograph 5 visits 

3.7 Valve Repair Open Mitral Valvotomy 2D ECHO 2D ECHO 5 visits 

3.8 Valve Repair Open Aortic Valvotomy 2D ECHO 2D ECHO , X-RAY 5 visits 

3.9 Valve Repair Open Pulmonary Valvotomy 2D ECHO 2D ECHO 5 visits 

3.10 Valve Repair Mitral Valve Repair 2D ECHO 2D ECHO , X-RAY 5 visits 

3.11 Valve Repair Tricuspid Valve Repair 2D ECHO 2D ECHO , X-RAY 5 visits 

3.12 Valve Repair 

Mitral Valve Repair + 

Tricuspid Valve Repair 

2D ECHO 2D ECHO , X-RAY 5 visits 

3.13 Valve Repair Aortic Valve Repair 2D ECHO 2D ECHO , X-RAY 5 visits 

3.14 

Valve 

Replacement 

Mitral Valve Replacement 2D ECHO 2D ECHO , X-RAY 5 visits 


3.15 

Valve 

Replacement 

Aortic Valve Replacement 2D ECHO 3D ECHO , X-RAY 5 visits 

3.16 

Valve 

Replacement 

Double Valve Replacement 2D ECHO 5D ECHO , X-RAY 5 visits 

3.17 

Valve 

Replacement 

Ross Procedure 2D ECHO 2D ECHO , X-RAY 5 visits 

3.18 

Congenital 

(Simple) 

ASD 2D ECHO 2D ECHO , X-RAY 5 visits 

3.19 

Congenital 

(Simple) 

VSD 2D ECHO 2D ECHO , X-RAY 5 visits 

3.20 

Congenital 

(Simple) 

AVSD/ AV Canal Defect 2D ECHO 2D ECHO , X-RAY 

3.21 

Congenital 

(Simple) 

ICR for TOF 2D ECHO 2D ECHO , X-RAY 5 visits 

3.22 

Congenital Pulmonary Valvotomy + RVOT 

2D ECHO, X-RAY, 

2D ECHO 

(Simple) 

Resection 

clinical photograph 

5 visits 

3.23 

Congenital 


AP Window 

2D ECHO 

(Simple) 


3.24 

Congenital 


Surgery for HOCM 

2D ECHO/TEE 

(Simple) 


3.25 

Congenital 


Ebsteins 

2D ECHO 

(Simple) 


3.26 

Congenital 


Fontan 

2D ECHO 

(Simple) 


3.27 

Congenital 

2D ECHO , clinical 

TAPVC 

2D ECHO 

(Complex) 

photograph 

3.28 

Congenital Pulmonary Atresia with or 

2D ECHO , X-RAY, 

2D ECHO 

(Complex) 

without VSD 


3.29 

Congenital 


TGA 

2D ECHO/Angio 

(Complex) 


3.3 

Congenital 


Arterial Switch Operation 

2D ECHO/Angio 

(Complex) 


3.31 

Congenital 

(Complex) 

ALCAPA 

3.32 Congenital Sennings 2D ECHO/Angio 2D ECHO , X-RAY, 


3.33 

3.34 

3.35 

3.36 

3.37 

3.38 

3.39 

(Complex) 

Congenital 

(Complex) 

Congenital 

(Complex) 

Congenital 

(Complex) 

Congenital 

(Complex) 

Congenital 

(Complex) 

Congenital 

(Complex) 

Congenital 

(Complex) 

3.40 Acquired 

3.41 Acquired 

3.42 

3.43 

3.44 

3.45 

3.46 

Closed 

Heart 

Procedures 

Closed 

Heart 

Procedures 

Closed 

Heart 

Procedures 

Closed 

Heart 

Procedures 

Closed 

Heart 

Procedures 

Mustards 

Pulmonary Conduit 

Truncus Arteriosus Surgery 

Root Replacement (Aortic 

Aneurysm/ Aortic Dissection) 

/ Bental Procedure 

Aortic Arch Replacement 

Aortic Aneurysm Repair using 

CPB 

Aortic Aneurysm Repair 

without using CPB 

Pulmonary Embolectomy / 

Endarterectomy 

Surgery for Cardiac Tumour/ 

LA Myxoma/ RA Myxoma 

2D ECHO 

2D ECHO 

2D ECHO 

2D ECHO 

2D ECHO 

2D ECHO 

2D ECHO 

ABG, 2D ECHO, X- 

Ray 

2D ECHO 




















Closed Mitral Valvotomy 2D ECHO 2D ECHO , X-RAY 

PDA Closure 2D ECHO 2D ECHO , X-RAY 5 visits 

Coarctation Repair 2D ECHO, CAG Doppler 

Coarctation Repair with graft 2D ECHO, CAG Doppler 

BT Shunt (inclusives of 

grafts) 

2D ECHO 

2D ECHO, x-RAY 


3.47 

3.48 

3.49 

3.50 

3.51 

3.52 

3.53 

3.54 

3.55 

3.56 

3.57 

3.58 

3.59 

3.60 

3.61 

Closed 

Heart 

Procedures 

Closed 

Heart 

Procedures 

Closed 

Heart 

Procedures 

Closed 

Heart 

Procedures 

Closed 

Heart 

Procedures 

Cardiac 

Injuries 

Cardiac 

Injuries 

Thoracic 

Surgery 

Thoracic 

Surgery 

Thoracic 

Surgery 

Thoracic 

Surgery 

Thoracic 

Surgery 

Thoracic 

Surgery 

Thoracic 

Surgery 

Thoracic 

Surgery 

Glenn Shunt 2D ECHO 2D ECHO, x-RAY 

Central Shunt 2D ECHO 2D ECHO, x-RAY 

Aortic arch Anamolies 2D ECHO 2D ECHO, x-RAY 

Pericardiectomy 2D ECHO 2D ECHO , X-RAY 

Thoracoscopic surgery CT Chest X-Ray 

Surgery without CPB CT Chest X-Ray 

Surgery with CPB CT Chest X-Ray 

Lobectomy 

Pneumonectomy 

Pleurectomy 

Decortication 

Mediastinotomy 

Pulmonary AV Fistula surgery 

Lung Cyst 

SOL mediastinum 

CT-Chest , X-RAY 





Biopsy , CT , X-RAY 



Clinical Photograph , 

X-RAY 


X-RAY 


X-RAY 


X-RAY 


X-RAY 

Biopsy , Clinical 

Photograph , X-RAY 


X-RAY 


X-RAY 


3.62 

3.63 

3.64 

3.65 

3.66 

3.67 

3.68 

3.69 

3.70 

3.71 

Thoracic 

Surgery 

Thoracic 

Surgery 

Thoracic 

Surgery 

Thoracic 

Surgery 

Thoracic 

Surgery 

Thoracic 

Surgery 

Thoracic 

Surgery 

Thoracic 

Surgery 

Thoracic 

Surgery 

Thoracic 

Surgery 

Surgical Correction of 

Bronchopleural Fistula. 

Diaphragmatic Eventeration 

Diaphragmatic Hernia 

Oesophageal Diverticula 

/Achalasia Cardia 

Diaphragmatic Injuries 

Thoracotomy, Thoraco 

Abdominal Approach 

Foreign Body Removal with 

scope 

Bronchial Repair Surgery for 

Injuries due to FB 

Gastro StudyFollowed by 

Thoracotomy & Repairs for 

Oesophageal Injury for 

Corrosive Injuries/FB 

Oesophageal tumour removal 


Barium Study, CT 

SCAN 

BArium Study, X- 

RAY, ENDOSCOPY, 

USG 

Barium Study, CT 

SCAN 



CT-Chest , 

BRONCHOSCOPY 

CT-Chest , 

BRONCHOSCOPY 

GASTROSCOPY 

ENDOSCOPY, X- 

RAY, BARIUM 

STUDY 

Biopsy , CT , 

Endoscopy , USG 



RFP FOR HOSPITAL EMPANELMENT UNDER ‘MA’ YOJANA-GUJARAT Page 104 

USG 

BIOPSY, CLINICAL 

PHOTOGRAPH 

USG 


X-RAY 


X-RAY 

ENDOSCOPY 

PICTURE 

ENDOSCOPY 

PICTURE 

ENDOSCOPY 

PICTURE 


Photograph , USG 

3.72 

Thoracic 


Oesophagectomy 

Surgery 


Thoracic 

3.73 

Surgery 


Lung Injury repair 


(Chest 

X-RAY 

Injuries) 

Thoracic 

3.74 

Surgery 


Diaphragmatic injury repair 


(Chest 

X-RAY 

Injuries) 

3.75 Thoracic Thyomectomy CT-Chest , X-RAY Clinical Photograph ,

Surgery 

(Chest 

Injuries) 


X-RAY 

Cluster 3A. CARDIOLOGY FOLLOW UP PACKAGES 


Sr. No Sub Specialty Procedure Name Follow up Rates per Follow up (Rs.) 


package (as 



3A.1 CABG CABG 5 

3A.2 CABG CABG with IABP 5 

3A.3 CABG Aneurismal repair 5 

3A.4 CABG CABG with MV repair 5 

3A.5 CHD VSD/ASD/PDA/TOF 5 

3A.6 Valve Repair Valvotomy 5 



3A.9 Valve Repair Mitral Valve repair 5 

3A.10 Valve Repair Tricuspid Valve Repair 5 

3A.11 Valve Repair Aortic Valve Repair 5 

3A.12 

Valve 

Replacement 

Replacement 5 


3A.13 

3A.14 

Valve 

Replacement 

Valve 

Replacement 

Replacement 5 

Replacement 5 

3A.15 Procedures Valvotomy 5 

3A.16 Vascular Venous 5 

3A.17 Vascular Venous 5 

Sl. 

No. 

Subspecialty 


4.1 Vascular Patch Graft Angioplasty 

4.2 Vascular 

Femoropopliteal by pass 

procedure with graft (inclu. 

Graft) 

Cluster 4, CARDIOLOGY 

Main Specialty- Cardiovascular Surgery 

Package 

Rate 

Pre-operative 

Investigation 

Regional 

angiogram 


Investigation 

Angiogram report, 

clinical 

Photograph 

Follow up 

5 visits 

ANGIO Doppler 5 visits 

4.3 Vascular Thromboembolectomy ANGIO Color Doppler 5 visits 

4.4 Vascular 

Surgery for Arterial Aneursysm - 

Distal Abdominal Aorta 

Angiogram/spi 

ral CT 

Angiogram 

Color Doppler 

5 visits 

4.5 Vascular 

Surgery for Arterial Aneursysm - 

Upper Abdominal Aorta 

Angiogram/spi 

ral CT 

Angiogram 

Color Doppler 

5 visits 

4.6 Vascular 

4.7 Vascular 

Surgery for Arterial Aneursysm – 

Vertebral 

Intrathoracic Aneurysm (without 

graft)-Aneurysm not Requiring 

Bypass Techniques 

Angiogram/spi 

ral CT 

Angiogram 

CT-Angio , 

Cath 

Color Doppler 

DOPPLER 

5 visits 

5 visits 


4.8 Vascular 

4.9 Vascular 

Intrathoracic Aneurysm (with 

graft) -Requiring Bypass 

Techniques 

Dissecting Aneurysms with CPB 

(inclu. Graft) 

CT-Angio , 

Cath 

CT-Angio , 

Cath 

DOPPLER 

DOPPLER 

5 visits 

5 visits 

4.10 Vascular 

Dissecting Aneurysms without 

CPB (incl. graft) 

CT-Angio , 

Cath 

DOPPLER 

5 visits 

4.11 Vascular 

Vascular Procedure – Major 

Vessels 

color 

Doppler/Angio 

gram 

Color Doppler 

5 visits 

4.12 Vascular 

Vascular Procedure – Minor 

Vessels 

color 

Doppler/Angio 

gram 

Color Doppler 

5 visits 

4.13 Vascular 

4.14 Vascular 

Surgery for Arterial Aneurysm 

Renal Artery 


Carotid 

Renal arterial 

Doppler,angiog 

ram 

Carotid 

Doppler 

Clinical 

Photograph 

Clinical 

Photograph 

5 visits 

5 visits 

4.15 Vascular 

Surgery for Arterial Aneursysm 

Main Arteries of the Limb 

Peripheral 

Doppler 

Clinical 

Photograph 

5 visits 

4.16 Vascular 

Operations for Acquired 

Arteriovenous Fistual 

regional 

Angiogram 

Clinical 

Photograph 

5 visits 

4.17 Vascular 

4.18 Vascular 

4.19 Vascular 

Congenital Arterio Venous 

Fistula 

Operations for Stenosis of Renal 

Arteries 

Peripheral Embolectomy without 

graft 

regional 

Angiogram 

Renal arterial 

Doppler,angiog 

ram 

Angiogram/spi 

ral CT 

Angiogram 

Clinical 

Photograph 

Clinical 

Photograph 

Color Doppler 

5 visits 

5 visits 

5 visits 


4.20 Vascular 

Aorto Billiac / Bifemoral bypass 

with Synthetic Graft 

Angiogram/spi 

ral CT 

Angiogram 

Color Doppler 

5 visits 

4.21 Vascular 

Axillo bifemoral bypass with 

Synthetic Graft 

Angiogram/spi 

ral CT 

Angiogram 

Color Doppler 

5 visits 

4.22 Vascular 

Femoro Distal Bypass with Vein 

Graft 

Angiogram/spi 

ral CT 

Angiogram 

Color Doppler 

5 visits 

4.23 Vascular 

Femoro Distal Bypass with 


Angiogram/spi 

ral CT 

Angiogram 

Color Doppler 

5 visits 

4.24 Vascular 

Axillo Brachial Bypass using 


Angiogram/spi 

ral CT 

Angiogram 

Color Doppler 

5 visits 

4.25 Vascular 

Brachio - Radial Bypass with 


Angiogram/spi 

ral CT 

Angiogram 

Color Doppler 

5 visits 

4.26 Vascular 

Excision of Carotid body Tumor 

with vascular repair 

Angiogram/spi 

ral CT 

Angiogram 

Color Doppler 

5 visits 

4.27 Vascular 

Carotid artery bypass with 


Angiogram/spi 

ral CT 

Angiogram 

Color Doppler 

5 visits 

4.28 Vascular 

Excision of Arterio Venous 

malformation – Large 

Spiral CT 

Angiogram 

/MRI 

Angiogram 

Color Doppler 

5 visits 


4.29 Vascular 


malformation – Small 

4.30 Vascular Arterial Embolectomy 

Spiral CT 

Angiogram 

/MRI 

Angiogram 

Angiogram/col 

our Doppler 

4.31 Vascular D V T - IVC Filter color Doppler 

4.32 Vascular Vascular Tumors 

4.33 Vascular 

4.34 Vascular 

4.35 Vascular 

Small Arterial Aneurysms – 

Repair 

Medium size arterial aneurysms 

– Repair 

Medium size arterial aneurysms 

with synthetic graft 

Angiogram/Spi 

ral CT 

Angiogram 

Angiogram/Spi 

ral CT 

Angiogram 

Angiogram/Spi 

ral CT 

Angiogram 

Angiogram/Spi 

ral CT 

Color Doppler 

Color 

Doppler/SBP/PVR 

Plain X-ray 

abdomen 

Color Doppler 

Color Doppler 

Color Doppler 

Color Doppler 

5 visits 

5 visits 

5 visits 

5 visits 

5 visits 

5 visits 

5 visits 

Angiogram 

4.36 Vascular Carotid endarterectomy ANGIOGRAM X-RAY/DOPPLER 5 visits 


Cluster 4A, CARDIOLOGY FOLLOW UP 


Sr. No Sub Specialty Procedure Name Follow up 

4A.1 Vascular Patch Graft Angioplasty 5 

4A.2 Vascular 

Femoropopliteal by pass 

procedure with graft (inclu. 

Graft) 

5 

Rate per Follow 

up (Rs.) 


package (as 




4A.3 Vascular Thromboembolectomy 5 

4A.4 Vascular 


-Distal Abdominal Aorta 

5 

4A.5 Vascular 


-Upper Abdominal Aorta 

5 

4A.6 Vascular 


-Vertebral 

5 

4A.7 Vascular 

Intrathoracic Aneurysm 

(without graft)-Aneurysm not 5 

Requiring Bypass Techniques 

4A.8 Vascular 

Intrathoracic Aneurysm (with 

graft) -Requiring Bypass 

5 

Techniques 

4A.9 Vascular 

Dissecting Aneurysms with 

CPB (inclu. Graft) 

5 

4A.10 Vascular 

Dissecting Aneurysms without 

CPB (incl. graft) 

5 


Vascular Procedure – Major 

Vessels 

5 


Vascular Procedure – Minor 

Vessels 

5 



Renal Artery 

5 



Carotid 

5 



Main Arteries of the Limb 

5 


Operations for Acquired 

Arteriovenous Fistual 

5 


Congenital Arterio Venous 

Fistula 

5 


Operations for Stenosis of 

Renal Arteries 

5 


Peripheral Embolectomy 

without graft 

5 



Aorto Billiac / Bifemoral bypass 


5 


Axillo bifemoral bypass with 


5 


Femoro Distal Bypass with Vein 

Graft 

5 


Femoro Distal Bypass with 


5 


Axillo Brachial Bypass using 


5 


Brachio - Radial Bypass with 


5 


Excision of Carotid body Tumor 

with vascular repair 

5 


Carotid artery bypass with 


5 



malformation – Large 

5 



malformation – Small 

5 

4A.30 Vascular Arterial Embolectomy 5 

4A.31 Vascular D V T - IVC Filter 5 

4A.32 Vascular Vascular Tumors 5 


Small Arterial Aneurysms - 

Repair 

5 


Medium size arterial 

aneurysms - Repair 

5 


Medium size arterial 

aneurysms with synthetic graft 

5 

4A.36 Vascular Carotid endarterectomy 5 


Cluster 5, RENAL 

Main Specialty-Genito Urinary Surgery 

Sl. 

No. 

Subspecialty 


Package 

Rates (in 

Rs.) 

Pre-operative 

Investigation 


Investigation 

Follow 

up 

5.1 Urology Open Pyelolithotomy IVP , KUB , USG 

Clinical Photograph , USG , 

X-RAY, urine analysis 

2 

5.2 Urology 

Open 


IVP , KUB , USG 

Nephrolithotomy 

X-RAY, urine analysis 

2 

5.3 Urology Open Cystolithotomy IVP , KUB , USG 


X-RAY 

2 

5.4 Urology VVF Repair IVP , KUB , USG 


voiding cystogram 

3 

5.5 Urology Pyeloplasty IVP , KUB , USG 


IVP/DTPA renal scan 

3 

5.6 Urology Cystolithotripsy IVP , KUB , USG Clinical Photograph , X-RAY 2 

5.7 Urology 

PCNL (Percutaneous 

IVP , KUB , USG, Clinical Photograph , X-RAY 

Nephro Lithotomy) 

Spiral CT KUB 

KUB, USG KUB 

2 

ESWL (Extra 

5.8 Urology carporial shock-wave 

IVP , KUB , USG X-RAY and USG KUB 2 

lithotripsy) 

5.9 Urology URSL 

IVP , KUB , USG, 

Spiral CT KUB 

X-RAY KUB 2 

5.10 Urology Nephrostomy (PCN) IVP , USG Clinical Photograph 

5.11 Urology DJ stent (One side) IVP , USG X-RAY KUB 

5.12 Urology 

Urethroplasty for 

RGU & MCU, RGU & MCU, Uroflometry, 

Stricture Diseasessingle 

Uroflometry 

Clinical Photograph 

stage 

5.13 Urology 

5.14 Urology 


Stricture Diseases- 

First Stage 


Stricture Diseases- 

RGU & MCU, 

Uroflometry 

RGU & MCU, 

Uroflometry 

RGU & MCU, Uroflometry, 


RGU & MCU, Uroflometry, 


2 

3 


Second Stage 

5.15 Urology Hypospadiasis(Adult) 

5.16 Urology TURBT 

5.17 Urology TURP 

5.18 Urology Simple Nephrectomy 

5.19 Urology 

Lap. Nephrectomy 

Simple 

5.20 Urology 

Lap. Nephrectomy 

Radical 

5.21 Urology 

Lap. Partial 

Nephrectomy 


USG,Clinical 

Photograph 

Biopsy , CT , USG, 

ECHO 

USG, Uroflometry, 

ECHO 

Biopsy , CT KUB , 

USG 

USG, CT, ECHO 

CT, KUB , USG 

CT, USG 

Clinical Photograph, 

Uroflowmetry 

Biopsy , USG KUB 12 

Biopsy , USG bladder and 

prostate 

Biopsy , Clinical Photograph 

, USG 


, USG 


, USG 


, USG 

3 

3 

3 

3 

6 

6 

Cluster 5A, RENAL FOLLOW UP PACKAGES 


Sl. 

No. 

Subspecialty 


Follow 

up 

Rate per 

Follow up 

(Rs.) 

Total Follow up package (as 

included in above package) in 

Rs. 

5A.1 Urology Open Pyelolithotomy 2 

5A.2 Urology Open Nephrolithotomy 2 

5A.3 Urology Open Cystolithotomy 2 

5A.4 Urology VVF Repair 3 

5A.5 Urology Pyeloplasty 3 

5A.6 Urology Cystolithotripsy 2 

5A.7 Urology 

PCNL (Percutaneous Nephro 

Lithotomy) 

2 

5A.8 Urology ESWL (Extra carporial shock- 2 


wave lithotripsy) 

5A.9 Urology URSL 2 

5A.10 Urology 

Urethroplasty for Stricture 

Diseases-First Stage 

2 

5A.11 Urology 

Urethroplasty for Stricture 

Diseases-Second Stage 

3 

5A.12 Urology Hypospadiasis(Adult) 3 

5A.13 Urology TURBT 12 

5A.14 Urology TURP 3 

5A.15 Urology Simple Nephrectomy 3 

5A.16 Urology Lap. Nephrectomy Simple 3 

5A.17 Urology Lap. Nephrectomy Radical 6 

5A.18 Urology Lap. Partial Nephrectomy 6 

Cluster 6, NEUROLOGY 

Main Specialty- Neuro Surgery 

Sl. 

