STANDAR D FORMA T FO R PROVID ER BILLS

Transcription

1 STANDAR D FORMA T FO R PROVID ER BILLS 1. Components of standardization: Standardization involves three components: i. Bill Format ii. Codes for billing items and nomenclature iii. Standard guidelines for preparing the bills. 2. Form at Specified: The bill is expected to be in two formats. i. The summary bill and ii. The detailed breakup of the bills. 3. Explanation and Guidelines - Summary Bill i. The summary format is annexed in the Schedule-IV A ii. The Bill shall be generated on the letter head of the provider and in A4 size to aid scanning. iii. The summary bill shall not have any additional items (only 9) iv. The provider has to mention the service tax number in case they charge service tax to the insurance company. v. The payer mentioned in the bill has to be necessarily the insurance company and Not the TPA. vi. In case of package charged for any procedure/treatment, the provider is expected to mention the amount in serial no 9 only. Items beyond the package are to be mentioned in serial numbers 1 to 8. vii. The patient/attendant signature is mandatory on the summary bill viii. The additional guidelines to fill the summary format shall be as below: Field Name Remarks Provider Name Provider Registration Number Legal entity name and not the trade name Registration number of the provider with local authorities, once the clinical establishments (registration and regulation) bill, 2007 is passed, then registration number under this act Address Address of the Facility where m ember is admitted. A provider can have more than one facility.

2 IP No Unique number identifying the particular hospitalization of the member Patient Name Full name of the patient Payer Name Name of t h e Insurance company with whom the member is insured. In case of cash patient then the field is to be left blank. If the bill is raised to more than one insurer then the primary insurer who has given cashless is to be mentioned. The name of insurance company needs to be mentioned and not the TPA. Member address Bill Number Full address of the member Bill number of the provider Bill Date Date on which the bill is generated. PAN Number PAN Number Mandatory Service Tax Regn. No. Registration number from service tax authorities. Mandatory in case service tax is charged in the bill Date of admission Date of admission of the member IPD cases. In case of Day care procedures, this is the date of procedure. Date of discharge Date of discharge of the member IPD cases. In case of Day care procedures, this is the date of procedure (same as date of admission) Bed Number Bed number in which the patient is admitted. In case the member is admitted under more than one bed number, all the numbers have to be mentioned. SL No 1 of billing Summary All items under the primary head Rs in In case the procedure is, then only bills

3 amount beyond the package needs to be SL No 2 of billing Summary All items under the primary head Rs in In case the procedure is, then only bill amount beyond the package needs to be SL No 3 of billing Summary All items under the primary head Rs in In case the procedure is, then only bills amount beyond the package needs to be SL No 4 of billing Summary All items under the primary head Rs in In case the procedure is, then only bills amount beyond the package needs to be SL No 5 of billing Summary All items under the primary head Rs in the detailed bill have to be summarized into this. In case the procedure is Packages then only bills amount beyond the package needs to be SL No 6 of billing Summary All items under the primary head Rs in In case the procedure is, then only bills amount beyond the package needs to be SL No 7 of billing Summary All items under the primary head Rs in In case the procedure is, then only bills amount beyond the package needs to be

4 SL No 8 of billing Summary All items under the primary head Rs in In case the procedure is, then only bills amount beyond the package needs to be SL No 9 of billing Summary All items under the primary head Rs in the detailed bill have to be Schedule-IV summarized into this. I f more than one procedure is done, the total amount of the two procedures needs to be summarized Total Bill amount Sum total of all items 1 to 9 in the bill Amount paid by the member Amount of bill paid by the member including copay, deductible, non-medical items etc incl discount offered to member, if any. Amount charged to Payer Amount payable by Insurance Company Discount Amount Amount offered as discount to the insurance company Service tax Service Tax chargeable to insurance company Amount Payable Total amount payable by insurance company including service tax Amount in words above amount in words for the sake of clarity Patient s signature Signature of the patient or the attendant of the patient needs to be mandatorily taken Authorized signatory The signature of the authorized signatory at the provider 4. Explanation and Guidelines - Detailed Breakup of the Bill i. The summary format is annexed in Schedule-IV-B

