No.282-U/16/26/2017/Med Branch Date:-08/10/2018

EXPRESSION OFINTEREST

The Medical Superintendent, ESIC Hospital, Pandeypur Varanasi invites sealed

quotations for empanelment of recognized/Registered Hospital/Institutions for

Secondary care Treatment on contract basis initially for a period one year

which can be extended upto two years. The interested parties may submit

their proposals. The tender document may be obtained on submission of a

Demand Draft (only SBI) of Rs.1000/- in favour of “ESIC FUND A/C NO.1”

Varanasi. The document may be obtained from this hospital from 05/10/2018

to 30/10/2018 during working Hours and the duly filled documents must be

deposited latest by 30/10/2018 at 1.00PM and it will be opened on

30/10/2018 (2:00PM). The tender document can also be downloaded from our

website www.esic.nic.in and on this case the cost of tender may be submitted

along with tender application.

The Medical Superintendent, ESIC Hospital, Pandeypur, Varanasi

reserves all rights to reject one or all the tenders without assigning any reason

thereof.

Medical Superintendent

ESIC Hospital, Varanasi

No.282-U/16/26/2017/Med Branch Date:-08/10/2018

To

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

EXPRESSION OF INTEREST

(Please read all terms and conditions carefully)

The Medical Superintendent, ESIC Hospital, Pandeypur Varanasi invites Expression of

Interest from Government/Semi-Government/CGHS approved/Private Hospitals for

empanelment of centres for Secondary care treatment which are not available in Medical

Superintendent, ESIC Hospital, Pandeypur Varanasi,; on cashless basis at latest CGHS

Allahabad rates, ESIC rates, in a sealed envelope. Application forms along with Terms and

Conditions can be downloaded from the website www.esic.nic.in duly filled in forms,

complete in all respect along with EMD should reach the office of Medical Superintendent

by 30/10/2018 at 1:00PM. Bids will be opened on 30/10/2018(2:00PM) in the office of the

Medical Superintendent. If the opening date happens to be a holiday,; it will be accepted

and opened on the next working day. Tenderer/authorized person may choose to be

present at the time of opening of bids.

TENDER DOCUMENT FOR SECONDARY CARE TREATMENT

Tenderer downloading the form from website shall have to deposit Rs. 1000/-(Non

Refundable) separately as Tender Document cost along with EMD of RS. 20000/- in the form

of DD drawn on (only SBI) in favour of “ESI Fund account No.1” payable at Varanasi.

Document Acceptance: Documents may be dropped either in the tender box or sent by

Registered Post. Documents received by ordinary post will not be accepted at all.

Documents received after the scheduled date and time will be rejected out rightly.

Tenderers will be informed about date and time of inspection of their centre by a duly

constituted committee on the address given in Document Form.

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

Laboratories/Imaging centres.)

A. Multispecialty Hospital (Specialties given in Annexure-II) having 50 beds or more (Which

includes ICU beds) can apply as a multispecialty hospital. A single specialty hospital (EYE and

Dental) can also apply.

B. The health care organization should be approved by State Government /CGHS copy of

state registration certificate/Registration to be attached.

C. The Health care organization should preferably be accredited by NABH, similarly

Diagnostic Laboratories should preferably be accredited by NABL copy of NABH/NABL

accreditation. Copy of NABH/NABL application in case of non NABH/non NABL accredited

health care organization must be attached.

D. Registration under PNDT act for empanelment for ultrasound facility.

E. AERB approval for tie-up for radiological investigation wherever applicable.

F. The Health care organization must have the capacity to submit all claims all claims/bills in

computerized format to the Medical Superintendent, ESIC Hospital, Pandeypur Varanasi.

G. Intensive care unit (ICU) with minimum four beds (4beds and 4 ventilators).

H. Provision of dietary service.

II. GENERAL TERMS AND CONDITIONS

1. All service will be provided cashless to the patients under no

circumstances referred ESI Patients to be charged.

2. Rates to be charged: b

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

be paid.

(a)Package rate shall mean and include lump sum cost of in-patient

treatment/day care/diagnostic procedure for which a ESI beneficiary/ESI

Staff (serving and retired) has been permitted by the competent

authority or for treatment under emergency from the time of admission

to the time of discharge including (but not limited to):

1. Registration charges (2) Admission, accommodation charges (3)

including patients diet (4),Operation charges (5) Injection Charges (6)

Dressing charges (7) Doctor/Consultant visit charges (8) ICU/ICCU

charges (9) Monitoring charges (10) Transfusion charges (Anesthesia

charges) (12) Operation Theater charges (13) Procedural charges /

Surgeon’s Fee (14) Cost of surgical disposable and all sundries used

during hospitalization (15) Cost of medicines (16) all other related

routine and essential investigation (17) Physiotherapy (18) Nursing care

(19) Charges for its services and all other incidental charges related

thereto.