No. 


Package 

Rates (in 

Rs.) 

Pre-operative 

Investigation 

Implant/Device 

/Technique/ 

Consumables 

Subspecialty 

Postoperative 

Investigation 

Follow 

-up 

6.1 Brain 

6.2 Brain 

6.3 

6.4 

6.5 

Brain 

Tumor 

Brain 

Tumour 

Brain 

Tumour 

Craniotomy and 

Evacuation of 

Haematoma –Subdural 

CT 

Craniotomy and 

Evacuation of 

Haematoma – 

Extradural 

CT 

Excision of Brain Tumor 

Supratentorial- 

Parasagital 

CT 


Supratentorial-Basal 

CT 


Supratentorial- CT 

Antibacterial 

Coated Sutures 

Antibacterial 


Clinical 

Photograph 6 

Clinical 

Photograph 3 

Clinical 

Photograph 6 

Clinical 

Photograph 6 

Clinical 

Photograph 6 


Brainstem 

6.6 

Brain 

Tumour 


Supratentorial-C P Angle 

CT 

Clinical 

Photograph 6 

6.7 

Brain 

Tumour 


Supratentorial & others 

CT 

Clinical 

Photograph 6 

6.8 

Brain 

Tumour 

Excision of Brain 

Tumors –Subtentorial 

MRI 

Clinical 

Photograph 6 

6.9 Brain Intervention with coiling DSA Aneurysm Coils DSA 3 

6.10 Brain 

Ventriculoatrial 

/Ventriculoperitoneal 

Shunt 

CT 

Clinical 

Photograph 3 

6.11 Brain Twist Drill Craniostomy CT 

6.12 Brain Subdural Tapping CT 

6.13 Brain Abscess Tapping Single CT 

6.14 Brain 

Abscess Tapping 

multiple 

6.15 Brain Meningo Encephalocele MRI 

MRI, Clinical 

Photogaph, X- 

6.16 Brain Meningomyelocele 

Ray Spine 

6.17 Brain C.S.F. Rhinorrhoea CT 

1.Drug 

Impregnated 

Shunt catheter / 

2. Programmable 

Shunts 

Drill bits of 

varios sizes and 

Disposable 

perforators 

Clinical 

Photograph 3 

Clinical 

Photograph 3 

Clinical 

Photograph 3 


CT 

1. Drug 

impregnated 

Catheter 

2. Sutireless and 

Bioabsorbable 

dural substitute 

Clinical 

Photograph 3 

Clinical 

Photograph 3 

Clinical 

Photograph 5 

Clinical 

Photograph 3

6.18 Brain Cranioplasty 

CT , Clinical 

Photograph 

6.19 Brain Meningocele Excision MRI, Clinic 

6.20 Brain Excision of Brain Abcess CT 

6.21 Brain Aneurysm Clipping 

6.22 Brain 

6.23 Brain 

6.24 Brain 

6.25 Spinal 

6.26 Spinal 

6.27 Spinal 

6.28 Spinal 

6.29 Spinal 

Carotid angioplasty with 

stent 

Carotid angioplasty 

without stent 

External Ventricular 

Drainage (EVD) 

MRI Angio / 

DSA 

ANGIOGRAM 

ANGIOGRAM 

CT 

Antibacterial 


Disposable 

perforators 

Clips 

Nitinol Self 

Expandable 

Stent and 

Emboli 

Protection 

device. 

Drug 

impregnated 

Catheter 

Spinal Cord Tumours 

(extramedullary) 

MRI 

Antibacterial 


Excision of Cervical 

Inter-Vertebral Discs 

MRI 

Anterior Cervical Spine 

Surgery with fusion MRI Plate and Screws 

Anterio Lateral 

Antibacterial 

Decompression 

MRI Coated Sutures 

Laminectomy- 

Cervical/dorsal/lumbar 

MRI 

6.30 Spinal Discectomy-Dorsal MRI 

6.31 Spinal Discectomy-Lumbar MRI 

Clinical 

Photograph 3 

Clinical 

Photograph 3 

Clinical 

Photograph 6 

Clinical 

Photograph , 

X-RAY 3 

DOPPLER , 

X-RAY 6 

DOPPLER , 

X-RAY 6 

Clinical 

Photograph 3 

Biopsy , 

Clinical 

Photograph 3 

Clinical 

Photograph 3 

Clinical 

Photograph 3 

Clinical 

Photograph 3 

Clinical 

Photograph 3 

Clinical 

Photograph 3 

Clinical 

Photograph 3 


6.32 Spinal 

6.33 Spinal 

6.34 Spinal 

6.35 Spinal 

Discectomy + cost of 

implant MRI Plate and Screws 

Spinal Intra Medullary 

Tumours 

Spina Bifida Surgery 

Major 

Spina Bifida Surgery 

Minor 

MRI 

MRI 

MRI 

6.36 Spinal Stereotaxic Procedures CT/MRI 

Antibacterial 


Clinical 

Photograph 3 

Biopsy , 

Clinical 

Photograph , 

X-RAY 6 

Clinical 

Photograph , 

X-RAY 6 

Clinical 

Photograph , 

X-RAY 3 

Clinical 

Photograph 6 

6.37 Spinal Vertebral artery Stenting ANGIOGRAM DOPPLER 3 

6.38 

AAD 

Surgeries 

Transoral surgery and 

CV Junction 

MRI , X-Ray 

Cerical Spine 

Antibacterial 


Clinical 

Photograph 6 

6.39 

AAD 

Surgeries Trans oral Surgery CT 

Biopsy , 

Clinical 

Photograph 6 

6.40 Brain 

6.41 Spinal 

6.42 Spinal 

Trans Sphenoidal 

Surgery 

RF Lesions for Trigminal 

Neuralgia 

Corpectomy and Spinal 

Fixation 

CT, MRI 


MRI 

MRI 

Screws, Cut Rod 

& Mesh Cage 

Biopsy , 

Clinical 

Photograph 6 

Clinical 

Photograph 3 

Clinical 

Photograph 3 

6.43 Spinal 

Spinal Fixation Rods 

and Plates 

MRI 

Screws & Cut 

Rod 

Clinical 

Photograph 3 

6.44 

Neuro 

Surgery 

Muscle Biopsy with 

report EMG, NCV Biopsy 1 

6.45 Spinal MVD MRI 

Clinical 

Photograph 3

6.46 

6.47 

6.48 

6.49 

Neuro 

Surgery Nerve Biopsy with report EMG, NCV Biopsy 1 

Neuro 

Antibacterial Clinical 

Surgery Nerve Decompression MRI Coated Sutures Photograph 3 

Neuro 

Surgery 

Neuro 

Surgery 

Peripheral Nerve Surgery 

Major 

Peripheral Nerve Surgery 

Minor 


EMG, NCV 

EMG, NCV 

Clinical 

Photograph 6 

Clinical 

Photograph 3 

Sl. 

No. 

Cluster 6A, NEUROLOGY FOLLOW UP PACKAGES 


Sub-specialty Procedure Name Follow-up 

6A.1 Brain 

6A.2 Brain 

6A.3 Brain Tumor 

Craniotomy and Evacuation of Haematoma – 

Subdural 

Craniotomy and Evacuation of Haematoma – 

Extradural 

Excision of Brain Tumor Supratentorial- 

Parasagital 

6A.4 Brain Tumour Excision of Brain Tumor Supratentorial-Basal 6 

6A.5 Brain Tumour 

Excision of Brain Tumor Supratentorial- 

Brainstem 

6 

6A.6 Brain Tumour Excision of Brain Tumor Supratentorial-C P Angle 6 

6A.7 Brain Tumour Excision of Brain Tumor Supratentorial & others 6 

6A.8 Brain Tumour Excision of Brain Tumors –Subtentorial 6 

6A.9 Brain Intervention with coiling 3 

6A.10 Brain Ventriculoatrial /Ventriculoperitoneal Shunt 3 

6 

3 

6 

Rate 

per 

Follow 

up (in 

Rs.) 


package (as 

included in 

above package) 

in Rs. 


6A.11 Brain Twist Drill Craniostomy 3 

6A.12 Brain Subdural Tapping 3 

6A.13 Brain Abscess Tapping Single 3 

6A.14 Brain Abscess Tapping multiple 3 

6A.15 Brain Meningo Encephalocele 3 

6A.16 Brain Meningomyelocele 5 

6A.17 Brain C.S.F. Rhinorrhoea 3 

6A.18 Brain Cranioplasty 3 

6A.19 Brain Meningocele Excision 3 

6A.20 Brain Excision of Brain Abcess 6 

6A.21 Brain Aneurysm Clipping 3 

6A.22 Brain Carotid angioplasty with stent 6 

6A.23 Brain Carotid angioplasty without stent 6 

6A.24 Brain External Ventricular Drainage (EVD) 3 

6A.25 Spinal Spinal Cord Tumours (extramedullary) 3 

6A.26 Spinal Excision of Cervical Inter-Vertebral Discs 3 

6A.27 Spinal Anterior Cervical Spine Surgery with fusion 3 

6A.28 Spinal Anterio Lateral Decompression 3 

6A.29 Spinal Laminectomy-Cervical/dorsal/lumbar 3 

6A.30 Spinal Discectomy-Dorsal 3 

6A.31 Spinal Discectomy-Lumbar 3 

6A.32 Spinal Discectomy + cost of implant 3 

6A.33 Spinal Spinal Intra Medullary Tumours 6 

6A.34 Spinal Spina Bifida Surgery Major 6 

6A.35 Spinal Spina Bifida Surgery Minor 3 

6A.36 Spinal Stereotaxic Procedures 6 

6A.37 Spinal Vertebral artery Stenting 3 

6A.38 AAD Surgeries Transoral surgery and CV Junction 6 

6A.39 AAD Surgeries Trans oral Surgery 6 

6A.40 Brain Trans Sphenoidal Surgery 6 

6A.41 Spinal RF Lesions for Trigminal Neuralgia 3 

6A.42 Spinal Corpectomy and Spinal Fixation 3 


6A.43 Spinal Spinal Fixation Rods and Plates 3 

6A.44 Neuro Surgery Muscle Biopsy with report 1 

6A.45 Spinal MVD 3 

6A.46 Neuro Surgery Nerve Biopsy with report 1 

6A.47 Neuro Surgery Nerve Decompression 3 

6A.48 Neuro Surgery Peripheral Nerve Surgery Major 6 

6A.49 Neuro Surgery Peripheral Nerve Surgery Minor 3 

Sr. 

No 

7.1 

7.2 

7.3 

Main 

Specialty 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Subspecialty 

Gastro 

Intestinal 

Tract 

Gastro 

Intestinal 

Tract 

Gastro 

Intestinal 

Tract 

Cluster 7, PAEDIATRIC 

Main Specialty- Paediatric Surgeries 

Packag 

Pre-operative 

Procedure Name e Rates 

Investigation 

(in Rs.) 

Oesophageal atresia – 

1.pure atresia- first 

stage(„o‟stomy & „G‟stomy) 

Oesophageal atresia – 

2.pure atresia- second 

stage(oesaphageal 

replacement) 

3.tracheo-oesphageal 

fistula(type c) 

X-ray with infant 

feeding tube or 

Dye study 

2D-ECHO, Dye 

study, 

ultrasound 

X-ray with infant 

feeding tube or 

Dye study 


Investigation 




Follo 

w up 

6 

visits 

6 

visits 

6 

visits 

7.4 

Paediatric 

Surgeries 

Gastro 

Intestinal 

Tract 

4. H- type fistula 

Dye study, 

Bronchoscopy 


6 

visits 

7.5 

Paediatric 

Surgeries 

Gastro 

Intestinal 

Tract 

Intestinal Atresias & 

Obstructions 

X-RAY /CT 


6 

visits 


7.6 

7.7 

7.8 

7.9 

7.10 

7.11 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Gastro 

Intestinal 

Tract 

Gastro 

Intestinal 

Tract 

Gastro 

Intestinal 

Tract 

Gastro 

Intestinal 

Tract 

Gastro 

Intestinal 

Tract 

Gastro 

Intestinal 

Tract 

Biliary Atresia HIDA scan Clinical Photograph 

Choledochal Cyst 

MRCP or CT 

scan 


Diaphragmatic Hernia USG/CT Clinical Photograph 

Anorectal Malformation1. 

Low ARM(male & female) 

2.Intermediate & High 

variety 

a. Stage 1 

colostomy 

b. Stage two 

PSARP/Abdominoperineal 

Pull through 

Invertogram or 

clinical 

photograph 


clinical 

photograph 

2-D ECHO, 

ULTRASOUND, 

Dye Study 




10 

visits 

6 

visits 

4 

visits 

6 

visits 

4 

visits 

4 

visits 

7.12 

Paediatric 

Surgeries 

Gastro 

Intestinal 

Tract 

c. Stage three colostomy 

closure/ Ileostomy closure 

Clinical 

photograph 


6 

visits 

7.13 

7.14 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Gastro 

Intestinal 

Tract 

Gastro 

Intestinal 

Tract 

ANORECTAL 

MALFORMATION.(Complex 

anomalies-CLOACA & 

POUCH COLON)-Staged 

surgeries 

Stage 1. 

colostomy/ileostomy/pouc 

hostomy 

Second stage- 

PSARVUP/Abdominoperine 

al Pull through Definitive 


clinical 

photograph, 

2-D ECHO, 

ULTRASOUND 

Dye Study 



4 

visits 

4 

visits 


7.15 

7.16 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Gastro 

Intestinal 

Tract 

Gastro 

intestinal 

tract 

surgery 

Third stage- Colostomy / 

ileostomy closure 

Hirschsprung's Disease- 

Single Stage 

2-D ECHO, 

ULTRASOUND 

Dye Study 

Dye Study/ 

Rectal Biopsy 


Clinical 

Photograph/Histopa 

thological Report 

6 

visits 

6 

visits 

7.17 

Paediatric 

Surgeries 

Gastro 

intestinal 

tract 

Hirschsprung's Disease- 

Staged Surgeries 1. 

Colostomy/ ileostomy 

Dye Study/ 

Rectal Biopsy 

Clinical 



4 

visits 

7.18 

Paediatric 

Surgeries 

Gastro 

intestinal 

tract 

Second stage-Definitive 

surgery 

Dye Study/ 

Rectal Biopsy 

Clinical 



4 to 6 

visits 

7.19 

7.20 

7.21 

7.22 

7.23 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Gastro 

intestinal 

tract 

Thoracic 

Surgeries 

GENITOU 

RINARY 

Surgeries 

GENITOU 

RINARY 

Surgeries 

GENITOU 

RINARY 

Third stage- colostomy/ 

Ileostomy closure 

Dye Study/ 

Rectal Biopsy 


Empyema Thoracis X-Ray/CT Scan Clinical Photograph 

HYPOSPIDIAS- 

1. SINGLE STAGE 

SURGERY 

HYPOSPIDIAS- 

2.STAGED SURGERIES 

a) 1 st Stage procedure 

a) 2 nd Stage procedure 

Surgeries 


Note the Suture should be US FDA approved only. 

Clinical 

Photograph 

Clinical 

Photograph 

Clinical 

Photograph 




6 

visits 

5 

visits 

6 

visits 

3 

visits 

6 

visits 


Sr. 

No 

7A.1 

7A.2 

7A.3 

7A.4 

7A.5 

7A.6 

7A.7 

7A.8 

7A.9 

7A.10 

7A.11 

7A.12 

7A.13 

Cluster 7A. PAEDIATRIC FOLLOW UP PACKAGES 


Main 

Specialty Sub-specialty Procedure Name 

Follow 

up 

Paediatric Gastro Intestinal Oesophageal atresia –1.pure atresia- first 

Surgeries Tract 

stage(„o‟stomy & „G‟stomy) 6 

Paediatric Gastro Intestinal 2.pure atresia- second stage(oesaphageal 


replacement) 

6 visits 

Paediatric Gastro Intestinal 

Surgeries Tract 3.tracheo-oesphageal fistula(type c) 6 visits 


Surgeries Tract 4. H- type fistula 6 


Surgeries Tract Intestinal Atresias & Obstructions 6 


Surgeries Tract Biliary Atresia 10 


Surgeries Tract Choledochal Cyst 6 


Surgeries Tract Diaphragmatic Hernia 4 

Paediatric Gastro Intestinal Anorectal Malformation1. Low ARM(male & 


female) 6 

Paediatric Gastro Intestinal 2.Intermediate & High variety a. Stage 1, 


colostomy 4 

Paediatric Gastro Intestinal b. Stage two PSARP/Abdominoperineal Pull 


through 

4 visits 

Paediatric Gastro Intestinal c. Stage three colostomy closure/ 


Ileostomy closure 6 

ANORECTAL MALFORMATION.(Complex 

Paediatric Gastro Intestinal anomalies-CLOACA & POUCH COLON)- 


Staged surgeries, Stage 1. 4 

Rates 

per 

follow 

up (in 

Rs.) 

Total Follow 

up package 

(as included 

in above 

package) in 

Rs. 


7A.14 

7A.15 

7A.16 

7A.17 

7A.18 

7A.19 

7A.20 

7A.21 

7A.22 

7A.23 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

Paediatric 

Surgeries 

colostomy/ileostomy/pouchostomy 

Second stage- 

Gastro Intestinal PSARVUP/Abdominoperineal Pull through 4 

Tract 

Definitive surgery 

visits 

Gastro Intestinal Third stage- Colostomy / ileostomy 

Tract 

closure 6 

Gastro intestinal 

tract Hirschsprung's Disease- Single Stage 6 

Gastro intestinal Hirschsprung's Disease-Staged Surgeries , 

tract 

1. Colostomy/ ileostomy 4 


tract Second stage-Definitive surgery 4 visits 


tract Third stage- colostomy/ Ileostomy closure 6 

Thoracic 

Surgeries Empyema Thoracis 5 

GENITOURINARY HYPOSPIDIAS-1. SINGLE STAGE 

Surgeries 

SURGERY 6 

GENITOURINARY HYPOSPIDIAS- 2.STAGED SURGERIES a) 

Surgeries 

1st Stage procedure 3 

GENITOURINARY 

Surgeries a) 2nd Stage procedure 6 

Sl. 

No. 

Subspecialty 

8.1 Polytrauma 

CLUSTER 8, POLYTRAUMA 

Main Specialty- Polytrauma 

Package 


rates (in 

Rs.) 

Nerve and tendon repair + Vascular 

repair 

Pre-operative 

Investigation 

Nerve Conduction 

study, CT scan 


Investigation 

Clinical 

Photograph 


Nerve & Tendon Repair + Vascular 

Repair (Grade-I& II) 



Clinical 

Photograph 



8.4 

Plastic 

Surgery 

Nerve & Tendon Repair + Vascular 

Repair (Grade-III) 

Flap cover Surgery for wound in 

compound fracture 



CLINICAL 

PHOTOGRAPH, X- 

RAY 

Clinical 

Photograph 

CLINICAL 

PHOTOGRAPH 


Other Small bonefractures/K-wiring (To 

be covered along with other injuries 

only and not as exclusive procedure) 

X-RAY 

X-RAY 


8.7 

8.8 

Plastic 

Surgery 

Pelvic Bone 

Fractures 

Surgery for Patella fracture (To be 

covered along with other injuries only 

and not as exclusive procedure) 

Facial bone fractures (Facio-Maxillary 

Injuries) 

Surgical Correction of Pelvic bone 

fractures. 


Note the Suture to be used should be US FDA approved Suture only. 

X-RAY 

CLINICAL 


RAY 

X-RAY 

X-RAY 

CLINICAL 


RAY 

X-RAY 

CLUSTER 8A. POLYTRAUMA FOLLOW UP PACKAGE 

Main Specialty- Polytrauma 

Sl. No. Sub-specialty Procedure Name Follow up 

8A.1 Polytrauma Nerve and tendon repair + Vascular repair 3 Visits 

8A.2 Polytrauma Nerve & Tendon Repair + Vascular Repair (Grade-I& II) 3 Visits 

8A.3 Polytrauma Nerve & Tendon Repair + Vascular Repair (Grade-III) 3 Visits 

8A.4 Plastic Surgery Flap cover Surgery for wound in compound fracture 3 Visits 

8A.5 Polytrauma 

Other Small bonefractures/K-wiring (To be covered along 

with other injuries only and not as exclusive procedure) 

3 Visits 

8A.6 Polytrauma 

Surgery for Patella fracture (To be covered along with other 

injuries only and not as exclusive procedure) 

3 Visits 

Rates per 

follow up 

(in Rs.) 


package (as included in 

above package) in Rs. 


8A.7 Plastic Surgery Facial bone fractures (Facio-Maxillary Injuries) 3 Visits 

8A.8 

Pelvic Bone 

Fractures 

Surgical Correction of Pelvic bone fractures. 3 Visits 


Note: The above package rate should include minimum 3 follow up at an interval of 9 months from the patients discharge date. 

Sr.No 

Subspecialty 

9.1* Breast 

9.2* Breast 


Adriamycin/Cyclophosp 

hamide (AC) 

5- Fluorouracil A-C 

(FAC) 

9.3* Breast AC (AC then T) 

9.4* Breast Paclitaxel 

9.5* Breast 

Cyclophosphamide/Meth 

otrexate/5Fluorouracil 

(CMF) 

9.6# Breast Tamoxifen tabs 

CLUSTER 9, ONCOLOGY 

Main Specialty- Medical Oncology 

Packag 

e Rates 

(in Rs.) 