5 ii. The Bill shall be generated on the letter head of the provider and in A4 size paper to aid scanning. iii. The billing has to be done at level 2 or 3 iv. In case of medicines/consumables, the relevant level code has to be mentioned (40100, ) and the text should indicate the actual medicine used v. If providers have outsourced the pharmacy to external vendors, in such cases the providers can attach the original bills separately. However, the summary of this original bill has to be mentioned in the summary bill. vi. In case of pharmacy returns the same code originally used is to be used with a negative sign in the units. vii. In case of cancellation of any service the same code originally used is to be used with a negative sign indicating reversal. viii. The date on which the service is rendered is to be mentioned in the bill. This would be a. the date of requisition investigations b. date of consultation for professional fees c. date of requisition pharmacy/consumables irrespective of when they were used d. date of return of pharmacy items for pharmacy returns ix. The additional guidelines to fill the summary form at shall be as below, except that the first section of the bill is same as the bill summary referred in 3 above. Field Name Remarks Date Code Particulars Rate Unit Amount Date on which service is rendered. For example, this is the date of investigation, date of procedure etc. Level 2 or 3 code of the billing item as per the codes ( Part II } Text explanation of the item charged Per unit price (per day room rent, per consultation charge) No of units charged (hours, days, number as appropriate) Rate*unit(s). Schedules: Schedule-IVA

6 SUMM ARY BILL FORMAT Provider Name Bill Number Provider Registration No. Bill Date Address PAN Number Service Tax IP No Regn No Date of Patient Name admission XXXX Insurance Date of Payer Name Company Ltd Discharge Member Address Bed Number Billing Summary SI No Primary Code Particulars Amount Room & Nursing ICU OT Medicine & Professional Fees' Investigation Ambulance Miscellaneous Package Total Bill Amount 0 Amount paid by Member... 0 Amount charged to Payer 0 Discount Amount 0 Service Tax 0 Amount Payable 0 Amount in Words Rupees Zero Only Patients Signature Authorized Signatory

7 Schedule-IV B DETAILED BREAKUP FORMAT PART-I Provider Name Provider Registration No. Address IP No Patient Name Payer Name Member Address Bill Number Bill Date PAN Number Service Tax Regn. No Date of admission Date of Discharge Bed Number Billing Details SI No Date Code Particulars Rate Nos (Unit) Amount General Ward XXX medicine XXX Medicine - return

8 PART-II: Level 1 Level 1 Level 2 Level 2 Level 3 Level 3 Remarks Code Code Code Room & Nursing Room & Nursing Room Room & Nursing Room General Ward charges Room & Nursing Room Semi-private room charges Room & Nursing Room Single Room charges Room & Nursing Room Single Deluxe room charges Room & Nursing Room Deluxe room charges Room & Nursing Room Suite charges Room & Nursing Room Electricity charges Room & Nursing Room Bed sheet charges Room & Nursing Room Hot water charges Room & Nursing Room Establishment Room & Nursing Room Alpha/Water Bed Room & Nursing Room Attendant Bed Room & Nursing Nursing charges Room & Nursing Nursing charges Nursing fees Room & Nursing Nursing charges Dressing Room & Nursing Nursing charges Nebulization Room & Nursing Nursing charges Injection charges Room & Nursing Nursing charges Infusion pump charges Room & Nursing Nursing charges Aya Room & Nursing Nursing charges Blood Transfusion Room & Nursing Duty Doctor fee Room & Nursing Duty Doctor fee Duty Doctor Fee Room & Nursing Duty Doctor fee RMO Fees Room & Nursing Monitor charges Room & Nursing Monitor charges Pulse Oximeter charges If used in Normal Room ICU ICU ICU ICU ICU Burns Ward ICU ICU HDU charges ICU ICU ICCU charges ICU ICU Isolation ward charges ICU ICU Neuro ICU charges ICU ICU Podiatric/neonatal ICU ICU ICU Post-Operative ICU ICU ICU Recovery Room ICU ICU Surgical ICU ICU ICU Nursing If ICU nursing Charged Separately ICU ICU Nursing Nursing fees If ICU nursing Charged Separately ICU ICU Nursing Dressing If ICU nursing Charged Separately ICU ICU Nursing Nebulization If ICU

