Ayushman Bharat Surgery List । Free Treatment up to 5 Lakhs

Ayushman Bharat Surgery List, Ayushman Bharat Procedure List,Ayushman Bharat Card Operation List,Ayushman Bharat Surgery Package List

Objectives of the Scheme

Ayushman Bharat Pradhanmantri Jan Arogya Yojna AB-PMJAY aims to reduce catastrophic health expenditure, improve access to quality health care, reduce unmet needs and reduce out of pocket healthcare expenditures of poor and vulnerable families falling under the deprivation criteria of D1, D2, D3, D4, D5 and D7, Automatically Included category and broadly 11 defined occupational un-organised workers (in Urban Sector) of the Socio-Economic Caste Census (SECC) database of the State/ UT along with the estimated existing RSBY Beneficiary Families not figuring in the SECC Database. These eligible AB-PMJAY beneficiary families

will be provided coverage for secondary, tertiary and day care procedures (as applicable) for treatment of diseases and medical conditions through a network of Empaneled Health Care Providers (EHCP).

Health Benefit Package (HBP)

The benefits within this Scheme under the basic risk cover are to be provided on a cashless basis to the AB PM-JAY Beneficiaries up to the limit of their annual coverage and includes:

• Hospitalization expense
• Day care treatment (as applicable)
• Follow-up care
• Pre and post hospitalization expense Newborn child / children

Package Rates

Insurer shall reimburse claims of EHCPs based on package rates determined as follows:

• If package rate for a medical treatment or surgical procedure requiring hospitalization or Daycare treatment (as applicable) is fixed in the HBP, then the package rate so fixed shall apply for the policy cover period.
• If package rate for a surgical procedure requiring hospitalization or Daycare treatment (as applicable) is not listed in the HBP, then the Insurer may pre-authorise an appropriate amount based on rates for similar procedures defined in the list, or based on other applicable national or state health insurance schemes such as CGHS. In case of medical care, the rate will be calculated on per day basis as specified in the package list except for special inputs like High end radiological diagnostic and High-end histopathology (Biopsies) and advanced serology investigations packages or some other special inputs existing in the HBP (or are released by NHA in future) which can be clubbed with medical packages.
• AB PM-JAY is a cashless scheme, where no beneficiary should be made to pay for availing treatment in any EHCP. However, upon exhaustion of the wallet, or if the treatment cost exceeds the benefit coverage amount available with the beneficiary families then the liability for such remaining treatment cost as per the package rates defined in the HBP list will not be of the insurer. Beneficiary and SHA (through ISA/TPA) will need to be clearly communicated in advance about the additional payment at the start of such treatment.
• In case a beneficiary is required to undertake multiple surgical procedures in one OT session, the procedure with highest rate shall be considered as the primary package and reimbursed at 100%, thereupon the 2nd surgical procedure shall be reimbursed at 50% of package rate, 3rd and subsequent surgical procedures shall be reimbursed at 25% of the package rate.
• Surgical and medical packages will not be allowed to be availed at the same time (Except for Add-on procedures as defined in the HBP and configured in NTMS). In exceptional circumstances, hospital may raise a request for such pre-authorization which will be decided by SHA with the help of concerned medical specialist.
• Certain packages as mentioned in the HBP master will only be reserved for Public EHCPs as decided by NHA. SHAs may permit availing these packages in private EHCPs only after a referral from a public EHCP is made. Some modifications (in not more than 10% of total number of packages) may be done by SHA in this regard.
• Incentivization will be provided to certain hospitals which will be over and above the rates defined in the HBP.

For the purpose of hospitalization expenses as package rates shall include all the costs associated with the treatment, amongst other things:

• Registration charges
• Bed charges
• Nursing and boarding charges
• Surgeons, anesthetists, medical practitioner, consultant’s fees etc.
• Anesthesia, blood transfusion, oxygen, O.T. charges, cost of surgical appliances etc.
• Medicines and drugs
• Cost of prosthetic devices, implants etc.
• Pathology and radiology tests: Medical procedures include basic radiological imaging and diagnostic tests such as X-ray, USG, hematology, pathology etc. However, high end radiological diagnostic and high-end histopathology (biopsies) and advanced serology investigations packages can be booked as a separate ‘Add-on procedure’, if required. Surgical packages are all inclusive and do not permit addition of other diagnostic packages.
• Food to patient
• Pre and post hospitalization expenses: Expenses incurred for consultation, diagnostic tests and medicines prior to admission of the patient in the same hospital and cost of diagnostic tests and medicines up to 15 days after discharge from the hospital for the same ailment / surgery. Any other expenses related to the treatment of the patient in the hospital