Pre-treatment Investigation 

Biopsy with immunohistochemistry, 

Mammography, 2D Echo, Chest X-ray, 

Sonography, Bone scan, Blood 

Investigations, clinical Photograph 






















Investigation 

Clinical 

Photograph, 

Mammography, 

chest X-ray 

Clinical 

Photograph, 

Mammography, 

chest X-ray 

Clinical 

Photograph, 

Mammography, 

chest X-ray 

Clinical 

Photograph, 

Mammography, 

chest X-ray 

Clinical 

Photograph, 

Mammography, 

chest X-ray 

Clinical 

Photograph, 

Mammography, 

chest X-ray 


9.7# Breast Aromatase Inhibitors 

9.8* Breast 

9.9* 

9.10* 

9.11* 

9.12* 

9.13* 

9.14* 

Cervical 

Cancer 

Vulval 

Cancer 

Vaginal 

Cancer 

Ovarian 

Cancer 

Ovarian 

Cancer 

Ovary 

Germ cell 

Tumor 

Dose dense AC followed 

by Taxanes with GCSF, 

Herceptin, Ta xol + 

Carboplatin 

Weekly Cisplatin 

Cisplatin/5-FU 

Cisplatin/5-FU 

Carboplatin/Paclitaxel 

Liposomal Doxorubicin 

& Gemcitabine 

Bleomycin /Etoposide/ 

Cisplatin (BEP) 









Biopsy, USG,CT scan/MRI, Chest X- 

ray, clinical Photograph. 

Biopsy, USG,CT scan/MRI, Chest X- 


Biopsy, USG, CT scan/MRI, Chest X- 



Chest X-ray, USG, CT scan, CA 125, 

Cytology, clinical Photograph 


Chest X-ray, USG, CT scan, CA 125, 

Cytology, clinical Photograph 

Biopsy with immunohistochemistry, CT 

scan, USG, Chest x-ray, Tumor 

markers, Clinical Photograph, 2 D 

echo. 

Clinical 

Photograph, 

Mammography, 

chest X-ray 

Clinical 

Photograph, 

Mammography, 

chest X-ray 

Clinical 

Photograph, 

USG,CT scan/MRI, 

Chest X-ray. 

Clinical 

Photograph, 


Chest X-ray. 

Clinical 

Photograph, 


Chest X-ray. 

Clinical 

Photograph, 

Sonography, CT 

scan, CA 125, 

chest x-ray. 

Clinical 

Photograph, 

Sonography, CT 

scan, CA 125, 

chest x-ray. 

CT scan, USG, 

Chest x-ray, Tumor 

markers, Clinical 

Photograph, 2 D 

echo. 


9.15* 

9.16* 

9.17* 

9.18* 

9.19* 

9.20# 

9.21* 

Gestationa 

l 

Trophobla 

st Ds.- 

Lowrisk 

Gestationa 

l 

Trophobla 

st Ds.- 

Lowrisk 

Gestationa 

l 

Trophobla 

st Ds.- 

Highrisk 

Testicular 

Cancer 

Testicular 

Cancer 

Prostate 

Cancer 

Prostate 

Cancer 

Weekly Methotrexate 

Actinomycin 

Etoposide-Methotrexate- 

Actinomycin / 

Cyclophosphamide - 

Vincristine (EMA-CO) 

Bleomycin-Etoposide- 

Cisplatin (BEP) 

Taxanes, Ifosphamides, 

Vinblastine, 

Gemcitabine, Docetaxol, 

Platin 

Hormonal therapy 

Docetaxol + steriods with 

G-CSF 

Biopsy, CT scan, USC, Chest x-ray, 

Tumor markers, MRI Brain, Clinical 

Photograph. 

Biopsy, CT scan, USG, Chest x-ray, 

Tumor markers, MRI, Brain, Clinical 

Photograph. 

Biopsy, CT scan, USG, Chest x-ray, 

Tumor markers, MRI Brain, Clinical 

Photograph. 



markers, Clinical Photograph, 2 D 

echo. 



markers, MRI Brain, Clinical 

Photograph. 

Biopsy, CT scan/MRI, USG, x-ray, 

Tumor markers, Bone scan, Clinical 

Photograph. 


Tumor markers, Bone scan, Clinical 

Photograph. 

CT scan, USC, 


markers, MRI, 

clinical 

Photograph. 

CT scan, USC, 


markers, MRI, 

clinical 

Photograph. 

CT scan, USC, 


markers, MRI, 

clinical 

Photograph. 

CT scan, USG, 


markers, Clinical 

Photograph, 2 D 

echo. 

CT scan, USG, 


markers, MRI 

Brain, Clinical 

Photograph. 

CT scan/MRI, 

USG, x-ray, Tumor 

markers, Bone 

scan, Clinical 

Photograph. 

CT scan/MRI, 

USG, x-ray, Tumor 

markers, Bone 


Photograph. 


9.22* 

9.23* 

9.24* 

9.25* 

9.26* 

9.27* 

9.28* 

Bladder 

Cancer 

Bladder 

Cancer 

Bladder 

Cancer 

Lung 

cancer- 

Non-small 

cell lung 

cancer 

(NSCLC) 

and SCLC 

Lung 

cancer- 

Non-small 

cell lung 

cancer 

(NSCLC) 

Esophage 

al Cancer 

Gastric 

Cancer 

Weekly Cisplatin 

Methotrexate Vinblastine 

Adriamycin 

Cyclophosphamide 

(MVAC) 

Gemcitabine/Carboplati 

n 

Platin/Etoposide 

Pemetrexed/ Platin 

Gemcitabine/ Platin 

Gefitinib 

Weekly Cisplatin/ 

Carboplatin Cisplatin- 

5FU Epirubicin/ 

Taxanes 

5-FU -Leucovorin 

(McDonald Regimen), 

Epirubicin/Taxanes/Plat 

in 


Urine cystology, Clinical Photograph. 






scan, USG, x-ray, Sonography, Bone 

scan, MRI Brain PET-CT Scan. 


scan, USG, x-ray, Sonography, Bone 

scan, MRI Brain PET-CT Scan. 

Biopsy, CT scan, USG, x-ray, 

Sonography, Endoscopy. 

Biopsy, CT scan, USG, x-ray, 

Sonography, Endoscopy. 

CT scan/MRI, 

USG, x-ray, Urine 

cystology, Clinical 

Photograph. 

CT scan/MRI, 



Photograph. 

CT scan/MRI, 



Photograph. 

CT scan, USG, x- 

ray, Sonography, 

Bone scan, MRI 

Brain PET-CT 

Scan, Clinical 

Photograph. 

CT scan, USG, x- 

ray, Sonography, 

Bone scan, MRI 

Brain PET-CT 

Scan, Clinical 

Photograph. 

Biopsy, CT scan, 

USG, x-ray, 

Sonography, 

Endoscopy, 

Clinical 

Photograph. 

Biopsy, CT scan, 

USG, x-ray, 

Sonography, 

Endoscopy, 


9.29* 

9.30* 

9.31* 

9.32* 

9.33* 

9.34* 

Colorectal 

Cancer 

Colorectal 

Cancer 

Colorectal 

Cancer 

Osteosarc 

oma Bone 

Tumors 

Lymphom 

a-Hodgkin 

disease 

Lymphom 

a-NHL 

Monthly 5-FU 

5-Fluorouracil- 

Oxaliplatin -Leucovorin 

(FOLFOX) (Stage III only) 

5-FU, Irinotican, 

Leucovorin, (FOLFIRI) 

Capecitabine, 

Cisplatin/Adriamycin + 

ifosmide (IAP) 

Adriamycin/ 

Bleomycin/Vinblastine/ 

Dacarbazine (ABVD), 

Cyclophosphamide/Vinc 

ristine/Prednisolone/Pro 

carbazine (COPP). 

Cyclophosphamide/Adri 

amycin/Vincristine/Pred 

nisolone (CHOP), 

Rituximab, Chlorambucil 

CVP 

(Cyclophosphamide/Vinc 

ristine,/Prednisolone), 

Bendamustine 

Cladribone High dose 

Biopsy, CT scan/MRI, x-ray, Tumor 

marker-S. CEA 


marker-S. CEA 


marker-S. CEA 

Biopsy, CT scan, MRI scan, x-ray, Bone 

scan, 2 D Echo. 

Biopsy- immunohistochemistry, Serum 

biochemistry, Bone marrow 

examination, CT scan, x-ray, 

Sonography, PET-CT Scan, 2 D Echo, 

PFT. 

Biopsy-, immunohistochemistry, 

Serum biochemistry, Bone marrow 

examination, CT scan, x-ray, 

Sonography, PET-CT, CSF cytology, 

MRI brain/spine, Viral markers,2 D 

Echo. 

Clinical 

Photograph. 

Biopsy, CT 

scan/MRI, x-ray, 

Tumor marker-S. 

CEA, Clinical 

Photograph. 

Biopsy, CT 



CEA, Clinical 

Photograph. 

Biopsy, CT 



CEA, Clinical 

Photograph. 

X-Ray, Clinical 

Photograph. 

Blood 

investigations & 

imaging-USG/CT 

scan/PET-CT scan, 

Clinical 

Photograph 

Blood 


imaging-USG/CT 

scan/PET-CT scan, 

Clinical 

Photograph 


9.35* 

9.36# 

9.37# 

9.38# 

9.39* 

9.40* 

9.41* 

Multiple 

Myeloma 

Multiple 

Myeloma 

Multiple 

Myeloma 

Multiple 

Myeloma 

Wilm's 

Tumor 

Hepatobla 

stoma 

Operable 

Childhood 

B Cell 

Lymphom 

Methotrexate/VCR/Proc 

arbazine- Cytarabine 

Vincristine, 

Adriamycin,Dexamethas 

one(VAD) 

Thalidomide+Dexametha 

sone(Oral) 

Melphalan -Prednisone 

(oral) 

Bortezamib, 

Lenalinomide, 

Bisphosphonates, 

Autologus stem cell 

transplant 

SIOP/NWTS 

regimen(Stages I - IV) 

Cisplatin – Adriamycin 

Variable Regimen - MCP 

841/BFM - 90, BFM- 

NHL, LMB 96, 

Hematology, Serum biochemistry, 

Serum Protein electrophoresis and 

immunofixatation, Bone marrow 

examination, skeletal survey & MRI 

Spine, 2 D Echo. 
















USG/CT, biopsy with 

Immunohistochemistry 

USG/CT, biopsy, Tumor marker-AFP, 

2D Echo. 

Hematology, Serum biochemistry, CT 

Scan whole body Or PET Scan, Tissue 

biopsy with immunochemistry/IPT, 

Blood 

investigations, & 

Bone marrow 

examination, X- 

Rays, Clinical 

Photograph 

Blood 


Bone marrow 

examination, 

Clinical 

Photograph 

Blood 


Bone marrow 



Photograph 

Blood 


Bone marrow 



Photograph 

Imaging USG/CT 


Photograph 

USG/CT, Tumor 

marker, Clinical 

Photograph. 

Bone marrow 

examination, 

Imaging- Studies, 


9.42* 

9.43* 

9.44* 

9.45* 

9.46* 

9.47* 

as Rasburrycase Bone marrow examination, CSF 

Cytology. 

Neuroblas 

toma ( 

Stages I-III 

) 

Retinoblas 

toma 

Histiocyto 

sis 

Rhabdomy 

osarcoma 

Ewings 

sarcoma 

Acute 

Myeloid 

Leukemia 

Variable Regimen 

Variable regimens, 

Autologous Stem Cell 

Carbo/Etoposide/Vincris 

tine, 

Endoxan/vincristine/do 

xorubicinplatin/Etoposide 

Variable Regimen- LCH- 

III, Vinblastine + 

Prednisolone, 6MP, MTX, 

Cladribone, Allergenic 

stem cell transplant. 

Vincristine-Actinomycin- 

Cyclophosphamide (VAC) 

based chemo 

Variable Regimen- 

Endoxan/VCR/Doxorubi 

cin- 

Ifosphamides/Etoposide. 

Induction Phase 

CT, Biopsy-With 

Immunohistochemistry, Blood 

investigations, MIBG scan, Bone 

marrow examination. 

Biopsy, Blood investigations, MRI Orbit 

& Brain, CSF study, Bone marrow 

examination, Bone scan. 

Hematology, Biopsy, Serum 

biochemistry, Bone marrow 

examination, Chest X-Ray, skeletal 

survey, MRI Brain, Endocrine 

evaluation, HAL typing & matching, 

serum cyclosporine level.CSF Cytology. 

Blood investigations, Biopsy & 

Immunohistochemistry, CT scan/MRI, 

Bone marrow examination, Bone scan. 

X-Ray/CT Scan/MRI, Biopsy & 

Immunohistochemistry, Bone Scan, 

Bone marrow examination, 2D Echo. 

Hematology, Bone marrow examination 

with Immunophenotyping, 

Conventional Cytogenetics and FISH 

studies, MRI Brain, X-Ray, 2D Echo. 

Clinical 

Photograph 

Blood 


imaging- USG/CT 

scan, MIBG scan, 

Clinical 

Photograph 

Ophthalmologic 

examination, 

Imaging-Studies, 

Clinical 

Photograph 

Blood 

investigations and 

imagine, Clinical 

Photograph 

Physical 

examination, 

Imagine MRI/CT 

can, Clinical 

Photograph 

Physical 


Ray/CT scan/MRI, 

Clinical 

Photograph 

Physical 

examination, Blood 

investigations, 

Bone marrow 

examination, 

Clinical 


Photograph 

Physical 

9.48* 



Acute 


with Immunophenotyping, 

Myeloid Consolidation Phase 

Bone marrow 

Conventional Cytogenetics and FISH 

Leukemia 

examination, 

studies, MRI Brain, X-Ray, 2D Echo. 

Clinical 

Photograph 

Physical 

9.49* 


Acute Induction phase 1st and 



Lymphobl 2nd months, MCP 

with Immunophenotyping, Cytogenetics 

Bone marrow 

astic 841/BFM 90 protocol, 

and FISH studies, CSF cytology, MRI 

examination, 

Leukemia 

Imatinib 

Brain, USG/CT scan. 

Clinical 

Photograph 

Physical 

9.50* 

3rd, 4th, 5th month- 


Acute 


MCP 841/BFM 90 


Lymphobl 

with Immunophenotyping, Cytogenetics 

protocol, Imatinib, 

Bone marrow 

astic 

and FISH studies, CSF cytology, MRI 

Allergenic stem cell 

examination, 

Leukemia 

Brain, USG/CT scan, 2D Echo. 

transplant 

Clinical 

Photograph 

Physical 

9.51* 


Acute 

Maintenance- MCP 


Lymphobl 

Hematology, Bone marrow 

841/BFM 90 protocol, 

Bone marrow 

astic 

examination, FISH study, CSF cytology. 

Imatinib 

examination, 

Leukemia 

Clinical 

Photograph 

Blood 

9.52* 


unlisted 

Palliative Chemotherapy 

Biopsy. CT, USG, Blood investigations USG/CT scan, 

regimen 

Clinical 

Photograph 

9.53* For Palliative and Supportive Biopsy , CT , USG Clinical 


9.54* 

9.55* 

9.56* 

9.57* 

Terminally 

ill cancer 

patient 

Colorectal 

Cancer 

Stage 2& 

3 

Febrile 

Neutropen 

ia- 

Highrisk-1 

Febrile 

Neutropen 

ia- 

Highrisk-2 

Relapsed 

lymphoma 

- NHL and 

HD 

9.58* APML 

Therapy 

XELOX along with 

Adjuvant chemotherapy 

1ST Line iv antibiotics 

And other supportive 

therapy ( third 

generation 

cephalosporin,aminoglyc 

oside, Comnination of 

Beta Lactum with beta 

lactamase inhibitor 

(Piperacillintazobactum), 

Vancomycin, Anti-Fun 

gals (azoles), G-CSF etc.,) 

2nd line iv antibiotics 

and other supportive 

therapy(Carbapenems, 

Fourth generation 

cephalosporins, 

Piperacillin, anti-fungal - 

azoles etc.,) 

Ifosphamides /Platin 

/Etoposide (ICE), 

Cytarabine/ Platin/ 

Steroids (DHAP), 

Autologous stem cell 

Transplant 

ATRA, Arsenic trioxide, 

Daunorubicin, 

Cytarabine 6 MP, 

methotrexate 

CT scan Abdomen, Pelvis, Tissue 

biopsy, Photograph, Tummor marker-S. 

CEA. 

Blood C&S, Urine C&S, Chest X-Ray, 

Tissue Biopsy, CT scan. 

Blood C&S, Urine C&S, Chest X-Ray, 

Tissue Biopsy, CT scan. 

Serum biochemistry, Bone marrow 

examination, CT scan, X-ray, 

Sonography, PET-CT scan 

Bone Marrow examination with 

Immunophe-notyping, Conventional 

Cytogenetics and FISH/RT-PCR 

studies, MRI Brain, X-ray, 2 D echo, 

Photograph 

USG/CT/biopsy, 

Biochemical 



Biochemical 

investigations. 


Blood 


Blood Culturesensitivity, 

X-Ray. 

Blood 


imaging- USG/CT 

scan/PET-CT scan 

Bone marrow exam 

with RT-PCR 

study, 


9.59* 

Paediatric 

AML 

9.60* CLL 

9.61# 

9.62^ 

9.63# 

9.64^ 

9.65^ 

CML 

Blastic 

crisis 

Aplastic 

Anaemia 

Myelodysp 

lastic 

syndrome 

Thalassem 

ia/Haemo 

globinopat 

hies Sickle 

cell 

anaemia 

Congenital 

condition 

BFM 93 

Fludarabine / 

Cyclophosphamide/ 

Rituximab (FCR), 

Chlorambucil/steroid, 

Bendamustine/Rituxima 

b, CVP-CHOP, 

Rituximab 

Imatinib, Nilotinib, 

Dasatinib Allogeneic 

stem cell Transplant 

ATG + Cyclosporine + 

Steroid Allogeneic stem 

cell Transplant 

Lenalinomide Decitabine 

Allogeneic stem cell 

transplant 

Allogeneic Bone Marrow 

Transplant 

Allogeneic stem cell 

Transplant 

ECG 

Bone Marrow examination with 

Immunophe-notyping, Conventional 

Cytogenetics and FISH study, MRI 

Brain, CSF cytology, X-ray, 2 D echo, 

ECG 

Hematology, Serum Biochemistry, Bone 

marrow examination with Immunophenotyping, 

Lymph node biopsy with IHC, 

USG/CT scan, 2 D Echo 

Hematology with serum biochemistry, 

Bone marrow examination, cytogenetic 

study, Ph by FISH or RT-PCR, USG 

study 

Hematology and serum biochemistry, 

Bone Marrow examination, viral 

markers, IPT for PNH, HLA typing & 

matching. S. Cyclosporine level 

Hematology, serum biochemistry, Bone 

marrow examination with cytogenetics, 

FISH study, 

Blood investigations Hb electrophoresis 

,HLA study 

Hematology, serum biochemistry, Hb 

electrophoresis , HLA typing 

Physical exam, 

Blood 


bone marrow exam 

(if clinically 

indicated) 


Blood 


Imaging USG/CT 

scan 


Blood 


Bone marrow 

study, RT- PCR for 

BCR-ABL 

Blood 


Blood 


Blood 


Blood 



9.66* 

9.67^ 

9.68^ 

amenable 

to BMT 

Medullobl 

astoma 

Relapsed 

Paediatric 

Solid 

Tumours 

Palliative 

package 

Cisplatin/cyclophospha 

mide/VCR/Procarbazine, 

Lomustine 

Autologous Bone Marrow 

Transplant 

Fixation of pathological 

fracture, pain killer, 

nerve blockage, G-CSF, 

Drainage – Biliary and 

urinary, Stenting, 

Oesophageal 

Stenting/prosthesis, 

Nutritional supplement 

Hematology, Serum biochemistry, RI 

brain & spine, Biopsy 

immunohistochemistry, CSF cytology 

Blood investigations and Imaging, 

Blood investigations and Imaging, 


MRI study 

Blood 


Imaging, 

Blood 


Imaging, 

9.69* 

Anal 

Cancer 

MITOMYCIN, 5FU CXR , USG ABDOMEN, CT Abdomen ULTRASOUND 

9.70* 

Head & 

Neck 

CISPLATIN WEEKLY Chest X ray, CT/MRI, Biopsy CT Scan Xrays 

9.71* 

Head & TPF (DOCETAXEL 

Neck ,CISPLATIN , 5-FU) 

X ray, CT, MRI Biopsy 

CT Scan X-rays 

9.72# 

Head & 

Neck 

CISPLATIN + MTX X ray, CT, MRI Biopsy CT Scan X-rays 

9.73# HCC SORAFENIB ORAL 

AFP , USG ABDOMEN, CT Scan, Chest 

x ray 

USG ABDOMEN 

9.74# RCC SUNITINIB USG, Biopsy, CT Scan, Chest x ray USG ABDOMEN 

9.75* 

Tenozolamide, 

Brain 

MRI Brain, Biopsy with 

Procarbazine, CCNU, 

Tumour 

Immunohistochemistry, X-ray 

Vincristine 

MRI Brain, X-ay 

9.76* 

9.77* 

Sarcomasoft 

tissue 

Hepatobilli 

ary tumor 

Cisplatin/ Adriamycin/ 

Ifosphamides 

Gemcitabine/ 

Oxaliplatin/ 

MRI, CT scan, Biopsy with 

Immunohistochemistry, X-ray 

CT scan, Biopsy, Tumor markers, X- 

ray, Sonography 

MRI, CT scan, X- 

ray 

CT scan, Tumor 

markers, X-ray, 


Capecitabine/ 5 FU 

Gemcitabine/ 

Pancreatic Oxaliplatin/ 

9.78* 

cancer Capecitabine/ 5 

FU/Erlotinib 

Endometri Weekly Platin Paclitaxel/ 

9.79* 

al cancer Carboplatin 


Note: * Rates are to be submitted per cycle 

# Rates are to be submitted per month 

^ Rates are to be submitted per course 

CT scan, Biopsy, Tumor markers, X- 

ray, Sonography 

CT scan/MRI study, X-ray, Biopsy, 

Sonography 

Sonography 

CT scan, Tumor 

markers, X-ray, 

Sonography 

CT scan, X-ray, 

Sonography 

Sr. 

No. 