(b)Cost of implant/stents/grafts is reimbursable in addition to package

rates as per CGHS/ESIC ceiling rates.

(c)The Package rates/rates given in rate list are for semi-private wards. If

the beneficiary is entitled for general ward there will be a decreases of

10% in the rates. For private ward entitlement, there will be an increase

of 15%. However, the rates shall be same for

(I) CONDITIONS FOR AWARD OF CONTRACT

Only those applications will be considered for award of contract which

fulfil all conditions and also have satisfactory report of Inspection

Committee.

1(a) Rates of package for procedure/treatment should be as per revised/

latest CGHS RATE BBSR for only NABH/NON/NABH centres. CGHS (Delhi rates

will be applicable where CGHS, Allahabad packages rates are not available).

ESIC PACKAGE RATES (where CGHS PACKAGE rates are not available, AIIMS

rate will be applicable.

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

ESIC/general patients.

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

II.

3. Successful tenderer shall have to deposit a security amount of Rs. 1,00,000/-

(Rupees one lakhs who apply for multiple specialties) and Rs. 50,000 (Fifty

thousand who apply for single specialty) in the form of Account payee demand

draft from any of the nationalized bank having validity of 24 plus 2 months (60

days extra from the expiry of contract) which will be refunded after

termination/completion of contract without any interest.

4. Bid must be accompanied by the following:-

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

DD drawn on any nationalized bank in favour of ESI Fund Account NO.1

payable at Varanasi. EMD of unsuccessful tenderers will be refunded within 3

days after award of contract without any interest. EMD of successful tenderers

will be refunded after deposit of security money without accrual of any

interest.

(b) Documents as per annexure-I must be submitted.

5. Every page of tender document must be signed and also Annexure-I & II

should be duly signed.

6. Centres de-empanelled by any Govt. Organization within last 3 years will not

be considered. Affidavit of not have been de-empanelled or black listed by

ESIC/Govt. Organization must be submitted with tender form.

7. An agreement on stamp paper of RS. 11/- shall be signed after finalizing and

verification/physical verification of records/Institutions and incidental charges

related to agreement shall be borne be the empanelled centre. Agreement will

be effective with effect from date of signing of the agreement.

8. Award of contract may be given to one or more tenderers.

Investigation irrespective of entitlement, whether the patient is admitted or

not and the test, per se, does not require admission.

(d) No charges admissible for post of complications.

B) Where CGHS rates do not exist

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

prescribed by CGHS. They will be called as ESIC rates. If the rates are also not

available, AIIMS rates will be paid.

(b) Discounts on drugs/treatment/procedures/devices have been finalized.

These are:-

1. 15% discount on hospital rates which already exist for other patients in case

ESIC /AIIMS rates are also not available.

2. For devices /stents etc. 15% discount on MRP (Maximum Retail Price)

3. IN case of drugs, discounts as follow: 15% discount on drugs are not

reimbursable.

D) The centre whose rates for treatment procedure/test are lower than the

CGHS prescribed rates shall charges as per the rates charged by them from

NON-ESIC patients and will furnish a certificate that rates charged are not

more than from non-ESIC patients. Rate list of the hospital/empanelled centre

to be submitted along with technical conditions.

DISCOUNT : ANY DISCOUNT ON CGHS/ESIC PACKAGE FOR SURGERIES ETC. TO

BE MENTIONED.

E) If one or more minor procedures form part of a major treatment procedure

then package charges would be permissible for major procedure and only 50%

of charges for minor procedures.

3. Duration of Indoor treatment:-

(a) As per package rates:-

1. Major Surgery-7 days.

2. Laparoscopy Surgery/Normal Delivery -3days.

3. Day Care /Minorprocedures-1 day

For non package procedures/management-7days.

(b) Increased duration of indoor treatment due to infection , or the

consequences of surgical procedure or due to any improper procedure if not

justified will not be reimbursed.

(c) For extended stay more than the period covered in package rate, in

exceptional cased, supported by relevant documents and medical records and

certified as such be hospital, the additional reimbursement shall be limited to

accommodation charges as per entitlement, investigation charges at approved

rates, doctors visit charges (two visit/day) and cost of medicine. The approval

from this office or the ESIC Hospital, Varanasi is required in the matter. The

approval must be attached with the bill so sent for payment to the concerned.

d) Two OPD visit after discharge along with dressing and suture removal will be

free of charge.

e) Beneficiary who had taken in patient treatment from all empanelled private

Hospital will be issued medicine form the treating hospital at the time of

discharge for a period of seven days. Provided that the cost of sixth medicine

shall not exceed Rs.2000/- nutritional supplement and non drug

items/equipments/appliances will not be issued.