For the purpose of Daycare treatment expenses shall include, amongst other things:

• Registration charges
• Surgeons, anesthetists, medical practitioners, consultants’ fees, etc.
• Anesthesia, blood transfusion, oxygen, operation theatre charges, cost of surgical appliances, etc.
• Medicines and drugs
• Cost of prosthetic devices, implants, organs, etc.
• Pathology and radiology tests: Medical procedures include basic radiological imaging and diagnostic tests such as X-ray, USG, hematology, pathology etc. However, high end radiological diagnostic and high-end histopathology (Biopsies) and advanced serology investigations packages can be booked as a separate add-on procedure if required. Surgical packages are all inclusive and do not permit addition of other diagnostic packages.
• Pre and post hospitalization expenses: Expenses incurred for consultation, diagnostic tests andmedicines prior to admission of the patient in the same hospital and cost of diagnostic tests and medicines up to 15 days after discharge from the hospital for the same ailment / surgery.
• Any other expenses related to Daycare treatment provided to the beneficiary by an EHCP.

 If NHA finds a treatment being booked under unspecified surgical procedure repeatedly, or some treatment is required to be included within the national HBP, to address a pressing health problem which is or have become widely prevalent, then NHA may add such treatment(s)  under national HBP.

The benefits under the ABPM-JAY cover shall, subject to the available ABPM-JAY sum Insured, be available to the beneficiary on a cashless and paperless basis at any EHCP.

Key highlights – HBP 2.0,HBP 2.1 & HBP 2.2

Ayushman Bharat Surgery List

Burns Management

• Total number of packages: 6
• Total number of procedures: 20
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Specific Pre and Post-op Investigations such as clinical photograph and diagram with Rule of 9 / L & B Chart for extent of burns at the time of
• admission and follow up clinical photographs on days 5, 10, 15, 20 as per requirements on the  basis of preauthorization would need to be submitted during claims.
• Admission Criteria to be followed for selecting packages for burn injured patients

1. Secondand third-degree burns greater than 10% of the total body surface area in patients under 10 or over 60 years of age
2. Secondand third-degree burns greater than 20% of the total body surface area in other age groups
3. Significant burns of face, hands, feet, genitalia, or perineum and those that involve skin overlying major joints
4. Third-degree burns greater than 5% of the total body surface area in any age group
5. Inhalation injury
6. Significant electric injury including lightning injury
7. Significant chemical injury
8. Burns with significant pre-existing medical disorders that could complicate management,prolong recovery, or affect mortality (e.g. diabetes mellitus, cardiopulmonary disease)
9. Burns with significant concomitant trauma
10. Burn injury in patients who will require special social and emotional or long-term rehabilitative support, including cases of suspected child abuse and neglect.

Cardiology

• Total number of packages: 21
• Total number of procedures: 27
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Specific Pre and Post-op Investigations such as ECHO, ECG, pre /post-op X-ray, label / carton of stents used, pre and post-op blood tests (USG, clotting time,prothrombin time, international normalized ratio, Hb, Serum Creatinine), angioplasty stills showing stents & post stent flow, CAG report showing blocks (pre) and balloon and stills showing flow (post) etc. will need to be submitted/ uploaded for pre-authorization/ claims settlement purposes. The costs for such investigations will form part of the approved package cost.
• It is prescribed as standard practice to use medicated stents (approved by FDA/DCGI) where necessary
• The carton / sticker detailing the stent particulars needs to be submitted as part of claims filing by Providers
• It is advised to perform cardiac catheterization as part of the treatment package for congenital heart defects

Cardio-thoracic & Vascular Surgery

• Total number of packages: 35
• Total number of procedures: 129
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Specific Pre and Post-op Investigations such as ECHO, ECG, postop scar photo, clinical photos of graft / filter / balloon & post flow,Angiography / CT / MRI /Doppler / CT angiogram reports etc. will need to be submitted / uploaded for pre-authorization / claims settlement purposes
• It is advised to perform cardiac catheterization as part of the treatment package for congenitalheart defects