10.1 

10.2 

10.3 

10.4 

10.5 

10.6 

Procedure 

Cobalt 60 

external beam 

radiotherapy 

Cobalt 60 

external beam 

radiotherapy 

Cobalt 60 

external beam 

radiotherapy 

3DCRT(3-D 

Conformationa 

l Radiotherapy) 

3DCRT(3-D 

Conformationa 

l Radiotherapy) 

Linear 

accelerators 

Subcategory 

Radical treatment 

Palliative treatment 

Adjuvant therapy 

Radical treatment 

Adjuvant therapy 

Radical treatment with 

photons (linear 

accelarator) 

Cluster 10, Oncology 

Main Specialty- Radiation Oncology 

Package 

Pre 

rates 

Post Investigations 

Investigations 

(in Rs.) 

Usg/x-ray/ct, 

biopsy 

Usg/x-ray/ct, 

biopsy 

Usg/x-ray/ct, 

biopsy 

USG/ X-ray/ 

CT/ MRI/ 

Biopsy 

USG/ X-ray/ 

CT/ MRI/ 

Biopsy 

Usg/x-ray/ct, 

biopsy 

Clinical photograph, rt 

treatment charts 





USG/ X-ray/ CT/ MRI/ 

Biopsy 


Biopsy 



Duration of 

Treatment 

6 to 7 weeks 

3 weeks 

4 weeks 

Upto 30 

fractions in 6 

weeks 

Upto 30 


weeks 

6 to 7 weeks 


10.7 

10.8 

10.9 

10.10 

10.11 

10.12 

10.13 

10.14 

10.15 

10.16 

Linear 

accelerators 

Linear 

accelerators 

Brachytherapy 

-intracavitaryii 

Brachytherapy 

-interstitial-ii 

Brachytherapy 

-Intracavitary-i 

Brachytherapy 

-Interstitial-i 

LA with multi 

leaf collimator 

LA with multi 

leaf collimator 

LA with some 

accessories 

LA with some 

accessories 

10.17 Brain Tumour 

10.18 Implants 

Palliative treatment 

with photons (linear 

accelarator) 

Adjuvant treatment 

with photons/electrons 

Ii. Hdr per application 

i. LDR per application 


IMRT 


IGRT 

SRS (Stereotactic 

Radiosurgery) 

SRT (Stereotactic 

Radiotherapy) 

Gamma Knife / Cyber 

Knife 

Thyroid/Breast/Prostat 

e 

Usg/x-ray/ct, 

biopsy 

Usg/x-ray/ct, 

biopsy 

Usg/x-ray/ct, 

biopsy 

Usg/x-ray/ct, 

biopsy 

Ii. Hdr - one 

application and 

multiple dose fractions 

i. LDR per application 

(Brachytherapyintracavitary) 

USG/X- 

RAY/CT, 

BIOPSY 

USG/X- 

RAY/CT, 

BIOPSY 

USG/ X-ray/ 

CT/ MRI/ 

Biopsy 

USG/ X-ray/ 

CT/ MRI/ 

Biopsy 

USG/ X-ray/ 

CT/ MRI/ 

Biopsy 

USG/ X-ray/ 

CT/ MRI/ 

Biopsy 









CLINICAL 

PHOTOGRAPH, RT 

TREATMENT CHARTS 

CLINICAL 

PHOTOGRAPH, RT 

TREATMENT CHARTS 


Biopsy 


Biopsy 


Biopsy 


Biopsy 

3 weeks 

4 weeks 

Weekly 

application for 

2 to 5 weeks 

5 days 

Weekly 

application for 

2 to 5 weeks 

5 days 

Upto 40 


weeks 

6 to 7 weeks 


1 day 

6 weeks 

CT CT 1 day 

USG/ X-ray/ 

CT/ MRI/ 

Biopsy 


Biopsy 

10.19 Total Body Pre Bonemarrow/Stem USG/ X-ray/ USG/ X-ray/ CT/ MRI/ 

For upto 12 

weeks

Radiation Cell Transplant CT/ MRI/ 

Biopsy 

USG/ X-ray/ 

10.20 Brachytherapy Breast Brachytherapy 

CT/ MRI/ 

Biopsy 


Biopsy 


Biopsy 

6 to 7 weeks 

Sr.No. 

Subspecialty 

Cluster 11, ONCOLOGY 

Main Specialty- Surgical Oncology 

Package 

Pre-operative 


Rates (in 

Investigation 

Rs.) 


Investigation 

11.1 Ear Labyrinthectomy Audiogram Audiogram 

11.2 Throat 

Microlaryngeal Surgery including 

Phonosurgery 

Biopsy, CT Scan/ MRI 

Biopsy 

11.3 Throat 

Excision/ Hypopharynx of Tumors 


Biopsy, CT Scan/ MRI 

in Pharynx 

biopsy 

11.4 Pancreas Distal Pancreatectomy CT , CA 19-9, PET Scan Clinical Photograph 

11.5 Pancreas Enucleation of Cyst CT, CA 19-9 Clinical Photograph 

11.6 Pancreas Whipples - any type 

CT , ERCP, CA 19-9, PET 

Scan, EUS 


11.7 Spleen Splenectomy USG/CT 


, USG 

11.8 

11.9 

Genito 

Urinary 

System 

Genito 

Urinary 

System 

Radical Nephrectomy 

Radical Cystectomy 

Biopsy , CT , IVP , KUB 

,USG 


,USG 






11.10 

11.11 

11.12 

11.13 

11.14 

11.15 

11.16 

11.17 

Genito 

Urinary 

System 

Genito 

Urinary 

System 

Genito 

Urinary 

System 

Genito 

Urinary 

System 

Genito 

Urinary 

System 

Genito 

Urinary 

System 

Genito 

Urinary 

System 

Genito 

Urinary 

System 

Other cystectomies 

High Orchidectomy 

Bilateral Orchidectomy 

Emasculation 

Total Penectomy 

Inguinal Block Dissection-one side 

Radical Prostatectomy 

Partial Penectomy 


,USG 

CT Scan (Abdomen, 

Pelvis), Biopsy, USG, CT 

Scan Thorax 

Biopsy , USG, Bone 

Scan, Local X-ray 

Biopsy , USG 

Biopsy, CT Scan 

(Abdomen, Pelvis),Clinical 

Photograph 


phtograph, CT Scan 

CT , KUB , USG, Bone 

Scan, Biopsy 

Biopsy, Clinical 

Photograph, USG 

Abdomen Pelvis 

11.18 Gynaec Radical Hysterectomy Biopsy , CT , USG 

11.19 Gynaec Surgery for Ca Ovary - early stage 

11.20 Gynaec 

Surgery for Ca Ovary - advance 

stage 

CA 125, CEA, Biopsy/ 

cytology, αFP, βHCG, 

LDH, X-ray chest 

CA 125, CEA, Biopsy/ 

cytology, αFP, βHCG, 

LDH, X-ray chest 




















Photograph , USG, 

Tumor Marker 


Photograph , USG, 

Tumor Marker 


11.21 Gynaec Vulvectomy Biopsy, Photograph 

11.22 Breast Mastectomy - any type 

11.23 Breast Axillary Dissection 

11.24 Breast Wide excision 

11.25 Breast Wide excision + Reconstruction 

11.26 

11.27 

11.28 

11.29 

11.30 

11.31 

11.32 

11.33 

Lung 

Cancer 

Lung 

Cancer 

Lung 

Cancer 

Lung 

Cancer 

Head & 

Neck 

Head & 

Neck 

Head & 

Neck 

Head & 

Neck 

Pneumonectomy 

Lobectomy 

Decortication 

Surgical Correction of 

Bronchopleural Fistula. 

Resection of Nasopharyngeal 

Tumor 

Craniofacial resection of any type 

Composite Resection & 

Reconstruction of any type 

Neck Dissection - any type 

Biopsy, X-rays, 

Mammogram, 

Photograph, USG, CT, 

Bone scan 


Mammogram, 

Photograph, USG, CT, 

Bone scan 


Mammogram, 

Photograph, USG, CT 


Mammogram, 

Photograph, USG, CT 

Biopsy , CT , X-RAY, PET 

scan, CT brain 


scan (SOS) 


scan, CT brain 


Biopsy, CT/MRI 

CT/ MRI, Biopsy 

Clinical Photograph/X- 

Ray,USG/biopsy/CT 


Photograph , USG , X- 

RAY, CT Scan 




Photograph 


Photograph 


Photograph 


Photograph 










Photograph 


Photograph 


biopsy 


Photograph 


11.34 

11.35 

11.36 

11.37 

11.38 

11.39 

11.40 

11.41 

11.42 

11.43 

11.44 

11.45 

Head & 

Neck 

Head & 

Neck 

Head & 

Neck 

Head & 

Neck 

Head 

&Neck 

Head 

&Neck 

Head & 

Neck 

Head & 

Neck 

Ca. 

Salivary 

Gland 

Ca. 

Trachea 

Ca. 

Trachea 

Ca. 

Parathyroi 

d 

Hemiglossectomy 

Maxillectomy - any type 

Thyroidectomy - any type 

Parotidectomy - any type 

Laryngectomy - any type 

Laryngopharyngo Oesophagectomy 

Hemimandibulectomy 

Wide excision 

Submandibular Gland Excision 

Tracheal Resection 

Sternotomy + Superior Mediastinal 

Dissection 

Parathyroidectomy 



RAY, MRI 

x-ray of maxilla, 

CT/MRI, biopsy 



RAY, CT Scan 



RAY, CT Scan 



RAY, CT Scan 



RAY, CT Scan 



RAY, OPG/CT scan 



RAY 



RAY 

Biopsy, CT, 

Bronchoscopy 

Biopsy, CT 



RAY, Serum 

Parathormone 


Photograph 

biopsy and Clinical 

Photograph 


Photograph 


Photograph 


Photograph 


Photograph 


Photograph 


Photograph 


Photograph 


biopsy 


biopsy 


Photograph 


11.46 

11.47 

Ca. Gastro 

Intestinal 

Tract 

Ca. Gastro 

Intestinal 

Tract 

11.48 Ca.Rectum 

11.49 

Ca. Gall 

Bladder 

Small bowel resection 

CT/ Barium Meal Follow 

through 


biopsy 

Closure of Ileostomy/ Colostomy Colonoscopy Clinical Photograph 

Abdomino Perineal Resection (APR) 

+Sacrectomy 

Radical Cholecystectomy 

CT/BMFT, 

Colonoscopy,Biopsy, 

CEA, PET Scan 

CT , USG, PET Scan 

11.50 Spleen Radical Splenectomy CT , USG 

11.51 

11.52 

11.53 

11.54 

11.55 

11.56 

11.57 

Gastro 

Intestinal 

System 

Gastro 

Intestinal 

System 

Gastro 

Intestinal 

System 

Urinary 

Bladder 

Gastro 

Intestinal 

System 

Gastro 

Intestinal 

System 

Gastro 

Intestinal 

System 

Resection of Retroperitoneal 

Tumors 

Abdominal wall tumor Resection 

Resection with reconstruction 

Bilateral pelvic lymph Node 

Dissection(BPLND) 

Oesophagectomy - any type 

Gastrectomy - any type 

Colectomy - any type 

Barium meal test, CT 

abdomen, biopsy 

USG, CT abdomen, 

biopsy 

USG, CT abdomen, 

biopsy 

CT, Biopsy 

Biopsy , CT , Endoscopy 

,USG, PET SCAN 

Biopsy , CT , Endoscopy 

,USG, PET SCAN 

Biopsy , CT , Endoscopy , 

USG, CEA 


biopsy 





Biopsy, clinical 

photograph 


PHOTOGRAPH 


PHOTOGRAPH 


biopsy 








11.58 

11.59 

11.60 

11.61 

Gastro 

Intestinal 

System 

Gastro 

Intestinal 

System 

Gastro 

Intestinal 

System 

Gastro 

Intestinal 

System 

Anterior Resection 

Abdominoperinial Resection 

Triple Bypass 

Other Bypasses-Pancreas 


USG, CEA 


USG, CEA 


USG 


USG 

11.62 Gynaec Radical Trachelectomy CT/MRI, Biopsy 

11.63 Gynaec Radical vaginectomy CT, Biopsy 

11.64 Gynaec 

11.65 

11.66 

11.67 

11.68 

Gynaec- 

Ca.Cervix 

Gynaec- 

Ca.Cervix 

Gynaec- 

Ca.Cervix 

Gynaec- 

Ca.Cervix 

11.69 Chest 

11.70 Chest 

Radical vaginectomy + 

Reconstruction 

Radical Hysterectomy +Bilateral 

Pelvic Lymph Node Dissection 

(BPLND) + Bilateral Salpingo 

Ophorectomy (BSO) / Ovarian 

transposition 

Anterior Exenteration (Gynaec) 

Posterior Exenteration (Gynaec) 

Total Pelvic Exenteration 

Chest wall resection for SOFT 

tissue bone tumors 

Chest wall resection + 

Reconstruction 

CT, Biopsy 

Pap Smear / biopsy, CT 




Biopsy, CT Chest, Bone 

Scan 

Biopsy, CT Chest, Bone 

Scan 










biopsy 


biopsy 


biopsy 


biopsy 


biopsy 


biopsy 


biopsy 


biopsy 


biopsy 


11.71 

11.72 

11.73 

11.74 

11.75 

11.76 

11.77 

Bone / soft 

tissue 

tumors 

Bone / soft 

tissue 

tumors 

Bone / soft 

tissue 

tumors 

Bone / soft 

tissue 

tumors 

Renal Cell 

Cancer 

Renal Cell 

Cancer 

Testes 

cancer 

Limb salvage surgery for Bone 

Tumors with modular Prosthesis 

Forequarter amputation 

Hemipelvectomy 

Bone resection 

Partial Nephrectomy 

Nephroureterectomy for 

Transitional Cell Carcinoma of 

renal pelvis (one side) 

Retro Peritoneal Lymph Node 

Dissection(RPLND) (for Residual 

Disease) 

11.78 Tumours Adrenalectomy 

11.79 

11.80 

11.81 

11.82 

Testes 

cancer 

Testes 

cancer 

Ca. 

Urinary 

Bladder 

Ca. 

Urinary 

Bladder 

Urinary diversion 

Retro Peritoneal Lymph Node 

Dissection RPLND as part of 

staging 

Anterior Exenteration (Urinary 

Bladder) 

Total Exenteration (Urinary 

Bladder) 

CT-Local part, CT 

Chest,MRI, Bone Scan 

Biopsy, CT Chest 

Biopsy, CT/MRI Pelvis, 

CT Chest, PET scan 

CT/MRI, Biopsy 

CT/Isotope renogram 

CT, Biopsy 

CT-Chest, CT.Abd+Pelvis, 

Tumor markers, biopsy 

CT/MRI, Urinary 

hormones 

biopsy, USG Scrotum 

CT, biopsy 

Cystoscopy, biopsy/CT 

Cystoscopy, biopsy/CT 


biopsy 

Clinical 

Photlograph/ X-Ray, 

biopsy 

Clinical 

Photlograph/ X-Ray, 

biopsy 

Clinical 

Photograph/X-ray, 

biopsy 


biopsy 


biopsy 


biopsy 


biopsy 


biopsy 


biopsy 


biopsy 


biopsy 


11.83 

11.84 

Ca. 

Urinary 

Bladder 

Thoracic 

and 

Mediastinu 

m 

Bilateral pelvic lymph Node 

Dissection(BPLND) 

Mediastinal tumor resection 

11.85 Lung Lung metastatectomy of any type 

11.86 Lung Sleeve resection of Lung cancer. 

11.87 Esophagus 

11.88 Esophagus 

11.89 

11.90 

11.91 

11.92 

11.93 

11.94 

11.95 

11.96 

11.97 

Palliative 

Surgeries 

Palliative 

Surgeries 

Palliative 

Surgeries 

Palliative 

Surgeries 

Palliative 

Surgeries 

Palliative 

Surgeries 

Palliative 

Surgeries 

Palliative 

Surgeries 

Palliative 

Surgeries 

Oesophagectomy with Two field 

Lymphadenectomy 

Oesophagectomy with Three field 

Lymphadenectomy 

CT, biopsy 


biopsy 


CT 

CT, biopsy, Bone scan/ 

PET scan 

CT/ Bronchoscopy, 

biopsy, PET scan 

UGI Endoscopy, biopsy / 

CT 

UGI Endoscopy, biopsy / 

CT 


biopsy 

X-Ray, Biospy 

X-Ray, Biospy 


biopsy 


biopsy 

Tracheostomy Clinical Photograph Clinical Photograph 

Gastrostomy Clinical Photograph Clinical Photograph 

Jejunostomy Clinical Photograph Clinical Photograph 

Ileostomy Clinical Photograph Clinical Photograph 

Colostomy Clinical Photograph Clinical Photograph 

Suprapubic Cystostomy Clinical Photograph Clinical Photograph 

Gastro Jejunostomy 

Ileotransverse BYPASSColostomy 

Substernal bypass 

USG, CT SCAN, Clinical 

Photograph 

CT SCAN, USG, 

Endoscopy, Biopsy, 


CT SCAN, USG, 

Endoscopy, Biopsy, 


biopsy 


biopsy 


biopsy

11.98 

11.99 

11.100 

11.101 

11.102 

11.103 

Reconstruc 

tion 

Reconstruc 

tion 

Soft Tissue 

and Bone 

Tumors 

Soft Tissue 


Tumors 

Soft Tissue 


Tumors 

Genito 

Urinary 

System 

11.104 Ano-rectal 

11.105 

Gastro 

Intestinal 

Surgery 


Myocutaneous / cutaneous flap Clinical Photograph Clinical Photograph 

Micro vascular reconstruction 

Wide excision - for soft tissue and 

bone tumors 

Wide excision + Reconstruction for 

soft tissue and bone tumors 

Amputation for bone / soft tissue 

tumours (Major / Minor) 

Inguinal Block Dissection-both 

side 

Law Anterior resection OR 

Sphincter preserving surgery of 

any type 

Laproscopic resection of any type 

11.106 Liver Hepatic surgery of any type 

11.107 

Lung & 

Oesophagu 

s 

Thoracoscopic and Laproscopic 

surgery of any type 

Doppler study, Clinical 

Photograph 


biopsy 


biopsy 


biopsy 


Photograph, CT scan 

CT/ BMFT, Colonoscopy, 

Biopsy, CEA 

Barium meal test, CT 

abdomen, biopsy, 

Endoscopy, Tumor 

Marker 

CT abdomen, biopsy, 

Endoscopy, Tumor 

Marker 


Endoscopy 



biopsy 


biopsy 


Biopsy 












11.108 

11.109 

11.110 

11.111 

11.112 

11.113 

Genito 

Urinary 

System 

Brain 

Tumour 

Gynaec 

Body of the 

uterus 

Laproscopic surgery for kidney & 

supra renal any type 


Endoscopy 



Brain tumours surgery of any type CT/ MRI, Biopsy CT, Photograph 

TAH + BSO + BLND + O.S. 

Bone & 

Hind Quarter Amputation 

soft tissue 

Bone & 

soft tissue 

Gynaec 

CIN Early Radical Trachelectomy Cone 

cancer of Biopsy, 

Simple 

any female 

Hysterectomy 

organ 

Total of cluster 11 (1 to 113) 

Biopsy, CT scan, USG, 

CA 125 

MRI, Bone scan & PET 

scan 

CT, Biopsy, 

Photograph 

CT, Biopsy, 

Photograph 

Hip & Knee Disarticulation MRI Photograph 

Biopsy, CT scan, USG, 

CA 125 

Biopsy, USG 

Sr. No. 

11A.1 

Main 

Speciality 

Oncology 

Hematology 

with imaging 

Cluster 11A, Oncology Follow-up packages 


Subspeciality 

Lymphoma - 

NHL and HD, 

CLL 

Essential/ Mandatory 

investigations required 

Physical examination, Blood 

investigation, Imaging - CT 

scan/USG, Chest X-ray 

Minimum Standard 

follow-up required in 

years (Expected No. 

of Survivors in %) at 

last follow-up 

Physical examination 

& lab investigations- 

1-3 monthly for 1-2 

years, 3-6 monthly 

for 3-5 years and 

then as clinically 

indicated. Imaging - 

Maximum 

extended 

follow-up 

(Expected no. 

of survivors 

in %) 

5 years 

Rate 

per 

follow 

up (in 

Rs.) 


CT scan 6 monthly 

for 2 years and then 

as clinically indicated 

11A.2 

Oncology 

Hematology 

without 

imaging 

Multiple 

Myeloma 

11A.3 Oncology AML, ALL 

11A.4 Oncology APML 

Physical examination, Blood 

investigation, Protein 

electrophoresis, Imaging (as 

indicated) 

Physical examination and 

Complete blood counts (CBC) 

with peripheral smear 



with peripheral smear, RT- 

PCR for PML-RARa 


& lab investigations 

with protein 

electrophoresis 3 

monthly. (Bone 

marrow exam, 

skeletal survey, MRI 

- as clinically 

indicated) 


&Complete blood 

counts (CBC) for 1-3 

monthly for 2 years, 

then 3-6 monthly for 

5 years. Bone 

marrow examination 

only if abnormal 

peripheral smear 



counts (CBC) for 1-3 

monthly for 2 years, 

then 3-6 monthly for 

5 years. Bone 


only if abnormal 

peripheral smear. 