4) Room Rents

(a) The maximum room rent for different categories would be : General Ward

Rs.1000/- per day, semi-private Ward Rs.2000/- day Private Ward Rs.3000/-

per day, Day Care ( 6 to 8 hours ) Rs.500/- (Same for all categories).

(b) Room rent is applicable only for treatment procedures for which there is no

CGHS prescribed package rate. Room rent will include charges for occupation

of Bed, diet for the patient, charges for water and electricity supply, linen

charges, nursing and routine up keeping.

(c) During the treatment in ICU , no separate room rent will be admissible.

(d) Private ward is defined as a hospital room where single patient is

accommodated and which has an attached tiled (lavatory and bath). The room

should have furnishing . The room shall have furnishing like wardrobe, dressing

table, bedside table, sofa set etc. as well as a bed for attendant The room has

to be air conditioned.

(e) Semi private ward is a hospital room where 2 or 3 patients are

accommodated which has attached toilet facilities and necessary furnishings.

(f) General ward is defined as Halls that accommodate 4 to 10 patients.

(g) Normally treatment in higher category of accommodation that the entitled

category is not permissible. However, in case of an emergency when entitled

category accommodation is available. Even in this case the empanelled centre

has to charge as per entitlement of the patient.

5. Any legal liability arising out of such service shall be the sole responsibility of

the 2nd Party and shall be dealt with be the concerned empanelled

hospital/diagnostic center.

6. Patient will be referred with a Permission letter signed by the competent

authority.

Cases referred between 4 pm to 9 am next morning (Emergency cases) will be

signed by Casualty Medical Officer . The empanelled hospital has to take

regular permission from MS in prescribed format on next working day. These

cases will be referred only after discussion with the concerned specialist which

has to be mentioned on the referral form.

7. IN case of any natural disaster/epidemic, the hospital/diagnostic hospital

shall have to fully cooperate with the ESIC and will convey/reveal all the

required information, apart from providing treatment.

8. The EMPANELLED CENTRE will investigate/treat the ESI beneficiary patient

only for the condition for which they are referred with permission, and in the

specialty and/or purpose for which they are approved by ESIC. In case of

unforeseen emergencies of these patients during admission for approved

purpose/procedure, necessary life saving measures be taken and concerned

authorities may be informed accordingly later with justifications for approval.

9. The tie-up hospital will not refer the patient to other specialist/other

hospital without prior permission/intimation of ESIC authorities.

10. The empanelled centre will have to report on daily basis to Medical

Superintendent on e-mail address ms-varanasi.up@esic.in giving details of ESI

Insured Persons under indoor treatment failing which hospital may be de-

empanelled.

11. Feedback form will be filled by the patient/attendant after discharge.

12. Refusal to entertain a referred ESI Patient will result in de-

empanelment/black listing of the hospital.

(III) PAYMENT SCHEDULE

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

bill processing agency (BPA) for scrutiny and processing of all bills for

beneficiaries referred from ESIC MH, Rourkela. The empanelled hospital will

have to enter (Mandatory) into MOU with UTI-ITSL to engage them as BPA (Bill

processing agency in relation to payments and re-imbursement of medical

expenses. The empanelled hospital/diagnostic centre will send bills along with

necessary supportive documents to UTI_ITSL. Copy of the discharge slip

incorporating brief history of the case, diagnosis , details of procedure done,

reports of investigation , discharge summary, original receipt of

medicines/implants, sticker of implant, wrappers of costly

medicines/equipment (costing more than Rs.2000/-, treatment given and

advised shall be submitted by the hospital/diagnostic centre along with the bill

in duplicate in prescribed proforma as in ANNEXURE-A.

(IV) DUTIES AND RESPONSIBILITIES OF EMPANELLED HOSPITAL / DIAGNOSTIC

CENTRES.

It shall be the duty and responsibility of the hospital at all times, to obtain,

maintain and sustain the valid registration and high quality and standard of its

services and healthcare and to have all statutory/mandatory license, permits

or approvals of the concerned authorities as per the existing laws.

Display board regarding cashless facility for ESI beneficiary will be required.

The documents like referral from ESIC Hospital, eligibility etc. must be

mentioned on the board. The ESI patient must be entertained without any

queue/wait.