Emergency Room Packages

• Total number of packages: 3
• Total number of procedures: 4
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Nil
• Paper trail is to be maintained by the hospital treating the patient to be submitted during closure of claim
• In case hospitalization of more than 12 hours is required, the patient  will be admitted and treated accordingly in the related specialty
• For the package Animal bites (Excluding Snake Bite) (ER003A), payment to be made after the completion of 5th dose

General Medicine

• Total number of packages: 81
• Total number of procedures: 106
• Pre-authorization: Mandatory for all packages for progressive extension of treatment/ hospital stay
• Pre-authorization remarks: Prior approval must be taken for all medical conditions/ packages under this domain for progressive extension of therapeutic treatments (i.e. for extending stay at 1,5,10 days stay and beyond)
• Separate package for high end radiologic diagnostic (CT, MRI, Imaging including nuclear imaging,) relevant to the illness only (no standalone diagnostics allowed) – subject to preauthorization with a cap of Rs 5000 per family per annum within overall sum insured.
• Separate package for high end histopathology (Biopsies) and advanced serology investigations relevant to the illness only (no standalone diagnostics allowed) – after pre-authorization with a cap of Rs 5000 per family per annum within overall sum insured.
• Blood or Blood components transfusion if required, payable separately subject to preauthorization.Blood can be procured only through licensed blood banks as per National Blood Transfusion Council Guidelines
• All clinical test reports, diagnosis, TPR charting, case sheet / clinical notes and discharge summary need to be submitted for extension of packages and during claims submission

General Surgery

• Total number of packages: 105
• Total number of procedures: 159
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Nil
• Spinal / other regional anesthesiaare included under General Anesthesia  and need to be claimed accordingly.

Infectious Diseases

• Total number of packages: 3
• Total number of procedures: 4

Treatment and testing to be conducted as per the latest protocol from ICMR or State government & Recently added MIS-C packages under HBP 2.2

Interventional Neuroradiology

• Total number of packages: 10
• Page 26 of 64
• Total number of procedures: 15
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Specific Pre and Post-op Investigations such as pre/ post-op X-ray, CT/ ultrasound report, pre and post-op blood tests, post op clinical photographs with scar etc. will need to be submitted/ uploaded for pre-authorization/ claims settlement purposes. The costs for such investigations will form part of the approved package cost.

Medical Oncology

• Total number of packages: 72
• Total number of procedures: 264
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Prior approval must be taken for all treatments/ malignancies
• The type and duration of treatment is different for all cancers. It is very important to complete the entire treatment which may in some cases last longer than a year. Relapse/recurrence may sometimes occur
• Cancer care treatments are advised to go through a clinical treatment approval process before initiating the best suitable treatment. A clinical treatment approval  process is mandated for cancer care, since it involves a multi-modal approach covering surgical, chemotherapy and radiation treatments and appropriate supportive care that could assess to determine the best course of patient management for such conditions
• There should be pre-authorization at each step for cancer care
• It is advised that decision regarding appropriate patient care for cancer  care treatments would need to be taken by a multidisciplinary tumor board (if available within  the treating hospital or if not then it could be sent to the nearest regional cancer center (RCC) for approval) that should include a highly trained team of Surgical, Radiation and Medical Oncologist  in order to ensure the most appropriate treatment for the patient. A detailed Oncology Treatment Plan could prove to be very vital, such as implications on the financial cover and to avoid  unnecessary treatments

Mental Disorders Package

• Total number of packages: 10
• Total number of procedures: 10
• Page 27 of 64
• Pre-authorization: Mandatory for all packages for progressive extension
• of treatment/ hospital stay
• Pre-authorization remarks: Prior approval must be taken for all mental health conditions/ packages under this domain for progressive extension of therapeutic
• treatments
• Procedures can be done only in public sector hospital with specialty available
• All clinical test reports, diagnosis, Mental Status Examination (MSE), case sheet / clinical notes and discharge summary need to be submitted for extension of packages and  during claims submission

