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GOVERNMENT OF INDIA
MINISTRY OF ROAD TRANSPORT AND HIGHWAYS
LOK SABHA
UNSTARRED QUESTION NO. 905
ANSWERED ON 04.12.2025
CASHLESS TREATMENT FOR ROAD ACCIDENT VICTIMS
905. Shri Daggumalla Prasada Rao:
Shri G M Harish Balayogi:
Will the Minister of ROAD TRANSPORT AND HIGHWAYS
सड़क परिवहन औि िाजमार् ग मंत्री
be pleased to state:
(a) whether the scheme for providing cashless treatment to road accident
victims has been implemented across all States and Union Territories, if so,
the details thereof;
(b) whether all State Governments have issued the necessary orders for
implementation and the criteria prescribed for the empanelment of hospitals,
if so, the details thereof;
(c) the number and the details of hospitals empanelled under this scheme,
State-wise;
(d) the number of beneficiaries treated since the inception of the scheme and
the details of funds disbursed from the Motor Vehicle Accident Fund, State-
wise;
(e) the number and total value of claims raised by empanelled hospitals for
cashless treatment and the extent of payments disbursed to them; and
(f) whether insurance companies are involved in payment disbursal and if so,
the details thereof including their role, the claims raised through them and
the status of disbursal?ANSWER
THE MINISTER OF ROAD TRANSPORT AND HIGHWAYS
(SHRI NITIN JAIRAM GADKARI)
(a) In accordance with the legal mandate under Section 162 of the Motor
Vehicles Act, 1988, Cashless Treatment for Road Accident Victims
Scheme, 2025 has been notified vide S.O. 2015(E) dated 05.05.2025.
Furthermore, comprehensive guidelines detailing the process flow, roles
and responsibilities of various stakeholders, and the Standard Operating
Procedures (SOPs) for its implementation have been issued vide S.O. 2489
(E) dated 04.06.2025.
The victims are entitled to cashless treatment upto ₹1.5 lakh per victim
per accident for maximum period of 7 days from date of accident and
applicable to all road accidents caused by use of motor vehicle on any
category of road.
(b) ―Hospital Empanelment Guidelines for the Cashless Treatment of Road
Accident Victims‖ has been issued by National Health Authority (NHA) and
attached as Annexure A. The scheme has been formulated under the legal
mandate of the Motor Vehicle Act, 1988.
(c) As per the Scheme guidelines notified vide S.O. 2489 (E) dated 04th
June, 2025, designated hospitals under the Scheme—including empanelled
hospitals under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana
(AB PM-JAY) that comply with the guidelines issued by the National Health
Authority (NHA) for this scheme- shall be deemed designated hospitals for
the purposes of the Scheme.
The number and the details of hospitals empanelled under National Health
Authority, state-wise are as under
S.No State/Uts No. of empanelled Hospitals
ANDAMAN AND NICOBAR
1 ISLANDS 7
2 ANDHRA PRADESH 2472
3 ARUNACHAL PRADESH 56
4 ASSAM 356
5 BIHAR 1098
6 CHANDIGARH 33
7 CHHATTISGARH 16758 DELHI 180
9 DNH AND DD 20
10 GOA 25
11 GUJARAT 2076
12 HARYANA 1361
13 HIMACHAL PRADESH 294
14 JAMMU AND KASHMIR 270
15 JHARKHAND 555
16 KARNATAKA 3607
17 KERALA 607
18 LADAKH 10
19 LAKSHADWEEP 5
20 MADHYA PRADESH 1611
21 MAHARASHTRA 1698
22 MANIPUR 70
23 MEGHALAYA 180
24 MIZORAM 88
25 NAGALAND 79
26 ODISHA 787
27 PUDUCHERRY 31
28 PUNJAB 812
29 RAJASTHAN 1905
30 SIKKIM 19
31 TAMIL NADU 2295
32 TELANGANA 1526
33 TRIPURA 142
34 UTTAR PRADESH 6140
35 UTTARAKHAND 419
36 WEST BENGAL 48
Total 32557
(d) Out of the total number of 6,833 treatment requests raised, 5,480 victims
have been found eligible. The remaining cases have been rejected by the
Police. The total fund disbursed under the Motor Vehicle Accident Fund is Rs.
73,88,848/-.
(e) Out of the 2,644 claims raised by hospitals and approved by concerned
State Health Agency, payment of Rs. 73,88,848/- has been disbursed to
hospitals.
(f) The reimbursement to hospitals is being done through Motor Vehicle
Accident Fund (MVAF) which is funded through contributions from General
Insurance companies for cases where the Motor Vehicle involved isinsured and through budgetary support for other-than-insured motor
vehicle cases.