(V) DURATION OF EMPANELLMENT

The agreement shall remain in force for a period of one year and may be

extended by one year, at a time for amendment of 2 years at the sole

discretion of the Medical Superintendent subject to fulfillment of all terms and

conditions of this agreement and with mutual consent. Agreement to be

signed on Stamp Paper of appropriate value before starting services. Cost of

stamp paper and incidental charge related to agreement shall be borne by the

empanelled centre. Agreement will be effective from the date of signing the

agreement by both parties.

(VI) INTEGRITY AND OBLIGATIONS DURING AGREEMENT PERIOD

The Hospital is responsible for and obliged to provide all facilities in

accordance with the Agreement, using state-of-the-art methods and economic

principles and exercising all means available to achieve the performance

specified in the Agreement. The Hospital is obliged to act within its own

authority and abide by the directives issued by the ESIC. The hospital is

responsible for managing the activities of its personnel and will hold itself

responsible for their misdemeanor, negligence, misconduct or deficiency in

services, if any.

(VII) LIQUIDATEDDAMAGES

Empanelled centre shall provide the services as specified by the ESIC

under terms and conditions of this agreement in case of violation of the

provisions of the agreement by the empanelled centre there will be forfeiture

of payment of the incoming/pending bills. For over billing and unnecessary

procedure, the extra amount so charged will be deducted from the bills and

the ESIC shall have exclusive right to terminate the contract at any time, and

also render forfeiture of security amount.

(VIII) TERMINATION FORDEFAULT

a. Medical Superintendent, ESIC Hospital, Pandeypur Varanasi may

without prejudice to any to any other remedy and for breach of

agreement in whole part may terminate the contract.

b. The second Party will not terminate the agreement without giving

notice of three (3) months. If they do so security money will

beforfeited.

c. The Institution shall be de-empanelled if:

i) The Hospital fails to provide any or all of the services for which

it has been recognized within the period(s) specified in the

Agreement, or within any extension period thereof if granted

by the ESIC pursuant to condition of Agreement or

ii) The Hospital, in the judgment of the ESIC is engaged in corrupt

or fraudulent practices in competing for or in executing the

Agreement, or

iii) The hospital fails to follow instruction, guidelines, repeated

submission of bills as per own way and repeated deficiencies

etc, the Institution shall be de-empanelled without giving any

opportunity.

d. The Hospital is found to be involved in or associated with any

unethical illegal or unlawful activities, the Agreement will be

summarily suspended by ESIC without any notice and thereafter may

terminate the Agreement, after giving a show cause notice and

considering its reply, if any, received within 10 days of the receipt of

show cause notice. . Terms and conditions can be modified at sole

discretion of the First Party only.

(IX) PENALTY CLAUSE

Patient can’t be denied treatment on the pre text of non availability of

beds/specialists failing which treatment may be arranged from other hospital

and any excess payment made to the other centre for the management of such

cases will be deducted from the pending bills/security money.

(X) INDEMNITY

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

against all action suits, claims and demands brought or made against inn

respect of anything done or purported to be done by the Hospital in execution

of or in connection with the services under this Agreement and against any loss

or damage to ESIC in consequence to any action or suit being brought against

the ESIC along with (or, otherwise), Hospital as a party for anything done or

purported to be done in the course of the execution of this Agreement. The

Hospital will at all times abide by the job safety measures and other statutory

requirements prevalent in India and will keep free and indemnify the ESIC from

all demands or responsibilities arising from accidents or loss of life, the cause

or result of which is the Hospital negligence or misconduct. The Hospital will

pay all the indemnities arising from such incidents without any extra const to

ESIC and will not hold the ESIC responsible or obligated.

KESIC may at its discretion and shall always be entirely at the cost of the tie-up

Hospital defends such suit, either jointly with the tie-up Hospitals or separately

in case the latter chooses not to defend the case.

(XI) ARBITRATION

If any dispute or difference of any line whatsoever (the decision whereof if not

being otherwise provided for) shall arise between the ESIC and the Empanelled

Centre upon or relation to or in connection with or arising about of the

Agreement, if shall be referred to for arbitration by the Medical

Superintendent who will give written award of his decision to the parties.

Arbitrator to be appointed by Medical Superintendent. The decision of the

Arbitrator will be final binding. The provision of Arbitration and Conciliation

Act, 1996 shall apply to the arbitration proceedings. The venue of the

arbitration proceedings shall be at office of Medical Superintendent. Any legal

dispute to be settled in Varanasi jurisdiction only.