Neonatal Care Package

• Total number of packages: 10
• Total number of procedures: 10
• Pre-authorization: Mandatory for all packages for progressive extension of treatment/ hospital stay / shifting across packages
• Pre-authorization remarks: Prior approval must be taken for progressive extension of therapeutic treatments (i.e. for extending stay beyond the prescribed limit/ in cases  which might need shifting of packages based on clinical vitals and need – then the previously blocked package needs to be unblocked and the total amount of new package needs to be considered to be debited).
• All clinical test reports, diagnosis, TPR charting, case sheet / clinical notes and discharge summary need to be submitted for extension of packages and during claims submission.
• Packages would include neonates up to age of 28 days after birth
• All the packages are inclusive of everything including drugs, diagnostics, consultations, procedures, treatment modalities that the baby would require for its management
• In case a baby in a lower cost package develops a complication requiring higher level of care, the baby should be moved for higher cost package
• For procedures MN002A, MN003A, MN004A and MN005A, mother’s stay and food in the hospital [postnatal ward / special ward for such mothers] for breastfeeding, family centered care and KMC (Kangaroo Mother Care) is mandatory
• For procedures MN002A, MN003A, MN004A and MN005A mothers should be allotted KMC bed when the newborn is eligible for Kangaroo mother care. The cost of bare bed and food to the mother is included. If the mother requires treatment for her own illnesses, it would be covered under the mother’s packages
• It is mandatory to ensure that the neonate receives vaccination as per National Immunization Schedule before discharge

Neurosurgery

• Total number of packages: 63
• Total number of procedures: 96
• Pre-authorization: Mandatory for all packages Pre-authorization remarks: Specific Pre-op and Post-op Investigations such as pre/ post-op Xray, neuro-diagnostic studies, post-operative clinical photographs showing scars etc. will need to be submitted/ uploaded for pre-authorization/ claims settlement purposes. The costs for such investigations will form part of the approved package cost

Obstetrics & Gynecology

• Total number of packages: 60
• Total number of procedures: 79
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Prior approval must be taken for all elective  Surgeries/Procedures. Although the following packages, namely C-Section, High Risk Delivery, Hysterectomy are primarily for government facilities, they are open to the private hospitals upon referral by government hospitals/Doctors.
• Packages will include drugs, diagnostics, consultations, procedures, stay and food for patient.Medical conditions during pregnancy such at Hypertension, Diabetes etc. are to be treated as per medical packages.

Ophthalmology

• Total number of packages: 41
• Total number of procedures: 55
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Nil
• Following cataract surgery that implants an IOL, it is prescribed to mention/ attach the barcode no. on the lens used during claims submission by the provider as means to provide information on expiration dates and details from manufacturers for increased quality and safety.

Oral & Maxillofacial Surgery

• Total number of packages: 14
• Total number of procedures: 19
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Nil
• 3.16 Organ and Tissue Transplant
• Total number of packages: 01
• Total number of procedures: 06
• Pre-authorization: Mandatory for all packages Pre-authorization remarks: NOTTO ID of the recipient and / donor, donor work-up summary sheet, recipient work-up summary sheet, cross-match report with donor and recipient photo-IDproof, admission notes, undertaking signed by donor (in living donor transplant), hospital authorization letter on recipient.

Orthopedics

• Total number of packages: 73
• Total number of procedures: 134
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Prior approval must be taken for all replacement surgeries and othersas indicated.

Otorhinolaryngology (ENT)

• Total number of packages: 35
• Total number of procedures: 79
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Nil

Pediatric Medical Management

• Total number of packages: 48
• Total number of procedures: 67
• Pre-authorization: Mandatory for all packages for progressive extension of treatment/ hospital stay
• Pre-authorization remarks: Prior approval must be taken for all medical conditions/ packages under this domain for progressive extension of therapeutic treatments (i.e. for extending stay at 1,5,10 days stay and beyond)
• All clinical test reports, diagnosis, TPR charting, case sheet/ clinical otes and discharge summary need to be submitted for extension of packages and during claims submission
• Separate package for high end radiological diagnostic (CT, MRI, Imaging including nuclear imaging,) relevant to the illness only (no standalone diagnostics allowed) – subject to preauthorization with a cap of Rs 5000 per family per annum within overall sum insured.
• Separate package for high end histopathology (Biopsies) and advanced serology investigations relevant to the illness only after preauthorization with a cap of Rs 5000 per family per annumwithin overall sum insured.
• Blood or Blood components transfusion if required, payable separately subject to preauthorization.Blood can be procured only through licensed blood banks as per National Blood Transfusion Council Guidelines.
• If a medical condition requiring hospitalization has not been envisaged under this list, then a preauthorization can be sought as “Unspecified Medical”