Once the victim is discharged from the Scheme, the hospital will have to
submit the claim along with required documents to State Health Agency
(SHA). The claim will be verified and approved by the SHA. Once the claim
is approved, the payment will be made by General Insurance Council for
insured cases and by the District Collector for other-than-insured cases.ANNEXURE REFERRED TO IN REPLY TO PART (b) OF THE LOK SABHA
UNSTARRED QUESTION NO. 905 FOR ANSWER ON 04.12.2025 ASKED BY
SHRI DAGGUMALLA PRASADA RAO AND SHRI G M HARISH BALAYOGI
REGARDING CASHLESS TREATMENT OF ROAD ACCIDENT VICTIMS
Hospital Empanelment Guidelines for the Cashless Treatment of Road Accident
VictimsTable of Contents
1. INTRODUCTION .............................................................................. 3
2. PURPOSE AND SCOPE .................................................................... 4
2.1 PURPOSE ...................................................................................... 4
2.2 SCOPE ....................................................................................... 4
3. EMPANELMENT OF HEALTHCARE PROVIDERS – APPROACH &
CRITERIA......................................................................................... 5
3.1 APPROACH FOR EMPANELMENT ........................................................ 5
3.2 CRITERIA FOR EMPANELMENT .......................................................... 6
3.3 INFRASTRUCTURE REQUIREMENTS .................................................... 6
3.4 SPECIALITIES REQUIRED FOR EMPANELMENT ....................................... 6
3.4.1 SPECIALTIES REQUIRED FOR EMPANELMENT.................................... 6
3.4.2 SPECIALTIES FOR ENHANCED CARE ................................................ 6
3.4.3 QUALIFIED MEDICAL PERSONNEL ................................................... 7
3.4.4 LICENSE AND ACCREDITATION ....................................................... 7
3.4.5 24X7 SERVICE AND MONITORING .................................................. 7
3.4.6 GEOGRAPHICAL LOCATION ........................................................... 7
4. ROLE AND RESPONSIBILITY FOR EMPANELMENT ........................ 8
4.1 ROLE OF MORTH ....................................................................... 8
4.2 ROLE OF STATE ROAD SAFETY COUNCIL (SRSC ) ............................... 8
4.3 ROLE OF STATE HEALTH AGENCY (SHA) ........................................... 8
4.4 ROLE OF NATIONAL HEALTH AUTHORITY (NHA) ................................. 8
4.5 ROLE OF STATE EMPANELMENT COMMITTEE (SEC) ............................. 9
4.5.1 Structure of State Empanelment Committee (SEC) ............ 9
4.6 ROLE OF DISTRICT EMPANELMENT COMMITTEE (DEC) ......................... 9
4.6.1 ROLE OF DEC IN EMPANELMENT ................................................... 9
4.6.2 Structure of District Empanelment Committee (DEC) ...... 10
4.7 ROLE OF THIRD-PARTY EMPANELMENT AGENCY (TPEA) ................... 10
5. PROCESS OF EMPANELMENT ...................................................... 12
5.1 APPLICATION AND REGISTRATION ON THE PORTAL ............................ 12
5.1.1 Option 1: Fast-Track Empanelment .................................. 12
5.1.2 Option 2: Desktop and Physical Verification .................... 12
5.1.3 Empanelment in Brownfield states ................................... 13
5.2 ON-BOARDING PROCESSES AFTER APPROVAL ................................... 13
5.3 AB PMJAY EMPANELLED HOSPITAL ...................................... 14
6. INCENTIVE STRUCTURE FOR EMPANELMENT ............................ 15
7. DISCIPLINARY PROCEEDINGS AND DE-EMPANELMENT ............. 16
7.1 RATIONALE FOR DISCIPLINARY PROCEEDINGS .................................. 16
7.2 PROCESS FOR DISCIPLINARY PROCEEDINGS ..................................... 16
7.2.1 Empanelment Disciplinary Committee (EDC) ................... 16
7.3 DE-EMPANELMENT ....................................................................... 19
27.3.1 Presentation of case to the SEC and De-empanelment ... 19
7.3.2 Actions to be taken after De-empanelment ..................... 20
7.4 GRADATION OF OFFENCES ............................................................. 22
7.4.1 Penalties ............................................................................ 23
8. GRIEVANCE MANAGEMENT ......................................................... 25
9. ANNEXURES ................................................................................. 26
9.1 ANNEXURE 1: CRITERIA FOR EMPANELMENT .................................... 26
9.1.1 Minimum Criteria ............................................................... 26
9.1.2 Qualified Medical Personnel .............................................. 27
31.
Introduction
The National Health Authority (NHA) is the apex body responsible for
implementing India‘s flagship public health insurance scheme, the
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY). It has also
been entrusted with designing strategy, building technological
infrastructure, and leading the implementation of the Ayushman Bharat
Digital Mission to create a National Digital Health Ecosystem. NHA
manages the integration of health insurance schemes across Central and
State governments, ensuring the smooth delivery of healthcare services
through a robust IT infrastructure and by empaneling hospitals nationwide.
It collaborates with various ministries to standardize and enhance
healthcare delivery across India.
The Ministry of Road Transport and Highways (MoRTH) has recognized the
importance of hour when immediate care can save lives. MoRTH on 5th May
2025 has notified the scheme offering cashless treatment for road accident
victims. The scheme provides free treatment of up to Rs
1.5 lakhs per accident per person for a maximum period of 7 days.
The Ministry of Road Transport and Highways shall be the nodal authority
in the Central Government for notification of the guidelines and addressing
issues related to the Scheme. The implementation of the Scheme in each
State or Union Territory shall be monitored by the respective State Road
Safety Council. The implementation of the Scheme in each district shall be
monitored by the District Road Safety Committee constituted under sub-
section (3) of section 215 of the Act.
For the empanelment under the scheme, SHA shall be responsible in their
respective States/UTs. The treatment will be provided through hospitals
already empanelled under PM- JAY which have the facility to provide the
treatment for road traffic accidents victims.
42.
Purpose and Scope
2.1
Purpose
The primary purpose of these empanelment guidelines is to ensure smooth
onboarding and participation of hospitals which are equipped to provide
cashless medical treatment to road accident victims under the Scheme
launched by the Ministry of Road Transport and Highways (MoRTH). This
applies to hospitals across India that wish to participate in MoRTH‘s
accident care scheme.
These guidelines aim to ensure that only hospitals with the necessary
infrastructure, skilled personnel, and capacity to deliver high-quality, timely
emergency care, especially during the golden hour, are empaneled.
The ultimate objective is to reduce fatalities and improve recovery
outcomes for road accident victims.
2.2
Scope
The scope of these guidelines outlines the key areas to ensure
comprehensive and transparent process for empanelling hospitals for
providing cashless treatment to road accident victims under the scheme
2.2.1 Empanelment of Healthcare Providers: Approach, Criteria, and
Incentives
The guidelines detail the approach for selecting hospitals based on
infrastructure, medical specialties, and experience in trauma and
polytrauma care. Specific criteria and an incentive structure will be outlined
to encourage hospitals to join the network and maintain high standards of
care for road accident victims.
2.2.2 Institutional Setup and Oversight
A detailed framework for institutional roles at the national and State levels
is provided. The roles of the National Health Authority (NHA), State Health
Authorities (SHA), as well as State- Specific committees like the State
Empanelment Committee (SEC) and District Empanelment Committee (DEC),
5is described. Additionally, the function of Third-Party Empanelment
Agencies (TPEAs) in evaluating hospitals is also included.
2.2.3 Process of Empanelment and Disciplinary Actions
This guideline covers the application and approval process for hospitals to
be empanelled, including registration steps and post-empanelment
procedures. Processes for handling non- compliance, disciplinary actions,
and de-empanelment is also clearly outlined to ensure that hospitals adhere
to the required standards for trauma, polytrauma and emergency care.
63.