(XII)MISCELANEOUS

a. Nothing under this Agreement shall be construed as establishing or

creating between the Parties any relationship of Master and Servant

or Principle and Agent between the ESIC and Empanelled Centre.

b. The Empanelled Centre shall not represent or hold itself out as an

agent for the ESIC.

c. The KESIC will not be responsible in any way for any negligence or

misconduct of the Empanelled centre and its employees for any

accident, injury or damage sustained or suffered by the referred

patient/ESIC beneficiary or any their party resulting from or by any

operation conducted by or on behalf of the Hospital or rendering its

services under this Agreement or otherwise.

d. The Empanelled Centre shall notify the ESIC Hospital of any material

change in their status and their share holdings or that of any

Guarantor of the Empanelled Centre in particular where such change

would have an impact in the performance of obligation under this

Agreement .

e. This agreement can be modified or altered only on written

Agreement signed by both the parties.

f. Should the Empanelled Centre get wound up or partnership be

dissolved, the ESIC shall have the right to terminate the Agreement.

The termination of Agreement shall not relieve the Empanelled

Centre or their heirs and legal representatives from their liability in

respect of the services provided by the Empanelled Centre during the

period when the Agreement was enforce.

g. The Empanelled Centre shall bear all expenses incidental to the

preparation and stamping of their Agreement.

(XIII) TDSEDUCTIONS

TDS will be deducted as per Income Tax Rules.

(XIV) NOTICES

i) Any notice given any party to other pursuant to this Agreement

shall be sent to other party in writing by Registered Post at the

official address given in tender form.

ii) A notice shall be effective from the date on which it is served or

on the notice’s effective date, whichever is later. Registered

communication shall be deemed to have been served even if it

returned with the remarks like refused, left, premises locked etc.

Medical Superintendent reserves the right to accept or reject any

tender without assigning any reason thereof.

Signature of

Medical Superintendent

UNDERTAKING

I/We……………………………….(name of proprietor) have carefully gone through

and understood the Contents of the Document Form and I/we undertake to

abide by all terms and conditions set forth. I/We legally bound to provide

services as per rates/terms and conditions of Tender documents filing which

Medical Superintendent, ESIC Hospital, Pandeypur Varanasi is liable to take

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

alternative arrangement will be made at the risk and cost of our institute. We

undertake that the information submitted along with document and annexure-

I is correct and also fully understand that in case of default the security money

shall be forfeited.

Dated Signatures Name

Place (with seal /rubberstamp)

Annexure A

(Refto……………………..of ESIC Hospital/SMC

Office………………………….LetterNo………………………………………………………………..dated…………………

………………….) ADDENDUM TO MEMORANDUM OF AGREEMETN

DATED…………………………………This Memorandum of Understanding (MOU) entered into on

this the………..day of ………………………2017 between …………………...(Herein after referred to as

ESIC, which expression shall, unless repugnant to the context or meaning thereof, be

deemed to mean and include its successors and assigns) of the first part

AND

( Name of Empanelled Private Hospital/Diagnostic Centre) having its registered office at

………, India, herein referred to as “Empanelled hospital” which expression shall unless

repugnant to the context or meaning thereof be deemed to mean and include its

successors, liquidators, Administrators and permitted assigns) of the second part.

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

AND WHEREAS ESIC proposes to provide treatment facilities through its hospitals &

dispensaries to the Beneficiaries in the Empanelled Hospitals,

AND WHEREAS empanelled hospital offered to give the treatment / diagnostic

facilities/health benefits to ESIC Beneficiaries in the Empanelled Hospital,

Each of these empanelled Hospitals shall hereinafter be referred individually as a “Party”

and collectively as the “Parties”

Whereas the Parties have entered into this MOU to record their intention to jointly engage

UTITSL as Bill Processing Agency (BPA) in relation to payments and re-imbursement for

Medical Expenses.

The parties shall abide by all the following undertakings in addition to ESIC Policy and

Standard Operating Procedures, the clauses mentioned in the Memorandum of Agreement

with ESIC Hospital/SMC Office and for the purpose of bill processing:

A. The empanelled hospital shall acknowledge the referral from ESIS/ESIC

Hospital/institution online

B. The empanelled hospital on admission of and ESI Hospital/Institution Beneficiary

shall intimate online to BPA the complete details of the patient, proposed line of

treatment, proposed duration of treatment with Clinical History within 2 hours of

admission.

C. After the patient is discharged. The hospital will upload the claim related documents

as per SIOP and ESIC policy viz Referral letter, Bills, Lab reports, Discharge Summary,

Doctors report, indoor papers etc to BPS through the web based application within

seven working days.

D. The hard copies of the claim will be delivered/dispatched to the concerned referring

ESI

Hospital/Institution within seven (7) working days but not later than 30 days.