RT-PCR for PML- 

RARa 3 monthly for 2 

years 

5 years 

5 years 

5 years 


11A.5 Oncology CML 

11A.6 

Oncology 

Paediatric 

oncology 

with tumour 

markers 

Hepatoblasto 

ma, Germ 

cell tumours 

Neuroblasto 

ma, 

Retinoblasto 

ma, Wilm's 

tumour, E- 

wing's 

sarcoma, 

Rhabdomy 



with peripheral smear, RT- 

PCR for Bcr-abl 

Physical examination, 

Imaging, tumour markers 



counts (CBC) with 

peripheral smear 3 

monthly, RT-PCR for 

Bcr-abl every 3 

monthly, Bone 


and cytogenetics 

every 6 monthly for 

1-2 years and then 

as clinically indicated 

Physical 



Tumour markers 1-3 

monthly for first 2 

years then 3-6 

monthly for 3-5 years 

and then after 

annually. Imaging 

every 6 monthly for 2 

years and then as 

clinically indicated 


and blood 

investigations 1-3 

monthly for first 3 

years then 3-6 

monthly for 4-5 years 

and then after 

annually. Imaging 

every 6 monthly for 2 

years and then as 

5 - 10 years 

5 years 

Oncology 

Paediatric 

oncology 

11A.7 

with tumour 

markers osarcoma 

Physical examination, 

Imaging 

clinically indicated 5 years 

11A.8 Oncology Gynaec with Biopsy, Tumour Markers, X- 3 monthly for 2 5 years 


11A.9 Oncology 



Tumour 

markers 

(Carcinoma 

ovary & 

endometrium 

, GTN) 

Gynaec 

without 

Tumour 

markers 

(Carcinoma 

cervix, vagina 

& vulva) 

Solid 

tumours with 

tumour 

marker (GI 

tumour, 

testicular 

tumour, 

prostate 

cancer) 

Solid 

tumours 

without 

tumour 

marker (Lung 

tumour, 

breast 

cancer, 

sarcoma, 

bladder 

cancer, 

kidney and 

suprarenal 

cancer, 

ray, USG, CT scan 

Biopsy, X-ray, USG, CT scan 

Biopsy, X-ray, USG, CT scan/ 

MRI, PET, Tumour marker 

Biopsy, X-ray, USG, CT scan/ 

MRI, PET 

years, 6 monthly for 

3-5 years 

3 monthly for 2 


3-5 years 5 years 








oesophagus 

and stomach 

cancer) 

Sr. 

No. 

12.1 

Sub-specialty 

Solid tumours Initially 

inoperable disease (H&N 

cancer, Ca. Oesophagus, 

Ca. Ovary, Ca. Lung, 

Colorectal cancer, 

Osteosarcoma, E-wing's 

sarcoma) 

12.2 Breast Initially Inoperable 

12.3 Breast Initially Operable 

12.4 

Solid tumours - Initially 

operable (H&N cancer, Ca. 

Oesophagus, Ca. Ovary, 

Ca. Lung, Colorectal 

cancer, Osteosarcoma, E- 

wing's sarcoma, Ca. Testis, 

Ca. Bladder, Ca. penis, Ca. 

Cervix, Ca. Body Uterus, 

RCC, Pediatric solid 

tumours, Ca. Pancreas, 

Ca. GB, Brain Tumours) 

Cluster-12, Combined Oncological Packages 

Main Speciality: Oncology 

Package Rates 


(in Rs.) 

Neoadjuvant CT or 

Neoadjuvant CT + RT 

followed by surgery then 

Adjuvant CT +/- RT if not 

given in Neoadjuvant setting 

Neoadjuvant CT or hormonal 

therapy +/- Herceptin 

followed by Surgery - 

Adjuvant CT +/- RT +/- 

Herceptin 

Surgery followed by 

Adjuvant CT +/- RT +/- 

Herceptin 

Surgery followed by 

Adjuvant CT +/- RT 

12.5 Solid tumours requiring Initial palliative surgery 

Pre-operative 

Investigation 


Investigation 


initial surgery: (Ca. Testis, 

RCC, Colorectal- 

Colostomy, Ca. Ovary - de 

bulking, Brain tumour - 

De bulking) 

followed by palliative CT +/- 

RT 

12.6 Solid tumours advanced 

Plan a: Palliative CT +/- RT 

Plan b: Palliative hormonal 

treatment (Ca. Breast, Ca. 

Endometrium) 

Plan c: Palliative CT + 

Targeted therapy (Colorectal 

Ca., Ca. Breast, Ca. Ovary, 

Ca. Lung, Ca. Pancreas, Ca. 

Stomach, H&N Ca.) 

Hematological Malignancies: Specific treatment protocols contain all the components of therapy according to protocols 

Note: The pre-operative investigations and the post-operative investigations should be as per the standard 

procedures/ protocols required for individual patients 

Cluster12A, COMBINED ONCOLOGICAL FOLLOW UP PACKAGE 


Sr. No. Sub-specialty Procedure Name 

Solid tumours Initially 

inoperable disease (H&N 

cancer, Ca. Oesophagus, Ca. 

Ovary, Ca. Lung, Colorectal 

cancer, Osteosarcoma, E- 

12A.1 wing's sarcoma) 

12A.2 Breast Initially Inoperable 

Neoadjuvant CT or Neoadjuvant CT 

+ RT followed by surgery then 

Adjuvant CT +/- RT if not given in 

* Follow 

up 

Neoadjuvant setting 9 

Neoadjuvant CT or hormonal 

therapy +/- Herceptin followed by 

Surgery - Adjuvant CT +/- RT +/- 

Herceptin 9 

Rates per 

Follow up 

(in Rs.) 


package rate (as 

included in 

above package) 

in Rs. 


12A.3 Breast Initially Inoperable 

Solid tumours - Initially 

operable (H&N cancer, Ca. 

Oesophagus, Ca. Ovary, Ca. 

Lung, Colorectal cancer, 

Osteosarcoma, E-wing's 

sarcoma, Ca. Testis, Ca. 

Bladder, Ca. penis, Ca. 

Cervix, Ca. Body Uterus, 

RCC, Pediatric solid 

tumours, Ca. Pancreas, Ca. 

12A.4 GB, Brain Tumours) 

Solid tumours requiring 

initial surgery: (Ca. Testis, 

RCC, Colorectal- Colostomy, 

Ca. Ovary - de bulking, Brain 

12A.5 tumour - De bulking) 

Surgery followed by Adjuvant CT 

+/- RT +/- Herceptin 9 

Surgery followed by Adjuvant CT 

+/- RT 9 

Initial palliative surgery followed by 

palliative CT +/- RT 9 

Plan a: Palliative CT +/- RT 

Plan b: Palliative hormonal 

treatment (Ca. Breast, Ca. 

Endometrium) Plan c: 

Palliative CT + Targeted therapy 

(Colorectal Ca., Ca. Breast, Ca. 

Ovary, Ca. Lung, Ca. Pancreas, Ca. 

Stomach, H&N Ca.) 9 

12A.6 Solid tumours advanced 

* Follow up: The Number of follow ups are mentioned for the financial bidding purpose, which may increase or 

decrease as per the standard procedures/ protocols required for individual patients 

Cluster-13 

Rate per Km. of hearse (vehicle from transporting the dead body) in case if any 

death occurs at the network Hospital. 

Note: 

Rate per 1 km (in Rs.) 


If any bid submitted by any bidder is found to be unreasonable financial evaluation committee may ask for a 

detailed cost breakup to be presented on the stop and may then decide to qualify/disqualify that particular 

bid. 

The bidder with the lowest surgery package rate (L1) will be awarded that contract. However, the bidder will 

be awarded the contract ONLY if the bidder also agrees to match the lowest package rates of other surgeries of 

that particular cluster. 

If the L1 bidder does not agree to match L1 rate of other surgeries of that Cluster then L2 bidder will be given 

the choice to match both, the same particular surgery and the cluster surgeries lowest bids and so on. 

If at the end of negotiations no agreement is arrived at about the package rates financial evaluation committee 

may work out a formula for arriving at package rates based on the present bid rates or based on the advice of 

the expert committee. 

The rates finalized will be valid for next 3 years or as decided by the State Nodal Cell 

The empanelled Hospitals who are registered under NABH/JCI(Joint Commission International)/ 

ACHS(Australia) or by any other accreditation body approved by International society for Quality in 

Healthcare(ISQua) will get 2.5% extra as quality incentive over and above the Package Rates 


GENERAL GUIDELINES ON THE BENEFIT PACKAGE 

ANNEXURE – 6 

1. The Benefit Package includes cost of consultation, medicine, 

diagnostics, implants, food, transportation, Hospital charges etc. In 

other words the package covers the entire cost of treatment of patient 

from the date of reporting till the date of discharge from the Hospital 

and also post Hospitalization cost up to 10 days, making the 

transaction truly cashless to the patient. Further under any 

circumstances, Hospital shall not charge any money within the 

treatment period as covered under the package. 

2. The post-operative Hospital stay in all procedures shall be normally 

10 days. 

3. Provider shall conduct all required diagnostic tests and medical 

treatment free of cost for a beneficiary who is likely to undergo a 

surgery / therapy under Mukhyamantri Amrutum (MA) Yojana. The 

cost of various treatment/tests conducted on the BPL family members 

who are evaluated but ultimately do not undergo surgery or therapies 

shall be borne by the Provider and the Provider shall not charge any 

fee for consultation and investigation from the beneficiary. 

4. Provider shall provide 10 days post discharge free medicines to the 

patient within the package. 

5. Provider shall provide reasonably good food to the patient, and shall 

make alternate arrangement for food wherever in-house pantry is not 

available. The Hospital shall not give money as an alternative to food. 

6. Provider shall reimburse the cost of transport Rs.300 per visit with a 

maximum limit of Rs.3000 per year. The acknowledgement sheet 

generated from the portal needs to be signed by the Patient and the 

signed copy should be scanned and uploaded to the Implementing 

Support Agency (ISA) Portal. 

7. Provider shall use standard FDCA approved prosthetics and implants 

for surgical procedures and shall not charge extra cost from the 

patient on the ground of providing a better prosthetic/implant, 

however if there is genuine technical reason to justify such a higher 

value prosthetic/implant it can request Implementing Support Agency 

(ISA) to approve enhancement with evidence. 


8. Provider shall assist and facilitate the patient to procure compatible 

blood for the surgeries. The Hospital shall provide blood from its own 

blood bank subject to availability within the package. In case of nonavailability 

the Hospital shall make efforts to procure from other blood 

banks, Red Cross, voluntary organizations etc. The Hospital shall also 

issue a copy of the request letter to the patient. 

9. Prostheses: 

a. The prosthesis to be used are should be FDCA approved only. 

b. Cost of prosthesis is inclusive of foot and shoe, wherever 

required. 

c. Prosthesis must have been manufactured with the materials 

with BIS (Bureau of Indian Standards) certification. 

d. All prosthesis shall be functional in nature. 

e. Manufacturer shall give minimum of 3 years replacement 

Guarantee. 

f. Manufacturer shall provide free replacement of leather 

parts/straps etc., during this period apart from replacement 

guarantee. 


GENERAL GUIDELINES ON HOSPITAL SERVICES 

ANNEXURE- 7 

1. Allocation of beds in Network Hospitals for Mukhyamantri Amrutum 

(MA) Yojana Patients: The Network Hospitals shall allocate at least 

25% of the bed capacity for admitting Mukhyamantri Amrutum (MA) 

Yojana patients. 

2. Conduct of Outpatient services: 

a) Provider shall ensure separate OP facilities for Mukhyamantri 

Amrutum (MA) Yojana patients by establishing exclusive 

Mukhyamantri Amrutum (MA) Yojana counter / kiosk, to be manned 

by “Hospital Arogya Mitra” of the Network Hospital and Arogya Mitra 

appointed by ISA. 

b) General counseling should be done for all OP patients to ascertain 

their eligibility under Mukhyamantri Amrutum (MA) Yojana to avoid 

conversion in to cash patients at a later date. 

3. Conversion of cash patients into Mukhyamantri Amrutum (MA) 

Yojana: To avoid conversion of cash patients into Mukhyamantri 

Amrutum (MA) Yojana Beneficiaries, the Provider shall take a declaration 

from patient at the time of admission on the applicability or otherwise of 

Mukhyamantri Amrutum (MA) Yojana. In emergency /trauma cases, 

patients may be allowed 48 hours after admission to claim 

Mukhyamantri Amrutum (MA) Yojana benefit. 

However, Provider agrees to the package to be authorized even for those 

patients who were admitted as non-Mukhyamantri Amrutum (MA) Yojana 

out of ignorance but subsequently identified as Mukhyamantri Amrutum 

(MA) Yojana beneficiary during the course of stay in the Hospital. In the 

meanwhile, any payment received from the patient shall be refunded 

immediately after getting preauthorization approval and before discharge 

of the patient from the Hospital duly obtaining a receipt from the patient. 

4. Conduct of Inpatient services: Provider should not refuse to admit any 

Mukhyamantri Amrutum (MA) Yojana patients where it has consultants 

and equipment in any specialty that is covered under the Mukhyamantri 

Amrutum (MA) Yojana. A minimum of 25% of overall bed capacity under 

each specialty have to be made available to Mukhyamantri Amrutum 

(MA) Yojana patients in Network Hospitals. 


5. Conduct of Health Camps: Provider shall conduct Health Camps and 

adhere to the schedule as fixed by the Implementing Support Agency 

(ISA). In camps, Hospitals need to educate people on preventive 

measures, distribute medicines and ensure coordination with Arogya 

Mitra and the concerned SDH/DH/PHC / CHC doctors. 

6. Follow-up services to Mukhyamantri Amrutum (MA) Yojana 

Beneficiaries: Provider shall provide cashless facility for follow-up 

treatments for identified diseases. The follow-up benefit package 

includes the cost of medicines, diagnostic tests and consultations. 

(Please refer Annexure-VI for detail guidelines on follow-up services) 


ANNEXURE –8 

FOLLOW-UP SERVICES FOR MUKHYAMANTRI AMRUTUM (MA) YOJANA 

BENEFICIRIES 

The package charges will include the follow-up charges for the specific 

surgical procedures as mentioned in annexure-5. The follow-up includes 

the cost of consultation, investigations, drugs etc. for one year. Please refer 

following guidelines and process flow for providing cashless services during 

follow-up under Mukhyamantri Amrutum (MA) Yojana. 

A. Guidelines: 

1) The follow-up covers entire cost of follow-up i.e., consultation, medicines, 

diagnostic tests etc. for one year. 

2) Follow-up treatment shall be entirely cashless to the patient and will start 

on 11 th day after patient‟s discharge and will continue for one year after 

11th day of discharge. 

3) Pre-authorization will not be required for follow-up services. 

4) For operational convenience package amount is apportioned as total 

package charge including follow up charges. The bidder has to give rates per 

follow up and total follow up package rates as considered in the total 

package charge. 

For example: If the total package rate for Oesophageal atresia –1.pure 

atresia-first stage(‘o’stomy & ‘G’stomy) under Gastro Intestinal Tract under 

Paediatric Surgeries is of Rs.30,000/-. The total follow ups are- 6, and the 

rate per follow up is of Rs.500/-, then the first claim (bill) will be of 

Rs.27,000/- (subjected to submission of necessary documents as mentioned 

in RFP). The balance payment will be settled @ Rs.500/- per visit based on 

the actual no. of follow-ups taken up by the patient. 

The network Hospital will raise separate bill for the follow up packages along 

with the claim necessary papers. The follow up package amount will be 

released quarterly based on the no. of follow ups. 

Under oncological if the patient requires further follow-ups extending to next 

year then in such cases based on per follow up rate the claims will be 

reimbursed. 

5) However the entire package amount must be treated as single entity and 

Hospital shall not refuse to conduct investigations free of cost under the 

package any time during one year follow-up period. 


6) The Patient follow-up visits may be spaced according to medical 

requirement or as suggested in the RFP, but approval will be given for one 

quarter. 

B. Process Flow: 

1. Patient is counseled at the time of discharge about the importance of 

follow-up and availability of free services by the Hospital. 

2. The first follow-up date shall be on 11th day after discharge as first 10 

days treatment is provided under surgical benefit package. The date and 

other details shall be indicated in the Discharge Summary. 

3. Hospital shall specifically inform the patient about the date and time of 

subsequent follow-up visits, duly making entry in the online application of 

Implementing Support Agency (ISA) portal based on standard medical 

protocols. 

4. Hospital shall send proof of follow-up services of patient and submit to 

Implementing Support Agency (ISA) once in three months for each quarter 

by uploading the following details in the Implementing Support Agency (ISA) 

portal: 

1. Details of consultation 

2. Details of medicines given 

3. Details of Investigations done along with reports. 

4. Acquaintance from patients in the prescribed format 

5. Photograph showing the medicines provided to the patient. 

6. Bills for medicines and diagnostics (to be scanned and 

uploaded) 

5. Implementing Support Agency (ISA) shall settle claim as per package 

amount based on above proof. 

6. Hospital shall claim follow-up charges only for the disease mentioned 

along with the code and no other claim shall be entertained by 

Implementing Support Agency (ISA). 


PROCESS NOTE FOR DE-EMPANELMENT OF HOSPITALS 

ANNEXURE- 9 

Background 

This process note provides broad operational guidelines regarding Deempanelment 

of Hospitals which are empanelled in MA Yojana. The process 

to be followed and roles of different stakeholders have been outlined. 

Process To Be Followed For De-Empanelment of Hospitals: 

Step 1 – Putting the Hospital on “Watchlist” 

1. Based on the claims data analysis and/ or the Hospital visits, if there is 

any doubt on the performance of a Hospital, the ISA or its 

representative can put that Hospital in the watch list. 

2. The data of such Hospital shall be analysed very closely on a daily basis 

by the ISA or its representatives for patterns, trends and anomalies. 

3. The ISA will immediately inform the State Nodal Cell also about the 

Hospital which have been put in the watch list within 24 hours of this 

action. 

Step 2 – Suspension of the Hospital 

4. A Hospital can be temporarily suspended in the following cases: 

a. For the Hospitals which are in the “Watchlist” if the ISA observes 

continuous patterns or strong evidence of irregularity based on 

either claims data or field visit of Hospitals, the Hospital shall be 

suspended from providing services to MA patients and a formal 

investigation shall be instituted. 

b. If a Hospital is not in the “Watchlist”, but the SNC/SEGRDC 

observes at any stage that it has data/ evidence that suggests that 

the Hospital is involved in any unethical practice/ is not adhering to 

the major clauses of the contract with the ISA or their 

representatives/ involved in financial fraud related to MA patients, it 

may immediately suspend the Hospital from providing services to 

MA patients and a formal investigation shall be instituted. 

c. A directive is given by State Nodal Cell based on the complaints 

received directly or the data analysis/ field visits done by State 

Nodal Cell. 

5. The State Nodal Cell should be informed of the decision of suspension 

of Hospital within 24 hours of this action. 


6. To ensure that suspension of the Hospital results in their not being 

able to treat MA patients, a provision shall be made in the software so 

that Hospital cannot send electronic claims data to the ISA. 

7. A formal letter shall be sent to the Hospital regarding its suspension 

with mentioning the timeframe within which the formal investigation 

will be completed. 

Step 3 – Detailed Investigation 

8. The ISA can launch a detailed investigation into the activities of a 

Hospital in the following conditions: 

a. For the Hospitals which have been suspended. 

b. Receipt of complaint of a serious nature from any of the 

stakeholders 

9. The detailed investigation may include field visits to the Hospitals, 

examination of case papers, talking with the Beneficiaries (if needed), 

examination of Hospital records etc. 

10. If the investigation reveals that the report/ complaint/ allegation 

against the Hospital is not substantiated, the ISA would immediately 

revoke the suspension (in case it is suspended) and inform the same to 

the State Nodal Cell. 

a. A letter regarding revocation of suspension shall be sent to the 

Hospital within 24 hours of that decision. 

Step 4 – Action by the ISA 

11. If the investigation reveals that the complaint/allegation against the 

Hospital is correct then following procedure shall be followed: 

a. The Hospital must be issued a “show-cause” notice seeking an 

explanation for the aberration and a copy of the show cause notice is 

sent to the State Nodal Cell. 

b. After receipt of the explanation and its examination, the charges 

may be dropped or an action can be taken. 

c. The action could entail one of the following based on the seriousness 

of the issue and other factors involved: 

i. A warning to the concerned Hospital, 

ii. De-empanelment of the Hospital. 

12. The entire process should be completed within 30 days from the date of 

suspension. 

Step 5 – Actions to be taken after De-empanelment 

13. Once a Hospital has been de-empanelled from MA Yojana, following 

steps shall be taken: 

a. A letter shall be sent to the Hospital regarding this decision with a 

copy to the State Nodal Cell 


. MHC card of the Hospital shall be taken by the ISA and given to the 

District Key Manager 

c. Details of de-empanelled Hospital shall be sent by State Nodal Cell 

so that it can be put on MA website. 

d. An FIR shall be lodged against the Hospital by the ISA at the earliest 

in case the de-empanelment is on account of fraud or a fraudulent 

activity. 

e. The ISA which had de-empanelled the Hospital, may be advised to 

notify the same in the local media,, informing all Beneficiaries about 

the de-empanelment, so that the Beneficiaries do not utilize the 

services of that particular Hospital. 

f. If the Hospital appeals against the decision of the ISA, all the 

aforementioned actions shall be subject to the decision of the 

concerned Committee. 

Grievance by the Hospital 

14. The Hospital can approach the State Empanelment, Grievance 

Redressal and Disciplinary Committee for the Redressal. The State 

Empanelment, Grievance Redressal and Disciplinary Committee will 

take a final view within 30 days of the receipt of representation. 

However, the Hospital will continue to be de-empanelled till the time a 

final view is taken by the State Empanelment, Grievance Redressal and 

Disciplinary Committee. 

Special Cases for De-empanelment 

In the case where ISA does not want to continue with a particular Hospital 

in a district it can de-empanel that particular Hospital after consultation 

with the State Nodal Cell and the District Key Manager. However, it should 

be ensured that adequate numbers of Hospitals are available in the district 

for the Beneficiaries. 


ROLES AND RESPONSIBILITIES OF AROGYA MITRAS 

ANNEXURE-10 

1. He/She should deal with the patients in a friendly and pleasant 

manner. 

2. He/She should be in apron during duty hours and strictly adhere to 

duty timings 

3. He/She should show patience and empathy while dealing with 

patients. 

4. He/She should always keep the CUG switched on round the clock and 

should attend to all the Incoming calls politely. 

5. He/She should bring to the notice of their superiors any irregularity 

or inadequacy noticed. 

6. Maintain Help Desk at reception of the Hospital. 

7. He/She should receive the patients, verify the documents, register 

them and direct them to the Hospital Arogya Mitra ( Mukhyamantri 

Amrutum Yojana Medical Coordinator) for further screening and 

management. 

8. Facilitate the patient for a cashless transaction. 

9. Obtain photograph of the patient - bedside. 

10. Facilitate early evaluation and prevent delay in approvals by 

submitting the preauthorization complete in all respects. 

11. Should ensure that patient is on bed from the time of preauthorization 

request is sent till the approval is obtained. 