Empanelment of Healthcare Providers – Approach &
Criteria
3.1
Approach for Empanelment
The guidelines for empanelment of hospitals for cashless treatment of
Road Accident Victims (CTRAV) ensures that hospitals capable of
providing trauma and polytrauma care are empaneled. Hospitals should
be located not only in high-risk areas identified by MoRTH as accident
hotspots but also in other places (National Highways, State Highways,
municipal Roads, etc) to make sure accident victims can get quick and
easy access to care in all regions. The following approach outlines the
key steps for empaneling hospitals:
Deemed Empanelment for AB PMJAY Hospitals:
The empanelled hospitals identified by their respective states which are
equipped with trauma and polytrauma care support for treatment of road
traffic accident victims will be deemed empanelled and notified. These
provisions are made for immediate onboarding of hospitals to provide
critical trauma care services to the road traffic accident victims. Any
new hospital empanelled under AB PMJAY which is capable of providing
Trauma and polytrauma services to the Road Traffic Accident (RTA)
Victim will also be deemed empaneled.
New hospital empanelment exclusively for CTRAV Scheme
Under AB PM-JAY, fast-Track Empanelment is available for NABH-
accredited/AB-PMJAY quality accreditation or CGHS empanelled
hospitals which are equipped with trauma and polytrauma care support
for treatment of road traffic accident victims.
For hospitals that are not eligible for fast-track empanelment, the existing
verification process as used under AB PM-JAY shall be conducted
As per the scheme guideline, in case an accident victim reaches a
hospital which is not empanelled either under AB PM-JAY or MoRTH, the
hospital shall be still be required to provide initial treatment
(stabilization) to the accident victim and subsequently shall refer
him/her to nearby empanelled hospital.
7 Targeted Approach for Empanelment
The approach for empanelment is designed to strategically enhance the
healthcare network, with a focus on:
● Geographic Areas: Special consideration must be given
to hospitals with trauma and polytrauma facilities in
accident-prone areas as highlighted by MoRTH from
time to time. This ensures that trauma care is
accessible to accident victims in areas where medical
facilities may currently be limited.
● Accredited Hospitals: States are encouraged to
prioritise hospitals with trauma and polytrauma
facilities that are accredited by the
8NABH, NQAS and AB PMJAY quality accreditation, to ensure
high standards of care and service delivery.
● Use of Alternate Hospital Databases: Additional
efforts should focus on hospitals from alternate
hospital databases to further broaden the network,
ensuring adequate trauma care availability across
the country.
● Empanelment managed by States and Union Territories
SHA‘s SHA of AB PMJAY implementing States and
Union Territories are responsible for empanelling
healthcare providers within their respective regions.
3.2
Criteria for Empanelment
The empanelment criteria for hospitals under the CTRAV Scheme
for providing cashless treatment of Road Accident Victims, must
follow established guidelines to ensure that hospitals meet the
required standards for providing trauma and emergency care to
accident victims.
3.3
Infrastructure Requirements:
● The hospital should have a dedicated emergency
department equipped to handle trauma cases.
● Availability of a 24/7 emergency care facility and
adequate trauma care infrastructure, including
○ Fully equipped Intensive Care Unit (ICU)
○ Operation theatres with facilities for emergency surgery
○ IPD services
○ Imaging facilities (e.g., X-ray, CT scan, Ultrasound, MRI, etc)
○ Blood bank or blood storage facilities
○ Ambulance services with Basic Life support (BLS) /
Advanced Life Support (ALS) systems.
3.4
Specialities required for empanelment
3.4.1 Specialties Required for Empanelment:
● Emergency Medicine / General Medicine
● General Surgery
● Orthopedic Surgery / Polytrauma
93.4.2 Specialties for Enhanced Care
● Burns Management
● Cardiothoracic and Vascular Surgery (CTVS)
● Cardiology
● Ear, Nose and Throat (ENT)
● Neurosurgery
● Obstetrics & Gynaecology
● Ophthalmology
● Oral & Maxillofacial Surgery
● Paediatric Medical Management
● Paediatric Surgery
● Plastic & Reconstructive Surgery
● Urology
3.4.3 Qualified Medical Personnel
Please refer to Annexure 1
3.4.4 License and Accreditation:
● The Private hospital must be registered with the local health
authorities and meet any state- specific regulatory
requirements.
● National accreditation e.g., NABH, NQAS and AB
PMJAY quality accreditation will be preferred.
● Hospitals must have a valid licence for operation under
various medical and legal provisions, including licences for
imaging and surgical equipment, and waste management.
3.4.5 24x7 Service and Monitoring:
● Availability of round-the-clock diagnostic services,
including pathology and radiology, will be preferred for
empanelment.
3.4.6 Geographical Location:
● Hospital empanelment must be prioritised in the
accident hotspots as identified by MoRTH from time to
time.
104.
Role and Responsibility for Empanelment
4.1
Role of MoRTH
● MoRTH should identify the hotspots for empanelment of
Hospitals along accident prone areas, which are critical in
providing cashless treatment to victims of road accidents
under the scheme, which should be informed from time to
time by MoRTH.
4.2
Role of State Road Safety Council (SRSC )
● Coordinate with National Health Authority for adoption and
utilisation of the portal for onboarding of designated
hospitals1.
● Coordinate with State Health Agency to designate
hospitals under the Scheme for providing treatment, in
addition to the hospitals empanelled under the Ayushman
Bharat Pradhan Mantri Jan Arogya Yojana, as specified
by the National Health Authority;
● Coordinate with State Health Agency to implement
measures required for the detection and prevention of
fraud or misuse of the Scheme or its benefits;
4.3
Role of State Health Agency (SHA)
● The SHA will identify and empanel hospitals with trauma
and poly trauma care facilities that are essential for
managing road accidents.
● The SHA is required to take necessary action in cases of
irregularities, such as fraud, and to proceed in accordance
with the existing guidelines for disciplinary action against
hospitals, as outlined by the National Health Authority
(NHA).
● The SHA is tasked with raising awareness among
healthcare service providers regarding the scheme to
ensure maximum participation from eligible providers. This
may involve conducting Information, Education and
Communication (IEC) campaigns or sensitization
workshops at various levels district, sub district, taluka
and block etc.
11● SHA will maintain a list of empaneled hospitals and ensure
compliance with the set standards/ guidelines
● SHA will ensure creation of relevant application logins
through the system after onboarding the hospital in the
scheme.