E. The empanelled hospital shall submit all the medical reports in digital form as well as

in physical form as per ESIC policy and SOP

F. The empanelled hospital agrees that the actual processing shall start when physical

copies of the bills submitted by the empanelled hospitals to the concerned referring

ESIC/ESIS Hospital, are verified by them on behalf of respective ESIC/SEIS Hospital.

Counting of days shall start from such date for the purpose of TAT. In case of query

raised on the bills the TAT for the purpose of BPA shall start from the date of reply to

the last query raised by the Tie-up Hospital.

G. In case of absence of certain physical documents, the “Need More Information”

(NMI) status will be raised by the Verifier of the respective ESIC/ESIS Hospital, BPA or

Medical processing team of respective ESIC Hospital/SMC office to the empanelled

hospital/diagnostic center for the missing/ambiguous physical documents (As per

SOP). Empanelled hospitals/diagnostic centers shall have to submit the

clarifications/information inter alia for all bills returned online at any level under

“Need for more Info” category (NMI), within 15 days failing which which these on the

basis of available documents without any further intimation and such bills/claims will

be closed not to be opened further.

H. The BPA will audit the medical claims of the ESI Hospital/institution Beneficiaries in

respect of the treatment taken by them in the empanelled hospital and make

recommendations for onward payment to ESIC Hospital/SMC Office in a time bound

manner within; a period of 10 working days from the date for submission of bills in

physical formator reply to last query, whichever is later.

I. The empanelled hospitals shall have the necessary IT infrastructure for interaction

with BPA such as Desktop PC with internet connectivity features, High Speed High

resolution multi page Document Scanner, Printers , etc.

J. IN case of some mistakes in the scrutiny of claims recommendations there to by BPA

resulting in excess payment to the empanelled hospital by ESIC Hospital/SMC Office

the excess amount shall b e recovered from the future bills of the empanelled

hospital.

K. Subject to BPA rendering bill-processing services as per terms and conditions of their

agreement, the empanelled hospital/diagnostic centers/claimants shall pay to the

BPA, the service fees and service tax/any other tax by any name called as applicable

on per claim basis, as detailed below, through ESIC.

L. The amount deduced towards fee and service tax/GST/any other tax by any name

called from the payable claims of hospitals/diagnostic centers shall be forwarded by

ESIC to BPA simultaneously along with the payments to empanelled hospital through

ECS or any other mode of money transfer, as decided by ESIC.

M. The processing fee admissible to BPA will be at the rate of 2% of the claimed amount

of the bill submitted by the empanelled hospital/diagnostic center (and not on the

approved amount) and service tax/GST/any other tax any name thereon. The

minimum admissible amount shall be Rs.12.50 (exclusive of service tax/GST/any

other tax by any name, which will be payable extra) per individual bill/claim. The fee

shall be auto –Calculated by the software and promoted to the ESI Hospital office by

the system at the time of generation of settlement ID.

N. The fee shall also mean to include any additional payment of Service Tax, GST or any

other taxes by whatever name called as applicable on such fee amount admissible to

BPA.

O. If the claim is rejected or results into non payment to the empanelled

hospital/diagnostic center, ESIC Hospital Office shall recover the service charge and

service tax/GST/any other tax by any name due to the BPA from the subsequent

claims of the respective empanelled hospital/diagnostic center and shall pay to the

account of the BPA.

P. MEDICAL AUDIT FO BILLS: There shall be continuous medical audits of the services

provided/claims/raised by the empanelled hospital by ESIC/BPA.

IN WITNESS WHEROF the parties have caused this Agreement/MOU to be signed

executed on the day, month and year first above-mentioned.

Signed by (Authority of ESI Institution)

IN presence of (Witnesses)

1

2

Signed by( For and behalf of (empanelled hospital/diagnostic center name)

duly Authorized vide resolution No……………………………..Dated……………………………

1

2

ANNEXURE-I

MINIMUM REQUIREMENT

(To be submitted duly filled along with document form)

1. Name of the Hospital with complete address

2. Telephone No…………………………….

3. Fax No…………………………..

4. Mobile No…………………..

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

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

person:………………………….(attach authority letter)…………………

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

specialty………………………………………….

8. No. of ICU/NICU/PIU/SICU Beds (notlessthan4beds with 4 ventilators) if

available…………………….

9. No. of functioning Operation Theatres: ……………………

10. Name of existing empanelled organization/Institutions: ………………….

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

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

the organization for which centre is going to empanelled: (separate sheet to be

attached)

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

arrangement: (As per Annexure-II)……………

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

attached with invoice copy)……

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

paramedical and non-medical be attached)…….

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

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

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

18. (a). E.M.D……………………Rs. 20,000/-

Demand Draft to be submitted along with tender document

Name of Bank………………………

Branch………………………………….