12. He/She should do regular rounds in the wards and ensure that the 

patient is getting all the benefits of the Mukhyamantri Amrutum 

Yojana. 

13. Ensure that Hospital is giving free Quality Food to all the Beneficiaries 

who are In-Patients. 


14. Facilitate the patient to get the transport charges reimbursed and to 

ascertain whether follow-up Medicines are served as per the 

guidelines. 

15. At the time of discharge, He/She should take a photograph of the 

patient standing in front of the Mukhyamantri Amrutum Yojana 

KIOSK besides the Arogya Mitras with Discharge Summary in one 

hand and Transportation amount and slip in the other hand and 

upload the same in the website. 

a) Obtain feed back from the patient. 

b) Counsel the patient regarding follow-up. 

c) Coordinate with PHC/Government Hospital Arogya Mitrafor 

follow-up of Beneficiaries. 

16. Coordinate with the Implementing Support Agency (ISA) and ISA 

officers for any clarifications. 

17. He/She should inform the Call-Center immediately in case of a death 

and should send the Death Reports. 

18. Send Daily reports as per the formats given by the Head Office to the 

Call-Center and to the Team Leader/Co-coordinator. 

19. Facilitate Network Hospital in conducting Health Camps as scheduled. 

20. Facilitate Network Hospital in sending claims. 

21. There should be clear communication between Night shift and Day 

shift Arogya Mitras and handing over the Duty rooster must be 

smooth and complete. 

22. All Grievances should immediately be brought in to the notice of 

Grievance Department directly or through Hierarchy. 

23. Arogya Mitra should be un-biased while judging the 48 Hrs deadline 

given for the patient in furnishing Bar Coded Plastic Card at 

Mukhyamantri Amrutum Yojana Counter to avail Scheme benefits. 

The Arogya Mitrashall help the patient in producing the Bar Coded 

Plastic Card before the deadline. 

24. He/She should facilitate the Hospital in giving prior phone intimation 

to the Implementing Support Agency (ISA) for carrying out the 

emergency surgeries. 

25. He/She should ensure that all the updating like surgery, postoperative 

notes and discharge details are done in time on the website. 


ANNEXURE –11 

ROLES AND RESPONSIBILITIES OF HOSPITAL AROGYA MITRAS 

1. He/She shall ensure that all required evaluation including diagnostic 

tests are done free of cost for all Beneficiaries and the details of the 

same along with reports are captured in the Implementing Support 

Agency (ISA) portal. 

2. He/She shall upload the OP/IP status of the patient. 

3. He/She shall guide the patient in all aspects and sign the investigation 

request. 

4. He/She has to cross check whether diagnosis is covered in the Scheme. 

If doubtful about the plan of management then should coordinate with 

treating specialist along with Package list as specified in the Annexure- 

5 or Mukhyamantri Amrutum Yojana Manual on Surgical Treatments. 

5. He/She should facilitate the admission process of Patient without any 

delay. 

6. After admission He/She shall collect all the necessary investigation 

reports before sending for approval. 

7. He/She shall upload the admission notes and preoperative clinical 

notes of the patient. 

8. He/She shall ensure that pre-authorisation request is sent only for 

those who are on the bed (IP). 

9. He/She shall ensure before sending Preauthorization that all 

documents like Smart card, Patient photo and also necessary reports 

like CT Films, X-Ray films, Angio CD etc. are uploaded in the system. 

10. He/She shall upload the admission notes and preoperative clinical 

notes of the Patient. 

11. He/She shall coordinate with ISA and Implementing Support Agency 

(ISA) doctors if necessary. 

12. Preauthorization kept pending from ISA and Implementing Support 

Agency (ISA) will be verified on a regular basis and Hospital Arogya 


Mitra shall provide necessary information to the Arogya Mitra/ 


13. He/She shall furnish daily clinical notes about Pre-operative and Postoperative. 

14. He/She shall upload 3 Photographs of the Patient taken at the time of 

preoperative bedside, immediate post-operative showing operation 

wound and discharge. 

15. He/She shall update surgery and discharge details and hand over 

signed copy of the summary along with follow-up advice in preprinted 

stationary. 

16. He/She shall ensure free follow – up consultations, routine 

investigations and drugs to the Beneficiaries. 

17. He/She should attend to the grievances of the Mukhyamantri Amrutum 

Yojana Beneficiaries and coordinate with the Implementing Support 

Agency (ISA) if necessary to redresses it within 6 hrs. Further he will 

counsel the patient accordingly. 

18. He/She shall ensure at the time of discharge the transportation cost to 

and fro to be reimbursed to the patient. 

19. He/She shall upload the operation notes, post operative details and 

attach necessary post operative documents (like case sheet etc) for 

claim submission. 

20. He/She shall ensure that any claim kept pending from ISA for technical 

or financial reason is to be updated immediately. 

21. He/She shall verify and make sure that all documents are submitted in 

order before submission of claims. 

22. Any other responsibility as communicated by the Implementing 

Support Agency (ISA)/SNC. 


ANNEXURE -12 

ROLES AND RESPONSIBILITIES OF HOSPITAL AROGYA MITRAS 

DURING MEDICAL CAMPS 

1. He/She has to coordinate all activities related to Health Camps. 

2. He/She has to follow up with the patients referred from the Health 

Camps. 

3. After receiving Health Camp schedule from the Implementing Support 

Agency (ISA), he/she is responsible for submitting confirmation of 

camps. 

4. He/She has to update the details of IEC Activities, Facilities to be 

provided in the camp, Common drugs to be distributed in the camp at 

the time of confirming the Health camp. 

5. He/She has to follow the Health Camp Guidelines and Health Camp 

Work Flow Provided by the Implementing Support Agency (ISA). 

6. He/She has to start IEC activities in cordintation with the district 

health authorities at least 7 days prior to the camp date. 

7. He/She has to Mobilize the patients by doing various IEC activities 

like pamphlet distribution, mike announcement, advertisements in 

local daily‟s, beat of drum/tom-tom, SHG meetings, village meetings, 

scrolling in local T.V. channels, playing audio visual media etc. in 

coordination with the district health authorities. 

8. He/She has to do canvassing in surrounding villages of the PHC. 

9. He/She should provide facilities for patients like shamianas, chairs, 

pedestal fans, drinking water, screening enclosures and snacks etc. 

10. He/She has to provide common medicines in the Health Camp. 

11. Coordinating and ensuring participation of specialists in the Health 

Camp. 

12. He/She has to arrange diagnostic equipment for the Health Camp. 


13. He/She has to co-ordinate with PHC doctors/Govt. doctors, public 

representatives and local administration. 

14. He/She shall communicate with PHC doctor, District Coordinator of 

ISA to plan and deploy their manpower. 

15. After Successful completion of Health camp, HAM shall upload and 

submit declaration certificate by PHC medical officer/Arogya Mitra, 

drug dispensing registers, details of IEC activities, photographs of the 

camp and IEC activities in the camp in prescribed formats. 


NETWORK HOSPITALS - DO'S & DON'TS 

ANNEXURE – 13 

Do's: 

Conduct camps with qualified doctors / specialists, equipment, proper 

awareness and IEC program at the designated location. 

Register and admit the patients immediately once identified and shall 

render cashless treatment to all the eligible patients. 

Provide space for Kiosk in the reception for Arogya Mitra along with 

system, network connectivity, printer, scanner, digital camera etc. 

Evaluate the Beneficiaries by conducting free diagnostic tests and 

counsel the patients who are not covered under the Scheme in regard 

to further management. 

Provide a dedicated Mukhyamantri Amrutum (MA) Yojana Medical 

Coordinator (HOSPITAL AROGYA MITRA) to co-ordinate and perform 

an effective role. 

Provide reasonably good food according to dietary requirement. 

Provide cost of transportation Rs. 300 to Beneficiaries. 

Provide free follow-up for Beneficiaries according to provisions made 

in the package. 

Submit the claim only after 10 days of discharge. 

Appoint dedicated Hospital Arogya Mitra under Mukhyamantri 

Amrutum (MA) Yojana to coordinate with Arogya Mitra. 

Attend the periodical training workshops / programmes organized by 

ISA / Implementing Support Agency (ISA). 

Utilize the Mukhyamantri Amrutum (MA) Yojana manual on Surgical 

& Medical Treatments for cashless Treatment of BPL families provided 

by the Implementing Support Agency (ISA) to the best possible extent 

for proper understanding of the Scheme. 


Send proper pre-authorization and resubmit objected preauthorizations 

after thorough scrutiny with the required documents / 

reports to avoid delay in clearance of preauthorization. 

Don'ts: 

× Collect money from Mukhyamantri Amrutum (MA) Yojana patients 

towards cost of treatment. 

× Take possession of any original document from the patient at any 

point of time. 

× Charge from the patient in any form as the benefit package includes 

the entire cost of treatment including follow up charges from date of 

reporting to the completion of follow ups. 

× Send patients home during the waiting period of preauthorization 

approval. 

× Send for preauthorization approval in duplicate. 

× Misuse Telephonic intimation for approval for non-emergency cases. 

× Update operation notes and discharge summary for those cases in 

which surgery or follow up has not been performed. 

× Apply for multiple procedures for the same patient without clinical 

justification. 

× Submit pre-authorization approval repeatedly for the same patient. 

× Send patient or patient‟s relative to Implementing Support Agency 

(ISA) / ISA office for approval and enhancement as preauthorization 

has to be obtained only from the Hospital. 

× Mention wrong telephone numbers of treating doctors on the 

preauthorization as this may cause delay in issue of pre authorization. 

× Submit clinical photograph, which is incomplete and inconclusive. 

The postoperative photograph should reveal as much as possible the 

operative site and the patients face. 


× Collect any amount towards follow-up consultation & medicines for 

those cases where follow-up are included, as the services are inherent 

with the pre-defined package. 

× Collect money from patients / family to procure blood / blood 

products but facilitate to procure in case it is not available within the 

Hospital blood bank except in case of hematological disorders. 



UNDERTAKING TO PROVIDE INFRASTRUCTURE AT MUKHYAMANTRI 

AMRUTUM (MA) YOJANA KIOSK 

We hereby agree and undertake to provide P.C, Printer, Scanner, Digital 

camera, Webcam, Barcode reader, Mike, Speakers, Stationary etc., at 

Mukhyamantri Amrutum Yojana Counter/Kiosk which shall be exclusively 

for the use of Arogya Mitra from our end to ensure the smooth operation. 

Hospital Stamp Signature of Hospital CEO / 

CMD 

Date: 

Place 



GUIDELINES FOR POLYTRAUMA CASES 

The guidelines for treating Polytrauma cases are as follows: 

I. The road traffic accidents covered under the Motor Vehicles Act are not 

covered under Mukhyamantri Amrutum (MA) Yojana, however if the 

beneficiary is not entitled for any insurance relief then the beneficiary is 

eligible to avail the benefit of Mukhyamantri Amrutum (MA) Yojana. 

II. Components of Polytrauma: 

The following are the major components of Polytrauma based on the systems 

involved: 

1. Orthopedic trauma 

2. Neuro-Surgical Trauma 

3. Chest Injuries 

4. Abdominal Injuries 

The above major components separately or combined are defined as 

Polytrauma since Trauma cases are mostly associated with other minor 

injuries along with the major components. 

III. Coverage under Polytrauma: 

The following are the identified components of Polytrauma for providing 

coverage under Mukhyamantri Amrutum (MA) Yojana. 

• Orthopedic trauma 

a. Surgical Corrections 

• Neuro-Surgical Trauma 

a. Surgical Treatment 

• Chest Injuries 

a. Surgical treatment 

• Abdominal Injuries 

a. Surgical treatment 

• Initial diagnostic evaluations for all trauma patients have to be made 

free of cost. 

• Since majority of poly-trauma cases are emergency in nature, the 

emergency pre-authorization may be obtained by providing basic 

information like Bar Coded Plastic Card number if available. 

(Additional details provided in emergency E-preauthorization module). 

• Hospital shall give minimum 48 hours time for the patient to furnish 

Bar Coded Plastic Card for being a beneficiary of Mukhyamantri 

Amrutum (MA) Yojana and till that time no money in the form of 

advance shall be collected from the Beneficiaries. However the Arogya 


Mitrashall help the patient in producing the Bar Coded Plastic Card 

before the deadline. 

• After patient stabilizes, the Hospital shall mention full details like 

mode of injury and type of injuries sustained in the pre-authorization 

to help the ISA / Implementing Support Agency (ISA) doctors in 

assessing the preauthorization. 

IV. Note on Surgical Management: 

All surgeries related to the components of poly-trauma and mentioned in 

packages are covered irrespective of Hospitalization period. 

1) All surgical packages are maximum amounts that can be claimed 

under that category and claim shall be settled based on the type of 

surgery performed, number of days of Hospital stay and associated 

injuries treated that are not defined in the Scheme. 

2) Pre-Authorization shall be given for full amount and claim shall be 

settled as per above guidelines. 

3) Package for Surgical Correction of Long bone is for each bone and 

Hospital can claim multiples of the package amount for multiple 

fractures sustained. However for both bones fractures in forearms and 

legs the second package shall be halved as procedure involved for 

second bone is minor and involves same field of operation and same 

sitting. 

4) Separate package is provided for coverage of wound management in 

Compound Fractures. Since it is wound management in compound 

fracture, these packages shall only be used in association with 

fracture management of long bones in trauma either by Internal 

Fixation or by External Fixation. 

5) Separate packages are provided for surgical management of Facial 

Bone Fractures and Pelvic Bone Fracture in Trauma. 

6) Packages are provided for surgical management of Patella Fracture 

and small bone fractures in trauma; however these packages are 

applicable only when these fractures are sustained as a component of 

Poly-trauma i.e. in association with other injuries defined in polytrauma. 


Protocol/ Guidelines: 

1. Polytrauma case should be physically, hematologically, serologically 

and Biochemically Intensively monitored during first 72 hours of the 

injury. 

2. Definitive nerve repair or vascular repair should be performed earliest 

possible. If contamination present then after initial debridement, 

nerve repair or tissue coverage should be achieved with 72 hours of 

injury. 

3. Over all guideline for polytrauma cases is a definitive surgery should 

be performed within 72 hours of the injury accept patient is severely 

ill, severe head injury or patients general condition does not allow him 

to be operated. 


GUIDELINES FOR LAPAROSCOPIC PROCEDURES 

ANNEXURE–16 

1. Hospital shall upload intra-operative photographs depicting face of the 

patient and operative site along with specimen removed with date and 

time depicted on the print/image. 

2. Hospital shall upload intra-operative video endoscopic recording of entire 

Procedure along with claims attachment. The CD shall be converted to 

Web-ex recorded format available in Hospital login. 

GUIDELINES FOR OBSTETRICS & GYNAECOLOGY: 

a. In case of Radical Hysterectomy, the investigation reports like Pap Smear, 

Cervical Biopsy, Endometrial Biopsy and USG are mandatory. 

b. Pre-authorization for prolapsed/decent of uterus shall be supported by 

Pre-op and Post-op USG respectively. 

c. For Laparoscopic Ovarian Cystectomy the size of the cyst should be more 

than 6 cm and the test CA 125 is mandatory. 

d. Avoid uploading clinical photographs without properly covering the 

patient. 

e. Biopsy report of the specimen is mandatory (Uterus /Cyst). 


GUIDELINES FOR GENITO-URINARY PROCEDURES 

ANNEXURE–17 

1. All symptomatic ureteric stones measuring more than 6mm only shall be 

taken up for lithotripsy procedures. 

2. Radiological proof of stone in USG/KUB/IVP/CT scan with clear mapping 

of size shall be provided in case of renal/ ureteric / vesical calculi for 

approval of lithotripsy procedures. 

3. Plain CT scan is required in cases of radiolucent renal/ureteric calculi 

which cannot be proved otherwise. 

4. Hospitals shall upload intra-operative video endoscopic recording for all 

endoscopic procedures at the time of submission of claims. The CD should 

be converted to Web-ex recorded format available in Hospital login. 

5. All post operative photographs shall show the face & operative scar in the 

same photograph. 

6. Photograph clearly showing the face of the patient lying on procedure 

table shall be uploaded in all cases of lithotripsy procedures. 

7. For all cases of TURP, it is desirable to have scan of post void residual 

urine of more than 100 ml or flow of < 10 uroflowmetry reading. 


ANNEXURE-18 

GUIDELINES FOR TRIPLE VESSEL DISEASE (CARDIOTHORACIC) 

1. Selection of procedure in case of Triple Vessel Disease (TVD) 

(whether CABG or Angioplasty): 

Whenever a treating doctor decides to perform angioplasty procedure for 

Triple Vessel Disease instead of CABG, either due to associated conditions 

or due to patient‟s choice of selection after being counseled about the 

advantages and disadvantages of both the procedures, the following 

evidence shall be uploaded for approval. 

(i) The detailed explanation letter by the treating doctor for opting for 

angioplasty procedure. 

(ii) A consent letter from the patient stating that the procedure was of his 

choice and decision was taken after due counseling in the mother tongue of 

the patient by the treating cardiologist and cardiothoracic surgeon. 

(iii) The consent letter must be duly signed by the treating cardiologist and 

cardiothoracic surgeon. 

2. Additional objective assessment required in case of moderate 

stenosis (

ANNEXURE-19 

GUIDELINES FOR CANCER PACKAGE 

The Chemotherapy and Radiotherapy should be administered only by 

professionals trained in respective therapies (i.e. Medical Oncologists and 

Radiation Oncologists) and well versed with dealing with the side-effects of 

the treatment. The Patients with hematological malignancies- (leukemia, 

lymphomas, multiple myeloma) and pediatric malignancies (Any patient < 14 

years of age) should be treated by qualified medical oncologists only. 

Each Chemotherapy cycle cost includes: 

• Cost of chemotherapy drugs 

• Hospital charges 

• All the infusion chemotherapy cancer cases must be 

treated as inpatients only. 

• Doctors fees 

• Supportive care medications (i.e. iv fluids, steroids, H2 

blockers, antiemetics) 

• All Investigations 

• Treatment of complications 

Tumors not included in this list, if have a chemotherapy regimen that is 

proven to be curative, or provide long term improvements in overall survival 

will be reviewed on a case by case basis by the technical committee of the 


Note: the procedures and protocalls are to be followed as per the NCCN 

guidelines which can be downloaded from http:// www.nccn.org/, and 

http://www.nccn.com/. 



Ultrasonic Energy Device for Tissue Dissection with Effective Hemostasis for 

Advanced Open Procedures 

With rapid advances in Surgery, there has been an increasing need for an ideal 

energy source for haemostasis (Controlling the blood loss while doing the Cancer 

Surgeries and Surgical Gastro Intestinal Procedures), as ligatures and clips are 

less than ideal. An optimal energy source should be safe, rapid, cost effective and 

should not interfere with visualization due to smoke generated while performing 

the surgeries, especially in Laparoscopic Surgery and Tertiary Care Open 

surgeries. 

Traditionally thermal haemostasis was achieved by electro surgery unit (Electrical 

Cautery) or laser surgery which induced high temperatures up to 100 - 400+ 

degree celsius. Consequently, undesirable tissue desiccation and char formation 

are induced, in addition to the protein coagulation which can be achieved at 

temperatures below 100 degree celsius. This induced zone of focal necrosis serves 

as a point of future adhesions and interferes with tissue healing. Moreover, 

considerable smoke is produced during electrocautery. 

Ultrasonic energy (Harmonic Scalpel) avoids the above drawbacks and is a 

potentially ideal energy source for advanced open surgeries like Gastro Intestinal, 

Onco, Endocrine Surgeries and Laparoscopic procedures. The comparison 

between Ultrasonic energy (Harmonic Scalpel) and Electro Surgical Energy 

(Electrical Cautery) is as follows: 

Sl. 

No. Technology Electrosurgical Unit 

1 Temperature mechanism 

2 Energy Modality 

Operates at temperatures above 

200-400 degree Celsius leading 

to tissue trauma. 

Current passes to and through 

the patient thereby unsafe. 

Ultrasonic 

Generator 

Operates 

less than 

150 degree 

Celsius 

thereby 

minimizing 

the tissue 

trauma. 

No current 

passes 

through the 

patient as 

Electrical 

Energy is 

transforme 

d into 


Tissue 

Damage 

3 

Prevention 

4 Thermal Spread 

5 Visibility during surgery 

6 Vessel sealing Capability 

7 Vessel Seal Strength 

8 Alternate Site Injuries 

High current concentration - 

results in desiccation of tissue 

may lead to necrosis of the tissue 

Lateral thermal damage is 

significantly high as heat 

percolates which results in 

damaging the visceral (nearby 

tissues/organs) structures. 

More smoke is produced during 

surgery hence leading to 

obstruction for surgeon to 

accessing surgical site. 

Can seal vessels up to 3mm 

vessels 

Seal strength is poor due to 

desiccation of tissue 

Chances of ground/Patient plate 

failure is high & resulting in 

alternate site burns 

mechanical 

motion 

improving 

safety. 

No current 

is involved 

hence 

necrosis of 

the tissues 

may be 

avoided 

The point of 

contact is 

the point of 

effect so 

lateral 

thermal 

spread is 

restricted 

under 150 

degree 

celsius. 

More visual 

clarity to 

the surgeon 

is ensured 

for 

accessing 

the desired 

surgical 

site 

Seals 

vessels 

to 5mm 

up 

Seal 

strength is 

3x systolic 

pressure 

Safety, No 

Electrical 

Current 

Passes 

through 

and 


9 

10 

Device 

Functionality 

Multi- 

Blood loss and 

Transfusion 

Not Applicable as it is used only 

for coagulation or cutting at a 

time 

More blood loss due to poor 

coagulation capabilities leading 

to blood transfusion 

coagulation 

happens 

through 

Mechanical 

Vibration 

Multi 

functionalit 

y device as 

it Grasps, 

Dissects, 

Cuts and 

Coagulates 

the tissues 

at a time 

Minimal 

blood loss 

Considering above factors Ultrasonic Energy (Harmonic Scalpel) is the preferred 

energy source for performing Laparoscopic and advanced open surgeries like 

Gastro Intestinal, Cancer & Endocrine Surgeries and following quality parameters 

may be set for usage of Ultrasonic Energy for delivering quality treatment for 

Scheme Beneficiaries: 

Sl. No. Factors affecting successful 

Outcomes 

EVIDENCE BASED 

1 

2 

3 

The technology must have approval from 

the appropriate governmental regulatory 

bodies 

The technology must offer Safe and 

Effective control of Intra operative Blood 

loss 

Precise technology that optimizes 

surgical outcomes 

Recommendations 

coverage 

FDA approved technology 

for 

The device must offer effective 

control of intra operative 

blood loss with minimal 

lateral thermal damage to 

surrounding tissue or 

structures 

A Multi functional single 

device that allows the 

simultaneous cutting, 

coagulation, dissection and 

grasping of the tissues, 

thereby with effective 

hemostasis. Lesser operative 

time. 