4.4
Role of National Health Authority (NHA)
● The National Health Authority (NHA) will continue to
support State Health Agencies (SHAs) in the empanelment
process by developing comprehensive guidelines that
establish systems and processes to ensure the quality of
services and maximise the empanelment of healthcare
1 Designated Hospitals refer to hospitals or clinical establishments
onboarded by the State Government or State Health Agency (SHA) for
providing cashless treatment to victims of road accidents arising from
the use of motor vehicles. This includes: Hospitals empanelled under AB
PM-JAY that are capable of providing trauma and polytrauma services,
and Hospitals specifically empanelled for the CTRAV scheme.
12providers, especially in critical areas.
● NHA recognizes the need to consider state-specific contexts
and provides SHAs with the flexibility to adapt and implement
these guidelines as per local needs.
4.5
Role of State Empanelment Committee (SEC)
● SEC will play a key role in the approval flow for the
submitted applications. The final decision to approve/reject
the application of the healthcare service provider will rest
with the SEC. The decision on relaxation to be given to any
healthcare service provider based on the recommendation of
the District Empanelment Committee (DEC) will also rest
with SHA. SHA to ensure that the quality of medical care
rendered to the patient is not compromised by this
relaxation.
● Additionally, SHA will be responsible for providing supportive
supervision to DEC and ensuring timebound empanelment
process throughout its lifecycle.
● SHAs shall take necessary action to empanel the hospitals
located near the accident hotspots identified by MoRTH.
● It will be the responsibility of the SHA/SEC to monitor
that the hospital maintains the capacity of delivering
quality services to the road accident victims in this
scheme from time to time. It may also include periodic
physical verification.
4.5.1 Structure of State Empanelment Committee (SEC)
The State/SHA may continue with existing institutions
under the AB PMJAY schemes with the vested powers
and responsibilities of SEC as per the guidelines.
4.6
Role of District Empanelment Committee (DEC)
The District Empanelment Committee (DEC) will play a critical support
role by assisting the State Empanelment Committee (SEC) and State
Health Agency (SHA) at the district level. The DEC will ensure that
13healthcare providers meet the required standards for empanelment
and handles disciplinary proceedings when necessary.
4.6.1 Role of DEC in Empanelment
Document Validation and Scrutiny
● Validation at Empanelment: At the time of empanelment,
the DEC will be responsible for validating and scrutinising
the documents uploaded by hospitals. This includes
verifying the completeness and accuracy of documents
such as hospital registration, staffing details, infrastructure,
and compliance with necessary standards.
● Ongoing Monitoring: The DEC performs regular checks to
ensure that hospitals maintain compliance with
empanelment requirements even after approval.
Field and Desktop-Based Verification
● Physical Inspections: In addition to desktop-based audits,
the DEC will conduct field verifications by visiting hospitals
to assess their infrastructure, equipment, and staffing
capabilities, ensuring that they meet the empanelment
criteria.
● Desktop-Based Audits: Can be initiated only in exigency
cases where physical inspection is not possible. The DEC will
carry out desktop-based verification by reviewing hospital
records and other submitted information to verify compliance
remotely.
Submission of Verification Reports
● Online Empanelment Portal: After completing verifications,
the DEC submits its reports to the SEC through the online
empanelment portal. The reports include detailed findings
and a recommended decision to either approve or reject
the hospital‘s empanelment application.
● Justification for Rejection: If the DEC recommends
rejection, it must provide clear reasons for rejection,
ensuring transparency in the decision- making process.
14Pre-Empanelment Orientation for Hospitals
● Orientation Sessions: The DEC, in collaboration with
SEC/SHA, can organise pre- empanelment orientation
workshops at the district level. These sessions aim to
educate hospital administrators on the empanelment
process, the required documentation, and the standards they
must meet.
● Guidance on Compliance: During these orientations,
hospitals shall be guided on all the parameters for
compliance including infrastructure, human resources, and
digital integration before getting empanelled under the
scheme.
4.6.2 Structure of District Empanelment Committee (DEC) -
The State may continue with existing DEC institutions under the
AB PMJAY schemes with the vested powers and responsibilities of
DEC as per the guidelines. In case of Third Party Empanelment
Agency (TPEA) being in use, a member of TPEA will assist the DEC
in its activities.
4.7
Role of Third-Party Empanelment Agency (TPEA) -
● If additional assistance is required for the empanelment
process, SHA may hire a third- party empanelment agency
which is either empaneled by NHA or hired by SHA
separately. The TPEA will be responsible for facilitating
verification of healthcare providers (both physical as well
as desk-top verification). However, the following must be
ensured while hiring TPEA:
● The third-party empanelment agency engaged for this
purpose shall not be the current implementation
support agency operating within the state or any other
agency that may create a conflict of interest or lead to
collusion. It is important that the physical verification
process remains transparent and impartial.
15● The TPEA should not be the same agency currently
engaged by the SHA for any other purpose
● Any agency that has previously worked as a TPA for
insurance companies must observe a cooling-off
period of at least six months before applying to
become a TPEA.
● The TPEA must ensure that a physical verification
of healthcare service led by DEC
● The SHA, will conduct a sample physical audit of 10%
of the facilities verified by the TPEA
165.
Process of Empanelment
5.1
Application and Registration on the Portal
● It is mandatory that the hospitals willing to get empanelled
under the scheme are registered in the ―Health Facility
registry‖ under Ayushman Bharat Digital Mission. The
hospital can get themselves registered using the web based
portal (https://nhpr.abdm.gov.in/hfrAdmin/login)
● Hospital will register through User Management Portal (UMP)
portal (at URL : https://ump.pmjay.gov.in) for creation of
Hospital Engagement Module (HEM) and create logins of HEM
Portal to initiate registration.
● Further, using the credentials created using UMP for HEM
module, Hospital will login to the HEM Module and initiate
the registration process. URL for HEM portal
(https://hem.nha.gov.in)
● Once the healthcare provider has filled the application, the
verification and approval process will be undertaken by the
SHA/SEC. Only those healthcare providers will be allowed to
get empaneled under the scheme who have been registered
as an establishment under the relevant central or state acts
(if applicable).
5.1.1 Option 1: Fast-Track Empanelment
● Hospitals holding NABH accreditation / AB PM-JAY
certification for relevant specialty may be fast-tracked for
empanelment without physical verification.