9 nursing Charged Separately ICU ICU Nursing Injection charges If ICU nursing Charged Separately ICU ICU Nursing Infusion pump charges ICU Monitor charges ICU Monitor charges Monitor charges ICU Monitor charges Pulse Oxymeter charges If used in ICU ICU Monitor charges Cardiac Monitor charges ICU Monitor charges IABP charges ICU Monitor charges Phototherapy ICU ICU Supplies & Equipment ICU ICU Supplies & Oxygen charges Equipment ICU ICU Supplies & Ventilator charges Equipment ICU ICU Supplies & Suction pump charges Equipment ICU ICU Supplies & Bipap charges Equipment ICU ICU Supplies & Pacing Temporary equipment Pacemaker ICU ICU Supplies & Defibrillator Equipment OT OT OT rent OT OT rent Major OT charge OT OT rent Minor OT Charge OT OT rent Cath Lab OT OT rent Theatre charges OT OT rent Labour Room OT OT Equipment OT OT Equipment C-arm charges OT OT Equipment Endoscopy charges OT OT Equipment Laparoscope charges OT OT Equipment Equipment charges If not specified OT OT Equipment Monitor charges for OT monitoring OT OT Equipment Instrument charges for OT instruments OT OT Drugs & OT OT Drugs & OT Drugs

10 OT OT Drugs & Implants OT OT Drugs & OT includes guidewires Catheter etc OT OT Drugs & OT Materials OT OT Drugs & OT Gases OT OT Drugs & Anaesthetic drugs OT OT Sterilization OT OT Sterilization CSSD Medicine & Medicine & Medicine & Medicine & Medicine & Ward Medicines OT drugs under OT charges charges Medicine & Medicine & Ward Medicine & Medicine & Ward disposables Medicine & Medicine & Ward Materials Medicine & Medicine & Vaccination drugs Professional fees charges Professional fees charges Visit charges Professional fees charges Visit charges Consultation Professional fees charges Visit charges Medical Supervision Professional fees charges Visit charges Professional fees Professional fees charges Surgery Professional fees charges Surgery Surgeons Professional fees charges Surgery Assistant Surgeons Fee Would also Include Standby Surgeon Professional fees charges Anaesthetists Fee Professional fees charges Anaesthetists Anaesthetists fee Fee Professional fees charges Anaesthetists OT standby charges Providers Fee charge for stand by Anaesthetist Professional fees charges Intensivist

11 Professional fees charges Technician OT /Cath Lab Technician Professional fees charges Physiotherapy Professional fees charges Procedure Professional fees charges Procedure Bedside procedures Catheterization, Central IV Line, Tracheostomy, Venesection Professional fees charges Procedure Suture charges Investigation Investigation Bio Chemistry Serum Sodium, Users etc Investigation Cardiology for procedures like echo, ECG etc Investigation Haematology cross matching etc Investigation Microbiology blood culture, C&S Investigation Neurology for EMG, EEG etc Investigation Nuclear PETCT, Medicine Bone Scan etc Investigation Pathology Investigation Radiology X-Ray, CT, Services MRI etc Investigation Serology Investigation Medical Chrosom Genetics al Analysis etc Investigation Profiles Profiles Instead of Individual Tests (Lipid Profile, LFT etc.) Ambulance Ambulance Ambulance Miscellaneous charges Miscellaneous charges Admission charges

12 Miscellaneous charges Attendant food charges Miscellaneous charges Patient food Miscellaneous charges Registration Miscellaneous charges MRD Miscellaneous charges Documentation Miscellaneous charges Telephone Miscellaneous charges Bio Medical Waste Miscellaneous charges Taxes Luxury Excluding Tax/Surcharge/Service VAT & Charge Service Tax Package To be Used only in case of Package Cardiac Surgery ICD-10- CABG to be Package Cardiology Packages ICD-10- PTCA To be used only in case of Package Cath Lab ICD-10- CAG to be Package Dental ICD-10- Root Canal Treatment to be Procedures Package ENT ICD-10- FESS To be Packages Package Gastroenterology ICD-10- Gastrectomy - Partial To be used only in case of Package General Surgery ICD-10- Inguinal hernia To be Package Gynaecology ICD-10- LSCS To be Package Nephrology ICD-10- Nephrectomy To be

13 Package Neuro Surgery ICD-10- Craniotomy To be Package Oncology ICD-10- IMRT To be Procedures Package Ophthalmology ICD-10- Cataract To be procedures used only in case of Package Orthopaedic ICD-10- Bilateral TKR To be Surgery Package Plastic Surgery ICD-10- Skin Grafting To be Package Pulmonology ICD-10- Pleural Tapping To be Packages Package Urology ICD-10- ERCP To be Package Vascular ICD-10- Embolectomy To be Surgery