4 

SERVICE BASED 

5 

6 

7 

Vessel Sealing Capability and Seal 

Strength. 

A well established a Proven technology 

with more than 1000 Ultrasonic 

generator installations across India 

(incl. leading Govt. and Pvt. institutions) 

Strong professional education programs 

to train surgeons on minimal invasive 

procedures to boost their skillsets to 

improve procedural outcome. 

Range of instruments to perform various 

specialty procedures 

Device should have capability 

to seal up to 5mm vessels 

with seal strength up to 3 

times Systolic pressure. 

Sufficient volumes of 

successful 

surgeries 

performed in India using the 

technology/ 

device. 

Performance evaluation 

certificates from more than 

50 Govt. and Pvt. institutions 

across Tamilnadu. 

Must have history of 

conducting training programs 

/ animal lab training / 

workshops under the 

leadership of eminent 

surgical faculties. 

Should have Lap curved 

instruments/open surgical 

instruments with fine 

dissection capabilities. 



Ensuring successful patient results from Joint Replacement 

(TKR/THR): 

Ensuring successful outcomes for joint replacement patients is important. 

A substandard surgical outcome for patient can lead to problems such as 

continued immobility, which in turn can lead to diabetes, cardiac problem, 

blood pressure, physical pain and even psychological problems. These are 

not only a burden on the patient but can also become an added cost for 

insurer in terms of future claims and a productivity loss for the state. 

Hence it is important to identify the critical factors for successful patient 

outcome and design insurance coverage criteria which will ensure only those 

products are used which will be provide optimal outcomes. 

These factors can be grouped into two categories: 

1) Implant survivability – evidence based 

2) Service capability of implant vendor 

# Factors affecting successful 

outcome 

Evidence Based 

1 

2 

3 

Evidence of long term 

survivorship of implant in-vivo 

(after implantation into patient 

not laboratory simulator based 

evidence) 

Long term evidence in-vivo – i.e 

covering the expected life of the 

patient after surgery. Average age 

of surgery is 60-65 years. Implant 

must last at least another 15 

years. There should be adequate 

evidence over a large sample size 

of patients that this has happened 

in most of the patients. 

Minimizing risk factors – 

International Registries which 

track ALL implanted device 

survivorship over time identify 

some implants as being HIGH 

RISK ( “higher than anticipated 

rates of revision”) which means 

Recommendation 

coverage 

on 

Implant should be based on invivo 

survivorship 

Implant must have at least 15 

years of peer-reviewed 

published survivorship data 

Implant must not be identified 

in any registry as having „high 

risk‟ („higher than anticipated 

revision rates‟) 


4 

they have DOUBLE the risk of 

leading to failure 

Service based 

Implant and instrument: - Joint 

replacement surgery requires 

significant logistical capability. 

Dozens of sizes and size 

combinations of implants and 

many trays of instruments need 

to be provided by the vendor 

during the surgery to ensure 

optimal surgical outcome for 

patient. Many vendors do not 

have the organizational and 

financial resources to provide 

such service for multiple 

surgeries. Evidence of history of 

such service is required over a 

long period of time. 

Implant vendor must have 

sufficient service history in India 

i.e Successfully sold the joints 

products in India continuously 

for over five years. This will 

ensure service reliability for the 

patients. 

1) Implant survivorship ( for oncological implant): 

Implant should have evidence of long term survivorship in vivo. It is 

understandable that this prosthesis is not routine surface replacement 

(like those done in arthritic knee or hip). These are prosthesis which 

would replace joint along with a part of neighboring bone. Hence, the 

stresses are also going to be higher with likelihood of early fatigue failure 

of such implants. At the same time, most of the patients in whom these 

prosthesis as going to be implanted, are young patients with high 

functional demands. Limb salvage has recently become popular in 

country like India. Therefore there is a paucity of literature and evidence 

about long term survivorship of the Indian manufactured implants. 

However, this type of literature exists for expensive imported implants. 

2) Service capability of the implant vendor: 

Same as mentioned for routine prosthesis as point 4 above 


ANNEXURE- 22 

GUIDELINES FOR THE MANAGEMENT OF BURNS PATIENTS 

1. First 72 hours of burn injury with burn shock to be treated intensively 

with I.V. fluid resuscitation and physical, haematological, serological 

and biochemical monitoring. 

2. Dressing of the Burn wound should be done according to the type of 

Burn, depth of Burn and/or type of antimicrobial agent used 

3. Systemic antibiotics should be used as per bacterial culture. 

4. Enteral and/or parenteral nutrition should be maintained as per 

calorie requirement of Burns patient, the aim being to overcome the 

negative nitrogen balance 

5. Blood transfusion and haematinics to be used as per the 

haematological investigations 

6. Proper splintage should be applied during the early burn period to 

minimize various post burn deformities. 

7. Burns patients should be monitored with physical, haematological, 

serological, biochemical and culture examination during the entire 

course of their illness. 

8. Hypertrophic scar can be prevented by applying the pressure garment 

to affected burn area. Pressure garment should be applied as soon as 

the burn wounds are healed. 



DISPLAY OF BED STATUS AT MUKHYAMANTRI AMRUTUM (MA) 

YOJANA KIOSK 

The Network Hospital shall display the status of total number of beds 

available in the Hospital, total number of beds allocated under 

Mukhyamantri Amrutum Yojana and specialty wise total number of beds 

occupied by the Mukhyamantri Amrutum Yojana patients on a “White 

Board with Black Letters”. The Network Hospital shall update the Board 

from time to time in the following format placed at the Mukhyamantri 

Amrutum Yojana Kiosk. 

Date: 

Time: 


STATUS OF BEDS AVAILABILITY IN THE HOSPITAL 

Name of the Hospital: 

Total no. of Beds available in the Hospital: 

Total no. of Beds Occupied: 

Total no. of Beds allocated under MA Yojana: 

Total no. of Beds occupied by MA Yojana patients: 

Total No. of Beds available for MA yojana Patients: 

Specialties empanelled under MA Yojana: 

Specialty wise status of Beds available in the Hospital 

Specialty Name: 

Total no. of Beds available in the Hospital: 

Total no. of Beds Occupied: 

Total no. of Beds allocated under MA Yojana Scheme: 

Total no. of Beds occupied by MA Yojana patients: 

Total no. of Beds available for MA Yojana Patients: 

Signature of HAM 


ANNEXURE-24 

FORMAT OF AFFIDAVIT 

(TO BE FURNISHED BY THE PROVIDER ABOUT TIED UP DIAGNOSTIC 

FACILITIES) 

I______________________S/o.___________________,age_____,Occ:_______________ 

__, R/o.________________ do hereby solemnly affirm and state on oath as 

follows: 

That I am the MD/CEO/Superintendent / Director / Authorised Signatory 

of ______________________ Hospital and signed Agreement with 

____________________ Implementing Support Agency (ISA) to implement 

Mukhyamantri Amrutum (MA) Yojana. 

That as per the terms of the Agreement it is agreed by our Hospital to 

provide diagnostic services to the Mukhyamantri Amrutum (MA) Yojana 

patients on cashless basis. Further it is also agreed to facilitate and provide 

diagnostic services which are not available in our Hospital through tie-up 

diagnostic center on cashless basis to Mukhyamantri Amrutum (MA) Yojana 

patients. 

We have tied up with M/s._______________________ to provide diagnostic 

services to Mukhyamantri Amrutum (MA) Yojana patients on cashless basis 

for the diagnostic services which are not available in our Hospital. The 

details of tied up diagnostic services are as follows: 

1. ______________________, 2. ______________________, 3. _____________________ 

4. _______________________ 

The above mentioned diagnostic services will be provided to the 

Mukhyamantri Amrutum (MA) Yojana Patients on a cashless basis through 

above mentioned tied up diagnostic center. 

We are herewith submitting the tie-up letter issued by the Diagnostic 

Centre. 

That all the contents stated above are true and correct. 

Date:……….., 

DEPONENT 

Attestation: 

Place: 

The contents of the affidavit are read over and explained and who after 

understanding the same signed before me on this ____ day of ______ 2012. 

Hence attested. 

Date: . Place: ,ATTESTOR 


ANNEXURE-25 

LETTER FORMAT 

(TO BE FURNISHED BY THE TIED UP DIAGNOSTIC CENTER) 

I_____________________________S/o.______________________,age_____,Occ:_____ 

__, R/o._________________________do hereby solemnly affirm and state on 

oath as follows: 

I have entered in to MOU Agreement with the _____________________________ 

Hospital to provide the following diagnostics services to Mukhyamantri 

Amrutum (MA) Yojana Beneficiaries on cashless basis. 

1. ______________________ 

2. ______________________ 

3. ______________________ 

4. ______________________ 

It is agreed that the Mukhyamantri Amrutum (MA) Yojana patients referred 

to us by _____________________________ Hospital will not be charged any 

money for the above any diagnostic services. 

The bills for the above services will be submitted to the 

______________________ 

Hospital for payment as per the agreed terms and conditions. 

Date: Signature: 

Place: 

Stamp: 


ANNEXURE-26 

HEALTH CAMP GUIDELINES 

Access, Quality, and Cost of healthcare services can be defining dimensions 

of the health status of a community. The extant disparity across these 

dimensions among the poor and rural communities is seen to have a 

debilitating impact on their socioeconomic growth. Government have put 

forth continuous efforts to establish extensive public health infrastructure 

and facilities, i.e. MHC/PHC/DH, in order to bridge the gap on behalf of the 

undeserved community by providing affordable, preventative and curative 

services at the local level. Several programs such as national programmes, 

rigorous campaigns against infectious diseases and epidemics, primary 

health checkups and medicine distribution, etc. are carried out through 

regularly scheduled Health Camps serving as the platform for reaching 

those who would not be able to otherwise access or afford such level of care. 

Mukhyamantri Amrutum (MA) Yojana is a recent Gujarat State Government 

initiative aimed to improve access of Below Poverty Line families towards 

quality tertiary healthcare through an identified network of public and 

private providers. As the Scheme dramatically taps the hitherto untapped 

vast tertiary healthcare requirement, it envisages leveraging Public Private 

Partnerships to stimulate the latent demand, which has largely accumulated 

due to the inability to bear exorbitant expenditures of tertiary care, and 

ultimately administer universal quality care to the BPL population. Health 

Camps designated for the Scheme are one of the innovative mechanisms to 

identify and mobilize the latent demand for tertiary care into Super Specialty 

healthcare facilities. 

Objectives of a Health Camp: 

Generally, Health Camps have taken shape into a makeshift arena of 

providing quality primary, preventive, curative, promotive, and referral 

health services to the people in designated areas, who lack access to such 

services on various grounds. 

Structure of Health Camps under „MA‟ Yojana: 

Health Camps under Mukhyamantri Amrutum (MA) Yojanawill generate the 

demand for tertiary healthcare services at the grassroots level while also 

acting as the mobilizing vehicle to channelize this demand to the Network 

Hospitals, thus creating a continuous loop of end-to-end healthcare delivery 

to the Beneficiaries. These camps can serve a vital threefold function: first, 

provide free medical consultation, screening and medicines to incoming 

patients; second, identify those patients who require tertiary care; third, 


generate publicity of the programme at the ground level. Due to the nature 

of this Scheme and the diseases covered under the Scheme, it is felt that 

greater efforts have to be put forth through rigorous publicity campaigns 

and scheduled camps in order to properly reach the maximum number of 

eligible Beneficiaries. Hence, in order to adequately meet such requirements, 

it is envisaged to carry out regularly scheduled Health Camps designated 

specifically for the programme. The following components shall determine 

the conduct of the Health Camp: 

A. Frequency and Location of Camps: 

Several factors, such as disease burden of the designated area, the number 

of empanelled Providers, availability of specialists, etc. will come into play 

when prescribing the frequency and location of Health Camps to be 

conducted under „MA‟ Yojana. The frequency and location of camps are to be 

decided by the ISA and shall be intimated to the Network Hospital well in 

advance. 

The Network Hospital shall conduct Health Camps at least once a 

month at the designated Taluka. 

B. Participants: 

Network Hospitals empanelled under the Scheme are mandated to conduct 

free medical camps at the time and location specified by the ISA. Both 

private and public providers are expected to extend their services through 

such camps away from their regular setting and at the local level. 

Designated HAM, doctors and other supporting staff from the Network 

Hospitals shall also coordinate with the local government doctors to be 

present at the camps. The government doctors are expected to have a 

broader knowledge of the disease burden and treatment requirement of their 

local areas and thus will be able to assist the Network Hospitals to identify 

the members of the BPL families who may require surgeries covered under 

the Scheme. 

The following minimum personnel pattern is recommended on behalf of the 

Network Hospital: 


Name 

Doctor 

ANM/Staff 

Nurse 

Role Description 

He is the team Manager and should 

carryout screening of patients for 

determining requirement for referring the 

patient for tertiary care intervention at 

higher centre‟s, as well administer Primary 

Health Care Services like treatment, 

counseling, etc. 

Assist the Doctor for screening, Primary 

Health Care Service, counseling, moral 

support, immunization, cold chain 

maintenance for vaccine, minimum 

investigation like Hb percentage, Urine for 

albumin sugar & BP-BS. 

Minimum 

Qualification 

Specialist Doctor 

with 

PG 

qualification in 

concerned 

specialty 

ANM 

Trainee/Diploma 

in Nursing - 

Recognised by 

nursing council of 

Gujarat. 

Pharmacist Assist the doctor for procuring drugs and 

equipments, dispensing of drugs to the 

patient, collect blood smears , and 

generate the monthly reports on drug 

distribution 

Group „D‟ Assist the Doctor, Staff Nurse, and 

Pharmacist, dressing wounds and helps in 

sterilizing the materials. 

Diploma 

Pharmacy 

recognised 

institute. 

SSC Pass/Fail. 

in 

from 

C. Equipment: 

Network Hospitals are expected to carry necessary tertiary care diagnostic 

equipment for respective specialties, which will enable adequate screening of 

patient in order to ensure worthwhile referral to the Network Hospital for 

further care and in turn, facilitate a more accurate course of treatment. Also 

the Network Hospital shall ensure the availability of all necessary 

instruments and material for providing primary health care, such as 

designated lab tests, curative services, first aid, family planning services, 

various health education activities, etc. at the specified location of the camp. 

The Hospital shall coordinate with the Chief District Health Officer (CDHO) 

to see that facilities are available at the camp location. 

D. Treatment and Medicines: 

It is important to realize that many incoming local people at the camp will be 

requiring relatively minimal amount of medical attention, i.e. complaints of 

fever, bodily aches, etc. For such patients, appropriate treatment can be 

administered and medicine can be dispensed as per the list of common 


drugs below, and general counseling on preventive measures can be 

provided as per norms. When conducting the Health Camp under „MA‟ 

Yojana, while the focus is on identifying genuine tertiary care patients, one 

cannot be ignorant to the general ailments and disease burdens of the 

locality. Regardless of existing State level and national programmes aimed 

towards providing primary health care to underserved and remote areas, the 

goal under Mukhyamantri Amrutum (MA) Yojanashall still be to administer 

quality universal health care wherever possible. 

One of the essential activities of the Health Camp, aside from screening 

patients for tertiary care requirement, will be to provide treatment for 

common ailments and common drugs in the camps and prevent spread of 

communicable diseases. The Network Hospital shall be responsible for: 

Providing consultation for ailments other than those covered under 

the Scheme. 

Providing common drugs for general ailments as indicated in the list 

below: 

Catego 

ry 

I 

II 

III 

IV 

LIST OF COMMON DRUGS TO BE PROVIDED IN CAMPS: 

Drug type Sl. For Drug Strength Minimu 

No. m 

m Qty. 

Anti 

inflammato 

ry/antipyre 

tic/ 

analgesic 

Anti- 

Allergic 

Anti- 

Amoebic 

Anti- 

Helmenthic 

/ 

Deworming 

1 Tab Ibuprufen 400mg 500 

2 Tab Paracetomol 500mg 1000 

3 Tab Aspirin 300/500 500 

mg 

4 Tab Diclofenac 

Sodium 

100 mg 1000 

5 Tab Chlorphenira 4mg 5000 

mine Maleate 

6 Tab. Metronidazole 400 mg. 800 

7 Tab Albendazole 400 mg 100 

V Antibiotic 8 Tab Norfloxacin 400 mg 1000 

9 Tab Ciprofloxacin 500 mg 500 

10 Cap Ampicillin 250mg 500 

VI 

H1 

antagonist 

11 Tab Ranitidine 150 mg 1000 

VII Antacid 12 Tab Antacid 2000 


VIII 

IX 

Vitamins 

&Iron 

supplement 

For 

Children 

13 Tab Multivitamin 2000 

14 Tab. 

Iron+Folic 

Acid 

2000 

15 Tab B-Complex 1000 

16 Tab. Vit.C 500mg 1000 

17 Cap A&D 2000 

18 Syru Paracetomol 125 20 

p 

mg/5ml 

19 

20 

Syru 

p 

Syru 

p 

Ampicillin 

125mg/5 

ml 

10 

Antitussive 20 

Hospital shall carry at least 10 types of drugs from the above list and 

have at least one drug from each category. 

Distribution of all drugs for children (Category-IX) is mandatory. 

Minimum stock as stated in the list of common drugs must be 

carried to the camp. However Hospitals are free to distribute more 

number of drugs and left over stocks if any from other camps. 

Minimum of Rs.1500 worth medicines must be carried to each camp. 

Hospitals may carry generic drugs instead of proprietary 

preparations to keep the cost of medicines low. 

E. Facilities available at the Camp: 

Network Hospital personnel, i.e. HAM, shall asses the capacity of the 

available facilities in the designated location of the camp in advance and 

seek efforts to provide additional facilities for the comfort of Beneficiaries 

such as: 

Providing shade for waiting patients by erecting shamianas. 

Providing pedestal fans. 

Sitting arrangements for waiting patients by providing sufficient 

number of chairs. 

Drinking water for patients 

Screening enclosures for patients 

Snacks 

Any other activity chosen by the Hospital 

F. IEC Activities 

The purpose of such a programme, which provides cashless treatment of 

catastrophic illnesses, would not be fulfilled without proper utilization by 

genuine Beneficiaries. In order to ensure proper coverage of such individuals 

requiring tertiary care intervention and spreading awareness on the 


programme, the Network Hospital shall promote wide publicity of the health 

camps at each locality through various IEC activities such as: 

Pamphlet Distribution 

Public Address System / Mike announcements in Autos 

Beat of drum and tom-tom 

Playing of Audio-Visual media (Cassettes, Audio CDs and DVDs) 

Scroll in local cable networks. 

News/Advertisements in local dailies 

Posters 

Banners 

SHG meetings 

Village meetings 

Exhibits on hygiene, general health, prevention of communicable 

diseases etc. 

Exhibits on early detection and prevention of chronic diseases 

Any other activity chosen by the Hospital 

G. Allocation 

In order to encourage the above activities in the camps by Network 

Hospitals, the ISA will provide fund for each Camp to the Network 

Hospital and activity wise allocation of the said amount is as stated 

below: 

Sl. 

No. 

Activity 

1 IEC Activity 

2 Basic necessities to patients such 

as Shamiana, Chairs, Water, 

Fans, Snacks etc. 

3 Providing common drugs to the 

patients as indicated in the list 

4 Incentive to ASHA/Link 

workers/Anganwadi worker for 

Community Mobilization. 

Total 

Amount allocated 

in 

Rs. 

The detailed guidelines with regard to indent, approval and utilization of the 

above amount are as follows: 

H. CONFIRMATION OF CAMPS, INDENTING, APPROVAL, ORGANISING, 

CLAIMING AND REIMBURSEMENT OF AMOUNT: 


The ISA will communicate the schedule of the camps well in advance. 

Confirmation and indenting: The Hospital shall update the 

confirmation for each camp on the ISA portal well in advance as 

stipulated by the ISA. The details of doctors and paramedics attending 

the camp and equipments being carried shall also be indicated. Along 

with the confirmation, the network Hospitals shall put up the indent 

for each camp detailing the following: 

Details of IEC Activities with specific proposals and estimated 

amount. 

Details of facilities to be provided for the camps with specific 

proposals and estimated amount. 

Details of common drugs to be distributed in the camps with 

specific quantities and estimated amount. 

Incentives to be given to the ASHA‟s /Link Workers/Anganwadi 

Workers with their names that will be helping in community 

mobilization. 

 

 

 

 

Approval: Based on the indent the ISA will approve the maximum 

amount of Rs.5,000/- per Hospital per camp. Please note that the 

approved amount will be denied in case of rescheduling of camps after 

confirmation. 

Organising the camps: The Hospital shall conduct the camp as per the 

schedule and by undertaking the activities as given in the indent. The 

Hospitals shall ensure that Mukhyamantri Amrutum (MA) 

YojanaMedical Camp Coordinator (HAM) is earmarked for the purpose 

and is sent at least a week in advance to the camp area to undertake 

IEC activities as planned and arrange for the facilities to be provided 

for the camps. The Hospital camp coordinator shall ensure that the 

schedule of the camp is informed to all concerned stakeholders in the 

local area of the camp including the people‟s representatives. 

The following documentation have to be completed during the camp: 

Each patient has to be given an outpatient-cum-prescription card 

(Refer ANNEXURE–26.A for specimen copy). The details of medicines 

to be disbursed shall be mentioned in this card. 