5.1.2 Option 2: Desktop and Physical Verification
The entire process of desktop and physical verification for hospital
empanelment must be completed within 30 days. First, the DEC or
TPEA conducts a desktop verification, verifying documents
uploaded by the hospital. If discrepancies or missing documents
are found, the DEC will raise queries for clarification, and the
hospital must address these. This is followed by a physical
inspection by the District Empanelment Committee (DEC), district
17nodal officer, or TPEA, ensuring the hospital‘s compliance with the
application details
After Physical verification, the report, including pictures and
documents, is uploaded on the HEM portal. In case of non-
compliance of the requisite standard, the application request for
empanelment may be rejected for specific specialty or may be
rendered ineligible for empanelment as the case may be.
5.1.2.1 DEC Recommendations:
DEC can exercise the following options while forwarding the case to the
SEC:
● Recommend Approval: if the hospital meets the required
standards and findings are satisfactory as per applicable
norms, DEC can send the application to SEC for approval
of the application.
● Recommend Rejection: For applications that do not meet the
minimum standards or where healthcare providers have been
found to be misreporting information, the DEC will
recommend rejection. All rejections will be subject to review
by the SHA.
● Recommend relaxation and approval: DEC where they find
requirement of empanelling a hospital to ensure the
availability of an adequate number of empaneled facilities
within the district may recommend relaxations in
empanelment criteria for approval to the SHA. This
recommendation must be approved by the SHA, with a clear
and documented rationale provided. SHA to ensure that the
quality of medical care rendered to the patient is not
compromised by this relaxation.
5.1.2.2 SEC Approval
● SEC will review the reports and recommendations submitted
by the DEC. SEC/ SHA will also consider the DEC‘s
recommendations for ‗relaxation criteria of empanelment
based on the review, SEC/ SHA shall make the final decision
18on empanelment
● In case the empanelment is approved, the same will be
updated on the PM- JAY web- based portal and the
healthcare provider will be notified through SMS/email of the
final decision
● In case of rejection of an empanelment request, the SEC/
SHA will state the reasons for rejection of the request and
share it with the healthcare provider. The decision (and
reasons) will also be updated on the PM-JAY web portal
● Healthcare providers will have the right to file a review
against the rejection with the State Empanelment
Committee (SEC). In case the review request for
empanelment is rejected by the SEC, the healthcare
providers can approach the competent authority as defined
in the Grievance Redressal Mechanism for remedy.
5.1.3 Empanelment in Brownfield states
● Empanelment of hospitals for the states not using NHA‘s IT
application will continue in the same manner. These states
should comply with the guidelines laid for the MoRTH
scheme.
5.2
On-boarding Processes after Approval
● Once the application is approved, SHA will ensure that
the status of the application is updated on the PM-JAY
portal and the respective healthcare service provider is
informed about the decision through email / SMS on the
registered phone number. Once the hospital is empaneled,
a user admin login will be created for the hospital for
providing timely medical treatment to road accident
victims, especially during the critical golden hour.
● SHA will ensure creation of relevant application login
credentials through the system after onboarding under the
scheme
● SHA will also ensure that training on systems and processes
like beneficiary identification system, transaction
19management system, health benefit package, standard
treatment guidelines, claim settlement process is provided
to HCP.
5.3
AB PMJAY empanelled hospital
● AB-PMJAY empanelled hospitals having trauma and
polytrauma services will be deemed empanelled for the
CTRAV scheme.
206.
Incentive Structure for Empanelment
● An Incentive (in addition to the Package amount) will be
provided as per the current AB PMJAY scheme guideline /
latest Health Benefit Package (HBP) rates.
217.
Disciplinary Proceedings and De-Empanelment
7.1
Rationale for Disciplinary Proceedings
● Hospitals may face disciplinary actions if found indulging
in fraudulent activities, violating treatment guidelines, or
failing to provide quality care.
● Disciplinary proceedings/de-empanelment may be conducted
for an Empaneled Healthcare Provider (Hospital) under the
scheme if they fail to meet and uphold the necessary criteria
agreed upon during empanelment or indulge in wrongful acts
during treatment (detailed in section below). The key
objectives of NHA and SHA are to increase empanelment,
ensuring that quality care is provided and curtailing
unnecessary leakages in the form of fraud and abuse which
may bring disrepute to the scheme. Disciplinary
proceedings/de-empanelment processes have been
introduced primarily as a deterrence and control mechanism
in the scheme to ensure that medically appropriate quality
treatment is provided to beneficiaries at all times and all
wasteful and unnecessary expenditure is curtailed.
7.2
Process for Disciplinary Proceedings
● Disciplinary proceeding should be initiated based on
investigation findings and establishment of fraud
● Hospitals will be issued show-cause notices within 7
working days of investigation findings.
7.2.1 Empanelment Disciplinary Committee (EDC)
EDC will initiate disciplinary proceedings against errant health service
providers in the state. The institutional structure established for
empanelment will also be responsible for processes leading upto
disciplinary proceeding/ De-empanelment. The SHA, SEC and DEC at the
state and District level will form the key institutions in enforcing this
mechanism.
Process for Disciplinary Proceedings and De-empanelment
227.2.1.1 Show-Cause Notice to the Hospital
Based on the investigation report received, if there is sufficient
evidence/suspicion of the Hospital indulging in malpractices, a
show cause- notice shall be issued to the Hospital. All attempts
will be made to issue show cause notice within 7 working days
from receipt of the investigation report and in case of any delay,
the report must be submitted to CEO SHA, citing the reasons for
the same.
● In the show cause notice sent to the Hospital, it should be
explicitly communicated to not contact the beneficiaries in
question as this would lead to tampering of evidence, as per
the applicable laws. In case any such tampering is found,
legal action may be taken accordingly.
● The show-cause notice will be sent both to the Hospital‘s
registered email ID provided at the time of empanelment or
the most current one available/updated with SHA and a hard
copy will be sent via speed post or delivered by hand through
district coordinator to the Hospital‘s notified address.
● The show-cause notice will mention the email ID of the SHA
where the response to the show- cause needs to be sent by
the Hospital. The receipt of the registered speed post or
acknowledgement of receipt by Hospital (in case delivered
by hand) should be kept securely as proof by the SHA. The
show-cause notice will also be updated in the online portal
used by the Hospital.