Pediatric Surgery

• Total number of packages: 19
• Total number of procedures: 35
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Nil

Plastic & Reconstructive Surgery

• Total number of packages: 8
• Total number of procedures: 12
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Specific Pre-op and Post-op Investigations such as clinical and/or relevant imaging photographs of the patient are essential.
• In case of emergency/lifesaving/ limb saving operative procedures, preauthorization may not be required. However, formal intimation should be done within 24 hours of  admission.

Polytrauma

• Total number of packages: 10
• Total number of procedures: 21
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Specific Pre-op and Post-op Investigations such as pre/ post-op Xray,CT report, post-op scar photo, electro-diagnostic studies etc. will need to be submitted / uploaded for pre-authorization/ claims settlement purposes. The costs for such investigations will form part of the approved package cost.
• The minimum length of hospital stay admissible for polytrauma cases would be on a case-bycase depending on the nature, type, and vitals (for e.g. coagulation parameters). Howeverweekly submission of clinico-radiological vitals is desired.

Radiation Oncology (19)

• Total number of packages: 14
• Total number of procedures: 46
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Prior approval must be taken for all treatments/ malignancies
• The type and duration of treatment is different for all cancers. It is very important to complete the entire treatment which may in some cases last longer than a year. Relapse/recurrence may sometimes occur
• Cancer care treatments are advised to go through a clinical treatment approval process before initiating the best suitable treatment. A clinical treatment approval process is mandated for cancer care, since it involves a multi-modal approach covering surgical, chemotherapy and radiation treatments and appropriate supportive care that could assess to determine the best course of patient management for such conditions
• There should be pre-authorization at each step for cancer care
• It is advised that decision regarding appropriate patient care for cancer care treatments would need to be taken by a multidisciplinary tumor board (if available within the treating hospital or if not then it could be sent to the nearest regional cancer center (RCC) for approval) that should include a highly trained team of Surgical, Radiation and Medical Oncologist  in order to ensure the most appropriate treatment for the patient. A detailed Oncology  Treatment Plan could prove to be very vital, such as implications on the financial cover and to avoid  unnecessary treatments.

Surgical Oncology

• Total number of packages: 81
• Total number of procedures: 125
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Prior approval must be taken for all treatments/ malignancies
• The type and duration of treatment is different for all cancers. It is very important to complete the entire treatment which may in some cases last longer than a year. Relapse/recurrence may sometimes occur
• Cancer care treatments are advised to go through a clinical treatment approval process before initiating the best suitable treatment. A clinical treatment approval process is mandated for cancer care, since it involves a multi-modal approach covering surgical, chemotherapy and radiation treatments and appropriate supportive care that could assess to determine the best course of patient management for such conditions
• There should be pre-authorization at each step for cancer care
• It is advised that decision regarding appropriate patient care for cancer care treatments would need to be taken by a multidisciplinary tumor board (if available within the treating hospital or if not then it could be sent to the nearest regional cancer center (RCC) for approval) that should include a highly trained team of Surgical, Radiation and Medical Oncologist in order to ensure the most appropriate treatment for the patient. A detailed Oncology Treatment Plan could prove to be very vital, such as implications on the financial cover and to avoid unnecessary treatments.

Urology

• Total number of packages: 97
• Total number of procedures: 148
• Pre-authorization: Mandatory for all packages
• Pre-authorization remarks: Prior approval must be taken for surgeries requiring use of Deflux injection, Botox Injection, inflatable penile prosthesis, urinary sphincter, and metallic stents
• It is mandated to get approval for all non-surgical conditions (involving evaluation/ investigation/ therapeutic management / follow-up visits) as indicated
• For any procedure whose charges are Rs. 15,000 or higher, extra costs (in the sense other packages) cannot be clubbed / claimed from the following: cystoscopy, ureteric catheterization,retrograde pyelogram, DJ stenting, nephrostomy – as they would form part of such packages costing Rs. 15,000 or higher as per the need and donor with details of the surgery.

Source : National Health Benefit Package 2.2