Amount………………………………..

Date……………………………………..

(b) Tender document cost Rs. 1f000/- in case the tender document had been

downloaded from the website.

Name fo Bank Account No. 9ECS Transfer Details)……….

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

20. Rate list of hospital/centre which already exists for non-ESI general patients.

Enclosure: List as per Index.

(Name and signature of Proprietor)

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

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

documentary proof for the same. NO future correspondence in this regard shall be

entertained in this regard. A duly constituted committee will visit those centres for

inspection which qualify technical bid/need requirement as mentioned in the document.

ANNEXURE-II

SPECIALITIES/SERVICES FOR EMPANELMENT (Secondary care)

SI.NO. Name of Specialty

OPD, INDOOR and emergencies facilities to provide secondary care facilities in department of Medicine (ICU), Surgery (SICU), O&G (NICU is must for obstetrics empanelment), Orthopedics (Except joint replacement and reconstructive surgeries), Opthamology, TB &Chest, Paediatrics (NICU, PICU), Dental (Crown and Bridge work etc) with mandatory in house facility for ultrasonography and X-Ray and preferably CT Scan, ECHO, MRI, TMT, PFT, Endoscopy and 24 hours sophisticated Lab investigations.

A. Exclusively- Eye and Dental, B. Exclusive Diagnostic center provides the facility Digital X-Ray (All Body

Part), X-Ray contrast studies, X-Ray mammography, ECG, EEG, Ultrasound (All Body Part), Color Doppler, OPG, Dental X-RAY.

C. Exclusive center for Audiometry Test-Pure Tone Audiometry, Impedence, BERA, OAE, Hearing Aid Trial Speech Therapy.

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

investigations, authorization letter competent authority under PCPNDT and AREB is

mandatory.

Relevant documents like authorization letter with permission to perform the

above investigations from competent authority is mandatory and has to be

submitted while applying, from competent authority is mandatory.

ANNEXURE-III

Letterhead of Referring ESI Hospital (P-I)

Referral form (Permission letter)

Referral No:

I.P/Beneficiary/Staff

Name of the Patient: Age/Sex:

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

Entitled for Specialty/ SuperSptt: Yes/No

Identification marks (if any):

I.P/Beneficiary/Staff:

Relationship with IP/Staff:

Diagnosis/clinical opinion/case summary:

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

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

referral):

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

Ivoluntarily choose ………..Hospital for treatment of self or my…………………

Sign/Thumb Impression of IP/Beneficiary/Staff

Referred ………………………………………………..Hospital/Diagnostic Center for…………………………..

Date:

Sign & Stamp of Authorized Signatory**

*IN case of emergency, signature of referring doctor or Casualty Medical Officer. Record to

be maintained in the register., New form fully filled will be sent after signature of the

competent authority on the next working day.

Mandatory Instructions for Referral Hospital:

-Referral hospital is instructed to perform any the procedure/treatment for which the

patient has been referred to.

-In case of additional procedure/treatment/investigation is essentially required in order to

treat the patient for which he/she has been referred to, the permission for the same is

essentially required from the referring hospital either through e-mail, fax or telephonically

(to be confirmed in writing at the earlier).

The referred hospital is requested to raise the bill as per the agreement on the standard

proforma along with supporting documents within 6 days of discharge of the patient giving

account number and RTGS number etc.

Cheklist (Referring Hospital)

1. Duly filled & signed referral perform.

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

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

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

5. Reports of investigations and treatment already done.

6. Photograph

Date:

Signature of the Competent Authority

ANNEXURE-IV

To be used the tie-up Hospital (for raising the bill) (P-I)

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

(NABH accredited Superspeciality Hospital)

( Attach documentary Proof)

Date of Submission

Individual Case Format

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

Emergency/through

MEDICAL SUPDT/SMC:

Address:

Insurance Number/Staff Card No/Pensioner Card NO:

Date of Referral :

Diagnosis :

Condition of the patient at discharge :

(For Package Rates)

Treatment /Procedure done/Preformed :

Existing in the package rate list’s

CGHS/other Code no/nos for chargeable procedures :

SL.No Chargeable procedure

CGHS Code no with Page No. (1)

Other if not on (1f) prescribed code NO. with Page NO

Rate Amount claimed with date

Amount Admitted with Date (X)

Remarks

Charges of Implant/device used

Amount Claimed ……………………………Amount Admitted Remarks

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

SL.No. Chargeable Procedure

Amt. Claimed with date

Amt. admitted with date

Remarks (X)

III. Additional Procedure Done with rationale and documented permission

SL.No Chargeable procedure

CGHS Code with Page no(i)

Other if not on code no with page no.(i)

Rate Amt. claimed with date

Amt. admitted with date

Remarks (X)

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

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

Remarks

Certified that the treatment /procedure has been done/performed as per laid down norms

and the charges in the bill has/have been claimed as per the terms & conditions laid down in

the agreement signed with ESIC.