● The hospital shall respond to the show-cause notice within 5
working days from the date of receipt of show cause notice.
The response will be sent to the SHA at the email id provided
in the show-cause letter or address specified for registered
post along with supporting evidence collected as per the
applicable laws of India.
● In case, the response is not received within 5 working days,
the Hospital will be suspended. All its operations will be
blocked under PM-JAY through its web portal, for a specified
23time frame not exceeding 6 months or till a decision has
been taken on the proceedings, so that no new pre-
authorizations can be raised by the Hospital. However, the
treatment of existing patients will continue as usual till they
are discharged. The notification of suspension will be sent
through email and registered speed post. All attempts shall
be made to send the notification within 2 working days of
the decision and in case of any delay report must be
submitted to CEO SHA, citing the reasons for the same.
● In case, the response to the show cause received from the
hospital is found satisfactory, it will continue to function as
usual. However, if the response is not found satisfactory,
further information or evidence may be requested through
email. The Hospital shall provide the requested
documents/information within 3 working days through email,
failing which the Hospital may be suspended for a specified
time frame not exceeding 6 months or till a decision has
been taken on the proceedings. During suspension, the
Hospital will not be allowed to conduct any new pre-
authorizations. All admitted patients under the scheme will
be provided continued treatment as usual till they are
discharged. The notification of suspension will be sent
through email and registered speed post. All attempts will be
made to send this notification within 2 working days of the
decision taken by SHA. In case of any delay, a report must
be submitted to CEO SHA, citing the reasons for the same.
● If the above-mentioned timelines are not met, then either
party can approach competent authority as per the grievance
redressal guidelines.
● If there is no documentary evidence to suggest that the
show cause notice was received or the Hospital denies
having received the show cause notice, the SHA may share
the notice again either through physical delivery or
24registered email ID and receive an acknowledgement of the receipt.
Hospital will have to respond within 3 working days from the date of
receipt of the show-cause notice.
● Beneficiaries needing continued care beyond current pre-
authorization may be referred to another hospital to ensure
there is no disruption of services.
7.2.1.2 Detailed Investigation of Hospital
● A detailed investigation will be carried out in case the
Hospital is suspended due to the reasons mentioned above
or if a complaint containing sufficient material to raise
suspicion has been filed by the beneficiary. A detailed
investigation may include field visits to the Hospital,
examination of case papers, interaction with the
beneficiaries (if needed), examination of hospital records etc.
● All attempts will be made to complete the investigation and
submit the report within 10 working days of show-cause
issued. In case of any delay, a report must be submitted to
CEO SHA, citing the reasons for the same.
● All statements of the beneficiaries will be recorded in writing
in the language known to the beneficiary and ensured that
the said statement is read over to the beneficiary for
confirmation. The statement will be self-attested by the
beneficiary via signature or thumb impression for use as
evidence. Wherever possible, video recording will be taken
and if possible, a copy of photo identity proof of such
beneficiary will be maintained.
● If the detailed investigation reveals that the
report/complaint/allegation against the hospital is not
valid and no malpractices are detected, suspension will
be revoked and operations as usual will be initiated. All
attempts will be made by SHA to revoke the suspension
within 5 working days of the investigation report
submitted. In case of any delay, a report must be
submitted to CEO SHA, citing the reasons for the same.
● If the detailed investigation reveals that the
25suspicion/alleged malpractice on the part of the Hospital are
valid , the SHA may recommend suspension for a specified
time, not exceeding 6 months.
● However, if the original cause of suspicion/alleged
mischievous activities on the part of Hospital are not valid
but additional malpractices are identified, a new show-cause
notice will be issued to the Hospital. All attempts will be
made to issue the show cause notice within 7 working days
of noticing such malpractices. The Hospital will not be
allowed more than 10 working days to respond, and a similar
process of investigation will be followed. The time duration
may be decided by the SHA on a case-to-case basis.
7.2.1.3 Suspension of the Hospital
Upon receiving an investigation report indicating sufficient
evidence or suspicion of malpractice by an Empanelled
Health Care Provider (Hospital), the State Health Agency
(SHA) will issue a show-cause notice to the Hospital within 5
working days
This investigation includes field visits, examination of
case papers, discussions with beneficiaries, and review
of hospital records. The investigation aims to be
completed within 10 working days of issuing a show-
cause notice
The notice will instruct the Hospital not to contact the
beneficiaries involved, as this could lead to evidence
tampering, which may result in legal action. Beneficiary
statements are recorded in their known language, confirmed
by them, and self-attested, with video recordings and photo
IDs collected when possible
Notices are sent to the Hospital‘s registered email and via
speed post or hand delivery. The notice will specify the
SHA email for response submission, and proof of receipt
must be secured by the SHA.
The Hospital must respond within 5 working days, providing
supporting evidence. SHA to confirm receiving the notice to
the hospital within 5 working days, if the Hospital denies
26receiving the notice, SHA will resend it, requiring
acknowledgment, and the Hospital must respond within 5
working days.
If no response is received, the Hospital will be suspended,
blocking new pre- authorizations for up to 6 months, though
existing patient treatments will continue.
Suspension notifications will be shared with the
Hospital on registered mail/SMS.
If response received but is unsatisfactory, further
information may be requested, and failure to provide it
within 5 working days could result in immediate
suspension not extending 6 months
If response received and is satisfactory, then the
suspension may be revoked
If no malpractices are found, the suspension is revoked on
immediate basis of the report submission
If malpractices are confirmed, suspension but not
extending 6 months timelines
Direct suspension along with show-cause, if the SHA obtains
irrefutable evidence that the action of Hospital have or may
cause grievous harm to the patient‘s health or life, SHA may
immediately suspend the Hospital not extending 6 months
timelines
7.3
De-Empanelment
● Hospitals may be de-empanelled based on SEC
recommendations if found non- compliant.
● De-empanelled hospitals cannot seek re-empanelment for a
minimum period of 1 year.
7.3.1 Presentation of case to the SEC and De-empanelment
Presentation of case for de-empanelment may be initiated
by SHA after conducting proper disciplinary proceedings as
outlined above. The SEC will meet within 30 working
days/emergency meeting could be scheduled in exceptional
circumstances of the case being referred. All relevant
27documents including the detailed investigation report will be submitted
to the SEC either at the time of case filing or at least 10 working days
prior to the meeting. The SEC must ensure that the Hospital has been
issued a show- cause notice seeking an explanation for the alleged
malpractice. Both parties (SHA and Hospital) will be provided a fair
opportunity to present their case with necessary evidence at the
meeting conducted by SEC.