Those patients who are treated as outpatients shall be given medicines 

as prescribed in the outpatient-cum-prescription card. The Provider 

shall maintain a drug dispensing register for maintaining record of 

drugs disbursed at the camp and shall obtain the signature/ thumb 

impression of the patient on the register for being disbursed the 

medicines to the concerned patient (Refer ANNEXURE-26.B). The 


same shall be scanned and uploaded at the time of claiming the camp 

expenditure. 

Those patients who are referred shall be given Mukhyamantri 

Amrutum (MA) Yojanareferral card with details of date of reporting to 

the Hospital, name of consultant and mobile number of Network 

Hospital Arogyamitra. Refer ANNEXURE–26.C. 

The details of all outpatients and referred patients will be recorded by 

the Arogya Mitras in the camp register in triplicate. A copy of the same 

duly signed by the Medical Officer, Arogya Mitras and Specialist doctor 

from the network Hospital shall be kept with the Network Hospital and 

the same shall be scanned and uploaded/sent at the time of claim of 

camp amount. 

At the end of the camp the incentive shall be given to the participating 

ASHA/Link worker/ Anganwadi workers and the receipt shall be 

obtained as per the prescribed format which is enclosed herewith as 

ANNEXURE-26.D. 

The Mukhyamantri Amrutum (MA) YojanaMedical Camp Coordinator 

(HAM) of the Network Hospital shall also take a declaration for being 

conducted the health camp successfully from the concerned Block 

Health Officer of the respective Block. The Arogyamitra shall also sign 

the same. The Network Hospital shall upload/send the same at the 

time of claiming the camp expenditure. Refer ANNEXURE-26.E. 

Claim: Hospital shall raise the claim quarterly, i.e. every 3 months or 

upon completion of at least 3 camps, for the camps held during the 

year. Hospital shall upload and submit Utilization Certificates as per 

the ANNEXURE-26.F. Hospital shall also upload and submit the 

documents such as bills, copy of drug dispensing registers, details of 

IEC activity, photographs of the camps and receipt of payment of 

incentives paid to the ASHA/Link Worker/Anganwadi workers 

participating in the camp in prescribed formats as mentioned above. 

Reimbursement: The ISA will reimburse the health camp expenditure 

amount to the network Hospital based on uploaded and submitted 

documents quarterly, i.e. every 3 months or upon completion of at 

least 3 camps, through online transaction. 

J. ROLE OF DISTRICT ADMINISTRATION IN CONDUCTING THE CAMPS: 

The following steps may be taken by the District Administration for the 

successful conduct of the camps: 

1. Spreading awareness on the camps through all possible means. 

2. All public representatives including Ministers, MPs, MLAs, MLCs, ZP 

chairperson, and all people‟s representatives may be informed of camp 


schedule in advance so that they may participate in medical camps. 

The camp can be inaugurated by local MLA or by other people‟s 

representative depending on availability. Some time the camp can be 

earmarked for inauguration. 

3. Drinking water for patients shall be arranged through Panchayath 

Secretaries and Arogya Mitras. 

4. Minimum facilities like drinking water and food for doctors and staff 

participating in the camp may be arranged through the Arogya Mitras 

or the local Medical Officers. The cost of this will be borne by the 


5. Medical Officers in the nearby government Hospitals shall attend 

camps for general check-up. In camps where only one network 

Hospital is participating two medical officers shall be deputed and 

where two network Hospitals are participating four medical officers 

shall be deputed. 

6. The patients referred from the camps shall be followed up to report to 

the network Hospital. The Arogya Mitras (minimum two per camp if 

one network Hospital is participating and four per camp if two 

network Hospitals are participating) shall ensure referral cards are 

given to the referred patients in the camp with details of date of 

reporting to the Hospital, place of appointment, name of consultant 

and mobile number of Network Hospital Arogya Mitras. 

7. The District Coordinator of the ISA shall speak to the HAM of the 

Network Hospital and ensure that all the activities mentioned above 

are taking place in time and as planned. The details of Medical 

Officers and Arogya Mitras participated in the camps shall be given to 

the HAM. 

The following are more specific roles and responsibilities of the local health 

care officials: 

Chief District Health Officer: 

Shall be overall supervising officer of health camp activities in 

the district. 

Shall provide support to the Network Hospital and the staff of 

the Health Camp to carryout effective services in the area. 

Shall be responsible for monitoring and evaluation of the Health 

Camp as and when required. 


Shall be responsible to take appropriate action in case of any 

medical emergencies and out breaks in the area of operation. 

Shall be free to call any person from the Network Hospital for 

taluka level or district level periodical meetings, without 

jeopardizing the functioning of the Health Camps. 

Shall collect the progress report in a prescribed format 

periodically, incorporating it in the district report. 

Block Health Officer (BHO): 

Shall be monitoring officer for Health Camp, operating in the 

Taluka. 

Shall coordinate with the CDHO for requirements of the camp. 

Shall be responsible to take appropriate action in case of 

emergencies, out breaks in designated area 

Shall be responsible to check the qualifications of the staff as 

and when required. 

Primary Health Care (PHC) Medical Officer: 

Shall assist the Network Hospital in conducting proper 

screening of patients. 

Shall ensure proper treatment is administered to patients 

requiring primary health care services. 

He/she shall be responsible for highlighting any health status 

trends of the local population and their specific needs. 

Medical Officer of the concerned PHC shall also monitor the 

regularity and quality of services rendered by the Health Camp. 

Shall also deploy any staff of his PHC to take up IEC activities 

in the area along with IEC materials. 

Spread awareness of the Health Camps among the population of 

the Health Camp area. 

Shall furnish captured data on the camp to the district 

administration and ISA as and when required. 

Can promote other health programmes and health education 

activities, etc. at the Health Camp 

Monitoring and Evaluation: 

The Health Camps shall be monitored by concerned Block Health 

Officer (BHO), Medical Officers and other departmental officers 

periodically. The outcome indicators will be analyzed from time to time 

by the ISA. 


ANNEXURE-26.A 


HEALTH CAMP REGISTRATION CUM PRESCRIPTION CARD 

Date: …………………………… 

Place of Health Camp: ………………………………………………………… 

Patient Name:………………………………………………Age:………Sex:………, 

Full Name of Head of the Family:…………………………………………………. 

Relation with Head of the Family:…………………............. 

Address:……………..…………………………………………………………………… 

……………………………………………………………………………………… 

Tel No (if any):……………….. 

Clinical 

Notes:……………………………………………………………………………… 

Provisional 

Diagnosis:……………………………………………………………………… 

Treatment 

Advised:………………………………………………………………………… 

Details of Medicines Prescribed:………………………………………………… 

……………………………………………………………………………………………… 

……………………………………………………………………………………………. 

Name & Signature of the Treating 

Doctor 


ANNEXURE-26.B 


DRUG DISPENSING REGISTER 

Health Camp Date:…………………… 

Name and Address of the Network Hospital: 

………………………………………………..………………………… 

Place of the Health Camp:……………………………………….………………….. 

Taluk:.………………………………….. 

District:…………………………………………... 

Sl 

No 

1 

2 

Name of the Patient 

Drugs Dispensed 

Name Qty. 

1. 

2. 

3. 

1. 

2. 

3. 

Patient‟s Signature/ 

Thumb Impression 

Signature & Name of PHC, Arogya Mitra: 

Signature & Name of HAM, Network Hospital: 

Signature of PHC/CHC Medical Officer: 

The Hospital shall capture the details of drug distribution to all patients by 

adding sufficient number of rows and pages. 


ANNEXURE-26.E 


DECLARATION BY PHC MEDICAL OFFICER 

I, Dr………………..……..…………………………………………………. hereby 

declare that the Mukhyamantri Amrutum (MA) Yojana Health Camp was 

conducted successfully at ……………………………….…………………….. 

Venue, located at ………………………………Village on…………………. 

from.……….….AM to.………PM, by the following network Hospitals: 

1)…………………………………………………………………………………… 

2)…………………………………………………………………………………… 

The following activities were taken up by the Hospital: 

Sl. 

No 

Activity 

1 IEC 

2 Name of Villages Covered during 

publicity campaign 

Network 

Hospital 1 

Name: 

Network 

Hospital 2 

Name: 

2 Provision of facilities for the 

patients, shamiana, chairs, 

screening enclosures etc., 

2 Distribution of General 

Medicines 

3 Incentive to ASHA/Link 

Worker/ Anganwadi Worker. 

Total 

Signature of PHC Medical Officer 

Signature of PHC Arogya Mitra 


ANNEXURE-26.F 


UTILIZATION CERTIFICATE 

I hereby submit that ……………………………………… Hospital, which has 

conducted Health Camp under Mukhyamantri Amrutum (MA) 

Yojanat……………………………………(venue)……………………(Village)………………… 

………..(Taluk)……………………,……………………………………..District 

on………………..………….(date) and incurred expenditure of Rs………………… 

(Rupees ………………………) for conducting the Health Camp as stated below for 

various activities: 

Sl. Activity 

Amount 

No. 

1 IEC 

2 Provision of facilities for the patients, shamiana, 

chairs, screening enclosures etc., 

3 Distribution of General Medicines 

4 Incentive to ASHA/Link Worker/ Anganwadi 

Worker 

Total 

Seal of the Hospital 

Date: 

Place: 

Signature of Hospital Authority 

Name: 

Designation: 


ANNEXURE-26. G 


Medical Camp Indent form to be submitted to ISA 

Name of the Network Hospital: 

Date of Camp: 

Place of Medical Camp: 

Venue: 

Taluk: 

District: 

Name of HAM: 

Phone Number: 

A. Details of Specialists / Doctors attending the camp: 

Sl. No. Name of the Specialist / Doctors Specialty 

1 

2 

3 

B. Details of Paramedical Staff / Other Staff Participating in the 

Camp: 

Sl. No Name of Paramedical Staff / Other Staff 

C. Details of Diagnostic Equipment to be carried to Camp: 

Sl. No Name of the Diagnostic Equipment 

D. Details of Vehicles to be carried to the camp: 

Sl. No Description of Vehicle Registration Number 

E. Details of IEC Activities: 

Sl. Details 

of 

No Advertisement/Awareness/Publicity 

for the medical camp 

1 Pamphlets to be distributed 

2 Public Address System / Mike 

Estimated 

Amount 

Approved 

Amount 


announcement in Auto rickshaw 

3 Beat of Drum / Tom-Tom 

4 Playing Audio visual Media ( Cassettes, 

CD‟s & DVD‟s) 

5 Scroll in local cable network 

6 News/Advertisements in local dailies 

7 Posters 

8 Banners 

9 SHG Meetings 

10 Village Meetings 

11 Exhibits on hygiene, public health, 

Prevention of communicable diseases 

12 Exhibits of early detection and 

prevention of chronic diseases 

13 Others 

S No Description Estimated 

Amount 

1 Details of Exhibits if any 

2 No of Pamphlets distributed 

Approved 

Amount 

Campaign Date in villages 

From Date: 

To Date: 

I: Villages to be covered: 

II: Details of Facilities to be provided for Medical Camp: 

S 

No 

Details of Facilities to be provided 

for Medical Camp 

Estimated 

Amount 

Approved 

Amount 

1 Provide shade for waiting of patients 

by erecting Shamianas along with size 

( Yes/No) 

2 Providing Pedestal Fans 

3 Sitting arrangements for waiting 

patients by providing sufficient no of 

chairs ( No of Chairs ) 

4 Drinking Water facility for patients 


5 Screening enclosures for patients 

6 Snacks 

III: Details of common drugs to be distributed: 

S 

N 

o 

Category Name of 

the Drug 

1 Anti 

inflammatory/an 

tipyretic/ 

analgesic 

2 Anti-Allergic 

3 Anti-Amoebic 

4 Anti- 

Helmenthic/Deworming 

5 Antibiotic 

6 H1 antagonist 

7 Antacid 

8 Vitamins & Iron 

supplement 

9 For Children 

Paraceta 

mol 

Ampicillin 

Antitussiv 

e 

Quantity 

Being 

carried 

Estimat 

ed 

Amount 

Approved 

Amount 

IV: Incentives to be paid to the ASHA/Link Worker/Anganwadi Worker: 

S Name of the ASHA/Link Phone Number Incentive to 

No Worker/Anganwadi Worker 

be Paid 

1 

2 

Details of Arogya Mitra participating in the camp 

S Name of the Arogya Mitra 

No 

1 

2 

Phone Number 


Total Estimated Amount: 

S No Head 

1 IEC Activities 

2 Facilities to be Provided 

3 Common Medicines 

4 Incentives 

Total 

Estimated 

Amount 

Approved Amount 

Name of the HAM: 

Signature: 

Name of HAM: 

Signature: 

Name of the Arogya Mitra: 

Signature 


ANNEXURE-26. H 

HEALTH CAMP REFERRAL CARD TO NETWORK HOSPITAL 

Health Camp Date: 

Location: 

Ref. Card No.: ………………… ……………. 

Name: ……………………………………………….. Age: ………..…… 

Sex: …………………………………… Occupation: 

…........................................... 

Bar Coded Plastic CardNo.: 

………………………………….….................................. 

Address:……………………………………………………………………………………… 

…………………. 

Complaint : ……………………………………………………………….……. 

Provisional Diagnosis: …………………………………….………………....... 

Tests Done : ……………………………………………………………………. 

Final Opinion :……………………………………………………………….…… 

Operative Procedure : ………………………………………………………………… 

Date of Reporting to NetworkHospital:………. 

Name of the Specialist : ………..………………………………….…... 

REFFERED UNDER MUKHYAMANTRI AMRUTUM YOJANA SCHEME 

Name of the NetworkHospital : …………………………………… 

Address of the NetworkHospital : ………………………………….. 

Name of the NetworkHospital Arogya Mitra:………………………..……… 

Arogya Mitra Contact No ……………………………………………....... 

Name of the PHC Doctor: 

………………............................................................. 

Contact no. of PHC Doctor:…………………………………………………………….. 

Signature of the PHC Doctor: 

Signature of Arogya Mitra 

It is certified that: 


ANNEXURE-27 

UNDERTAKING TO SHARE CORE BANKING NUMBER - IFSC CODE 

We________________________________________________________ (Hospital) 

hereby declare that we have the core banking facility with the 

_______________________________ 

_______________________Bank having Branch at 

_______________________________ and the IFSC no. is _______________________ 

(Mention your core banking Number). 

Authorized Signatory 

IN CASE OF NON AVAILABILITY OF IFSC CODE 

I agree to provide the IFSC number within eight working days on receipt of 

this information. 

Hospital Stamp 

Date: 

Place: 

Signature of 

Hospital CEO/CMD 


DISTRICT WISE BPL FAMILY DETAILS: 

ANNEXURE-28 

No. of District 

Hospitals 

No. of BPL 

Sr. District Families 

1 Banaskantha 251743 1 

2 Sabarkantha 179689 1 

3 Narmada 83288 1 

4 Dang 35344 1 

5 Tapi 79466 1 

6 Ahmedabad 345324 1 1 

7 Gandhinagar 54096 1 1 

8 Kheda 191194 1 

9 Mehsana 123598 1 

10 Panchmahal 201403 1 

11 Bharuch 129263 1 

12 Dahod 218961 1 

13 Jamnagar 115285 1 1 

14 Kutch 118899 1 

15 Patan 118473 1 

16 Rajkot 205729 1 1 

17 Porbandar 33176 1 

18 Junagadh 127772 1 

19 Bhavnagar 111700 0 1 

20 Surendranagar 186228 1 

21 Amreli 83283 1 

22 Vadodra 310862 1 1 

23 Valsad 129024 1 

24 Anand 181686 1 

25 Navsari 68543 1 

26 Surat 167224 0 1 

Total of 1 to 26 3851253 24 7 

No. of Govt. 

Medical 

College& 

Hospitals 


ANNEXURE-29 

MUKHYAMANTI AMRUTUM (MA) YOJANA 

PHOTOGRAPH OF SPACE PROVIDED FOR AROGYAMITRA KIOSK 

Name of Network Hospital: 

Address: 

Affix the Photograph of the space provided in the 

Hospital for establishing Arogya mitra Kiosk 


ANNEXURE-30 

CHECK LIST 

1. Copy of Hospital registration certificate. 

2. Photograph of equipments available in ICU-Adult (duly attested by 

authorized signatory with seal). 

3. Photograph of equipments available in ICU-Pediatric (duly attested by 


4. Photograph of equipments available in Neonatal ICU (duly attested by 


5. Photograph of equipments available in Post Operative ward (duly 

attested by authorized signatory with seal). 

6. Photograph of equipments available in Step down ICU (duly attested 

by authorized signatory with seal). 

7. The about name of anesthetists, reg. no., qualification, no. of years of 

experience, university name and mobile no. 

8. Photograph of equipments available in OT in respective specialties 

(duly attested by authorized signatory with seal). 

9. The list of specialists available in the Hospital containing the 

information such as Name, Qualifications, Registration No., Years of 

Experience, Full time/ on call and no. of cases handled in the 

respective Hospital. 

10. Photograph of all equipment with make details available under 

diagnostic facilities. 

11. For outsourced diagnostic facilities and ambulance service furnish the 

affidavit. 

12. Certified copies of all the certificates/licenses/documents mentioned in 

the tender document. 

13. All other documents as mentioned in the tender document. 


PERFORMANCE SECURITY 

(PROFORMA OF BANK GUARANTEE) 

(To be issued by a Scheduled Bank in Indi) 

ANNEXURE-31 

THIS DEED OF GUARANTEE executed on this the ____day of ______, 2012 

at ________________ by ___________________________ (Name of the Bank) 

having its Head/Registered office at 

________________________________________ and amongst others, a Branch 

Office at __________________________ (hereinafter referred to as “the 

Guarantor” which expression shall unless it be repugnant to the subject or 

context thereof include successors and assigns); 

In favour of 

State Nodal Cell (SNC), a Body set up by the Government of Gujarat, for the 

implementation of the Mukhyamantri Amrutum Yojana (Scheme). (herein 

after referred to as the “State Nodal Cell”) and having its office at 

Gandhinagar, Gujarat, which expression shall, unless repugnant to the 

context or meaning thereof include its administrators, successors or 

assigns. 

WHEREAS 

By the Agreement (“the Agreement”) dated ------- entered into between the 

Implementation Support Agency (“ISA”) and 

____________________________________ owning the ________________________ 

Hospital ........................ (hereinafter referred to as the “Hospital”) the 

Hospital has agreed to provide services as per the Agreement for the 

Mukhyamantri Amrutum (MA) Yojana (hereinafter referred to as “the 

Scheme”) with the Implementation Support Agency. 

A. In terms of the Agreement, the Hospital is required to furnish to the State 

Nodal Cell, an unconditional and irrevocable bank guarantee for an amount 

of Rs.10.00 lakhs [Rupees ten lakhs only] as security for due and punctual 

performance/discharge of its obligations under the Agreement, relating to 

the execution of the Scheme. 

B. At the request of the Hospital, the Guarantor has agreed to provide bank 

guarantee, being these presents guaranteeing the due and punctual 

performance/discharge by the Hospital of its obligations relating to the 

Scheme of providing patient Services to Mukhyamantri Amrutum ‘MA’ Yojana 

Beneficiaries. 


NOW THEREFORE THIS DEED WITNESSETH AS FOLLOWS: 

1. The Guarantor hereby irrevocably guarantees the due and punctual 

performance by the Hospital of all its obligations relating to the Scheme 

and in connection with execution of the Scheme as envisaged in the 

Agreement. 

2. The Guarantor shall, without demur, pay to the State Nodal Cell sums 

not exceeding in aggregate Rs.10.00 lakhs [Rupees ten lakhs only], 

within 15 days of receipt of a written demand therefore from the State 

Nodal Cell stating that the Hospital has failed to meet its obligations 

under the Agreement. The Guarantor shall not go into the veracity of any 

breach or failure on the part of the Hospital or the validity of demand so 

made by the State Nodal Cell and shall pay the amount specified in the 

demand notwithstanding any direction to the contrary given or any 

dispute whatsoever raised by the Hospital or any other person. The 

Guarantor‟s obligations hereunder shall subsist until all such demands 

are duly met and discharged in accordance with the provisions hereof. 

3. In order to give effect to this Guarantee, the State Nodal Cell shall be 

entitled to treat the Guarantor as the principal debtor. The obligations of 

the Guarantor shall not be affected by any variations in the terms and 

conditions of the Agreement or other documents or by the extension of 

time for performance granted to the Hospital or postponement/non 

exercise/ delayed exercise of any of its rights by the State Nodal Cell or 

any indulgence shown by the State Nodal Cell to the Hospital and the 

Guarantor shall not be relieved from its obligations under this Guarantee 

on account of any such variation, extension, postponement, non exercise, 

delayed exercise of any of its rights by the State Nodal Cell or any 

indulgence shown by the State Nodal Cell, provided nothing contained 

herein shall enlarge the Guarantor‟s obligation hereunder. 

4. This Guarantee shall be irrevocable and shall remain in full force and 

effect for one year from the date hereof, with a claim period of one month 

thereafter, unless discharged/released earlier by the State Nodal Cell in 

accordance with the provisions of the Agreement. The Guarantor‟s 

liability in aggregate be limited to a sum of Rs.10.00 lakhs (Rupees .ten 

lakhs only). 

5. This Guarantee shall not be affected by any change in the constitution 

or winding up of the Hospital /the Guarantor or any absorption, merger 

or amalgamation of the Hospital/the Guarantor with any other person. 


The Guarantor has power to issue this guarantee and discharge the 

obligations contemplated herein, and the undersigned is duly authorised 

to execute this Guarantee pursuant to the power granted under 

______________. 

IN WITNESS WHEREOF THE GUARANTOR HAS SET ITS HANDS 

HEREUNTO ON THE DAY, MONTH AND YEAR FIRST HEREINABOVE 

WRITTEN. 

SIGNED AND DELIVERED 

by___________________________________Bank 

by the hand of Shri_____________________________ 

its_________________ 

and authorised official.

Revised MA hospital tender - Health and Family Welfare Department

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