Further certified that the treatment/procedure have been performed on cashless basis. No

money has been received / demanded/charged from the patient/his/her relative.

Sign/Thumb impression of patient with date Sign & Stamp of unauthorized Signatory with

date (for Official use fo ESIC)

Total Amt payable:

Date of payment :

Signature of Dealing Assistant Signature of Medical Superintendent

Date:

Signature of ESIC Competent Authority Medical Superintendent 1. Discharge slip containing treatment summary & detailed treatment record.

2. Bills(s) of Implants(s)/ Stent(s)/ device along with Pouch/Packet/invoice etc.

3. Photocopies of referral Performa, Insurance Card/Aadhar Card of IP /Referral

Recommendation of medical officer & entitlement certificate. Approval letter from

SMC/MEDICAL SUPDT in case of emergency treatment or additional procedure performed.

4. Sign & Stamp of Authorized Signatory.

5. Patient/Attendant satisfaction certificate.

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

ANNEXURE-V

To be used by Tie-up hospital (P-III)

Letterhead of Hospital with Address & Email/Fax/Telefax

Consolidated Bill Format

Bill NO……………………………..Date of Submission………………………………..

Bill details (Summary)]

Sl. No.

Name of Pateint

Ref .NO.

Diag/Procedure for which referred

Procedure performed/ treatment Given

CGHS code (with page) No. Nos

Other if not in CGHS rate list

Amt. claimed with date

Amt. entitled with date

Remarks

Certified that the treatment/procedure has been done/performed as per laid down norms

and the charges in the bill has/have been claimed as per the terms & conditions laid down in

the agreement signed with ESIC. Further certified the treatment/procedure have been

performed on cashless basis. No money has been received /demanded / charged from the

patient/his/her/relative.

The amount may be credited to our account no……………………..RTGS no…………………………and

intimate the same thorough email/fax/hard copy at the address.

Signature of the competent authority of the Hospital

Date:

Checklist

1. Duly filled up consolidated proforma.

2. Duly filled up Individual Pt Bill. Proforma

Certificate : It is certified that the drugs used in the treatment are in the standard

pharmacopeia IP/BP/USP.

It is certified that total amount of Rs………………has been credited to your account

no……………,RTGS no………………………on…………………………..

Date:

Signature of the Competent Authority.

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

ANNEXURE VI

Letterhead of Referring ESI Hospital-(P_IV)

Sanction Memo/Disallowance Memo

Name of Referral Hospital (Tie-up Hospital)

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

SL. No Name of the Patient & Referrance NO.

Amt. Claimed with Date

Amt. Sanctioned/Admitted with date

Reasons(s) For Disallowance

Remarks

Date :

Signature of Competent Authority with stamp

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

ANNEXURE-VII

Letterhead of Tie-up Hospital with Address details(P-V)Monthly Bill

Special Investigation For diagnosis centres/referral Hospitals

Bill NO………………..Date of Submission…………………………..

Sl NO.

Name of the Patient With Insurance/Staff NO.

Date of reference

Investigation Performed

CGHS/Other code in package rate list

Amount admitted with date

Amt claimed with date

Remarks Disallowances with Reasons

Certified that the procedure /investigations have been done/performed as per laid down

norms and the charges in the bill has/have been claimed as per the terms & conditions laid

down I the agreement signed with ESIC.

Further certified that the procedure/investigation have been performed on cashless basis.

NO money has been received /demanded/charged from the patient/his/her relative.

The amount may be credited to our account no………………………………RTGS no

………………………..and intimate the same through email/fax/hard copy at the address.

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

Checklist

1. Investigation Report of each individual/Pt.

2. Copy of Referral Document of each individual/Pt.

3. Serialization of individual bills as per the Sr. No. in the bill.

It is certified that total amount of Rs…………………….has been credited to your account

no…………………, RTGS no……………………………….on………………………………………………

Signature of Account department with stamp

Signature of Competent Authority

Date: Referral Hospital.

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

Patient Referral NO………………………………

ANNEXURE-VIII

PATIENT/ATTENDANT SATISFACTION CERTIFICATE (P-VI)

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

behavior of the hospital staff.

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

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

the stay at hospital.

Sign /Thumb impression of patient/Attendant

Date & Time: Name of the Patient/attendant

Name of IP

Insurance No/Staff no

Date of Admission

Date of Discharge