If the SEC finds that the complaint/allegation against the
Hospital is valid, it will order de- empanelment of the
Hospital based on appropriate legal advice along with
additional disciplinary actions like penalties, FIR etc. as it
may deem fit.
In case the SEC does not find adequate supporting
evidence against the Hospital, it may revoke the
suspension of the Hospital or reverse/modify any other
disciplinary action taken by SHA against the Hospital,
while making clear observations and reasons underlying
the final decision.
All attempts shall be made to take the final decision within
30 working days of 1st SEC meeting and in case of any
delay, a report must be submitted to CEO SHA, citing the
reasons for the same.
All attempts shall be made to implement any disciplinary
proceeding as decided by SEC within 30 working days of the
decision taken by SEC and in case of any delay, a report
must be submitted to PS/AS-Health and Family Welfare
Department of the State, citing the reasons for the same.
If either party is not satisfied by the decision of SEC, they
can approach competent authority as per the grievance
redressal guidelines.
7.3.2 Actions to be taken after De-empanelment
Once the hospital has been de-empaneled, a letter/email will be sent to
the Hospital regarding the decision at registered address/registered
email ID/of the Hospital within 3 working of the decision. Once de-
28empaneled, new pre- authorization will be disabled, and the existing
pre- authorizations/ treatment will have to be completed.
A decision may be taken by the SEC to ask the SHA to
either lodge an FIR in case there is suspicion of criminal
activity or take such other permissible legal action under
applicable laws of India.
In case of confirmed acts of professional misconduct and
violation of medical ethics, the appropriate professional
medical bodies/council at the national/state level should be
informed of the details of the case, the treating doctor and
the hospital involved. The Medical Council and State Medical
Council should take it up and take appropriate action as per
the Code of Medical Ethics Regulation, 2002 and/ or such
necessary action as may be required as per the applicable
laws. This information will be sent with other Insurance
Companies, ESIC, CGHS, IRDAI and other relevant regulatory
bodies and to NHA.
A list of de-empaneled hospitals will be enlisted on NHA and
SHA websites. The list should be prominently displayed and
easily accessible on the website to ensure beneficiary
awareness. SHA may notify in the local media about the
entities where malpractice is confirmed, and the action
taken against the Hospital engaging in malpractices.
The period of de-empanelment would be for 1 year, unless
stated otherwise. Once de- empaneled, the Hospital cannot
seek re-empanelment until completion of 1 year from the
date of such de-empanelment. Healthcare service providers
will not be allowed to change their names and re-apply. The
concerned local teams will keep a check on such practices. In
case SHA/SEC decides to re-empanel an hospital within a
period of 1 year, the same may be flagged in the system
through the HEM portal. The reason for re- empanelment of
the Hospital will also be documented in the HEM web portal.
If it is a hospital chain, only the branch will get de-empaneled
while the other branches of the hospitals will continue to
function.
Based on the severity of the offence, SEC may de-empanel
29the Hospital for more than 2 years or may blacklist a
hospital. In such cases, the SHA/SEC will inform NHA and
PS/AS (Dept. of Health and Family Welfare) of the concerned
state of its decision along with a detailed explanation/
recorded reason for the same.
Timeline for Disciplinary Proceedings and De-
empanelment
Investigation of suspect claims 10 working days of flagging
the cause
Show-cause Notice Issuance 7 working days of
submission of
investigation report
Response to Show-cause Notice by Within 5 working days
Hospital
Clarification of the Response from Within 3 working days
Hospital
Issuance of Show-cause Notice post Within 2 working days
Decision
Detailed Investigation along with
submission of Investigation Report Within 10 working days
Response to Suspension by Hospital Within 5 working days
Hospital can file an appeal against Within 30 working days
suspension
Final decision to suspend/suspend with Within 30 working
fine/ revoke suspension/de- days of the 1st
empanelment SEC meeting
7.4
Gradation of Offences
Based on the investigation report/field audits, the following
gradation of penalties may be levied by the SEC. However,
this tabulation is intended to be as guidelines rather than
mandatory rules.
30These penalties are recommendatory in nature and the state
may inflict larger or smaller penalties depending on the
severity/regularity/scale/intentionality on a case-to-case basis.
If any hospital is found to be involved in unethical
practices/malpractices/severe offence, then legal action may
also be taken by SHA.
317.4.1 Penalties
Penalties for Offences by the Hospital
Case Issue First Offence Second Third Offence
Offence
Full refund and penalty In addition to
Illegal cash upto 5 times of illegal actions as
De-
payments payment to be paid to the mentioned for
empanelme
by SHA by the hospital first offence,
nt/
beneficiary within 7 working days of rejection of
blacklisting
the receipt of notice. SHA claim for the
shall thereafter transfer case,
money to the beneficiary, suspension of
charged in- actual, hospital
within 7 working days
Rejection of
Rejection of claim and claim and
Billing for penalty upto 5 times the penalty of De-
services amount claimed for upto10 times empanelme
not nt/
services not provided, to the amount
provided blacklisting
SHA claimed for
services not
provided, to
SHA,
suspension of
hospital
Rejection of
Rejection of claim and claim and
penalty of up to 10 times penalty of up
Up coding/
the excess amount to 20 times the
De-
Unbundling
claimed due to up excess amount
empanelme
/
coding/unbundling/ claimed due to
nt/
Unnecessa
unnecessary procedures, up
blacklisting
ry
to SHA coding/unbundli
32Procedures SHA may decide the ng/
amount based on the unnecessary
severity of the breach procedures, to
SHA,
suspension
of hospital
Rejection of claim and Rejection of
penalty of up to 5 times claim and
Wrongful
the amount claimed for penalty of up
beneficiary De-
wrongful beneficiary to 10 times the
empanelme
identificati
identification to SHA if amount
nt/
on
hospital is found to be in claimed for
blacklisting
connivance SHA may wrongful
decide the amount based beneficiary to
on the severity of the SHA if the
breach hospital is
found to be in
connivance,
suspension
of hospital
In case of minor
gaps:
33Show cause notice with
compliance period of 2
weeks for rectification
and rejection of claims
Non- related to gaps Penalty of up to De-
adherence to In case major gaps and 5 times of all empanelment
minimum wilful the approved and penalty of
criteria for suppression/misrepresent claims related up to 5 times
empanelmen ation of facts: Show to the gaps of all the
t, quality and cause notice with observed and approved
service compliance period of 2 suspension claims
weeks for rectification,
standards as until related to the
suspended if not rectified
laid under rectification of gaps
after 2 weeks and
PM- JAY gaps and observed
rejection of claims
validation by
related to gaps and
DEC
penalty up to 3 times of
all cases related to gaps
observed
Suspension of services
until rectification of
gaps and
validation by DEC
348.
Grievance Management
● The Grievances of the Hospital will be managed as per
the Grievance redressal Guideline issued by NHA and
SHA.
359.
Annexures
9.1
Annexure 1: Criteria for Empanelment
This annexure contains the basic minimum criteria for
empanelment for all the healthcare service providers. It also
covers the criteria in Aspirational Districts and additional criteria
for empanelment of specialties under the scheme.
9.1.1 Minimum Criteria
A hospital would be empaneled as a network private hospital with
the approval of the respective State Health Agency if it adheres to
the following minimum criteria:
● Should have at least 10 inpatient beds with adequate spacing
and supporting staff as per norms:
● General ward - @80 sq ft per bed, or more in a room with
basic amenities: bed, mattress, linen, water, electricity,
cleanliness, patient-friendly common washroom, etc. Non-
AC but with fan/cooler and heater in winter.
● It should have adequate and qualified medical and nursing
staff (doctors and nurses), physically in charge round the
clock; (necessary certificates to be produced during
empanelment). The state should have specific guidelines on
the number of hospitals a doctor can work.
● Fully equipped and engaged in providing medical and
surgical services, commensurate to the scope of
service/available specialties and number of beds.
● Round-the-clock availability (or on-call) of Orthopaedic
Surgeon, General Surgeon, and anaesthetist services.
● Qualified nurses per unit per shift shall be available as per
requirement laid down by the Nursing Council/Clinical
Establishment Act/State government rules & regulations as
applicable from time to time. Norms vis-a-vis bed ratio may
be spelled out.
● Hospital should have adequate arrangements for round-the-
clock support systems required for the above services like
pharmacy, blood bank, laboratory, dialysis unit, endoscopy
36investigation support, post-op ICU care with ventilator
support (mandatory for providing surgical packages), X-ray
facility, etc., either ‗in-house‘ or with ‗outsourcing
arrangements‘ with appropriate agreements and in nearby
vicinity.
● Separate male and female wards with toilet and other basic
amenities.
● 24 hours emergency services managed by technically
qualified staff. Casualty should be equipped with monitors,
defibrillator, nebulizer with accessories, crash cart,
resuscitation equipment, oxygen cylinders with flow
metre/tubing/catheter/face mask/nasal prongs, suction
apparatus, etc., and with attached toilet facility.
● Round-the-clock ambulance services (own or tie-up).
● Fully equipped Operation Theatre of its own with
qualified nursing staff under its employment round the
clock.
● Post-op ward with ventilator and other required facilities.
It is mandatory to be equipped with an Intensive Care Unit (for
medical/surgical ICU/HDU)
DEC where they find a requirement of empanelling a hospital to
ensure the availability of an adequate number of empaneled
facilities within the district may recommend relaxations in
empanelment criteria for approval to the SHA. This
recommendation must be approved by the SHA, with a clear and
documented rationale provided. SHA to ensure that the quality of
medical care rendered to the patient is not compromised by this
relaxation. The following minimum requirements cannot be
compromised:
● Minimum Number of Inpatient Beds: Should have 5
inpatient beds with adequate spacing and supporting
staff as per norms, unless providing daycare packages
covered under PM- JAY.
● Minimum Number of Doctors and Nursing Staff as per the
requirement of speciality for which the hospital is
37empanelled.
● Licences and Certificates: A hospital registration certificate
as per state law is mandatory, if applicable.
● Equipment Requirements: The hospital needs to be fully
equipped according to the defined scope of services.
● Emergency Equipment: Must have life-saving and
resuscitation equipment as required by the facility.
● ICU/HDU Positioning: The ICU/HDU unit must be situated in
the same building or have a referral linkage with hospitals
where ICU/HDU facilities are available (mandatory self-
declaration) through an MoU or tie-up.
● OT Services: Fully equipped Operation Theatre with qualified
nursing staff (minimum qualification: ANM Course) under its
employment round the clock.
● Casualty Equipment: The casualty department should be
equipped with a minimum Emergency Tray.
9.1.2 Qualified Medical Personnel
S.N Speciality Required Doctor's Qualification
o
1 Ambulance Trained certified in BLS
Services
2 Burns MCH/ DNB/ Equivalent in (Plastic Surgery)
Management
3 Cardiology MD/DNB or equivalent to internal Medicine; DM
(Cardiology)
4 CTVS MCH/DNB / equivalent (Cardiothoracic Surgery)
385 Emergency MD/DNB in Emergency Medicine, General
Room Medicine, DM in Cardiology
Packages
6 ENT MS/DNB/ Diploma or equivalent in (ENT)
7 General Medicine MBBS (Essential), MD/DNB(Medicine)/ DM/DNB
(Paediatric) Desirable
8 General Surgery MS/DNB/ equivalent (General Surgery)
9 Neurosurgery MCH/ DNB/ Equivalent in (Neurosurgery)
10 Obstetrics & MS /DGO/DNB or equivalent in (Obstetrics &
Gynaecology Gynaecology)
11 Ophthalmology MD/MS/DNB/PG Diploma or equivalent in
Ophthalmology
12 Oral & MDS (Oral & Maxillofacial Surgery)
Maxillofaci
al Surgery
Diploma in Orthopedics with 5 years' Experience
13 Orthopaedics
(Essential), MS /DNB or equivalent in
Orthopaedics (Desirable )
Paediatric
14 MD/DNB/DCH/ equivalent (Paediatric)
Medical
Management
15 Paediatric MCH/ equivalent (Paediatric Surgery)
Surgery
Plastic &
16 Reconstructive MCH/ DNB- Plastic Surgery / Reconstructive
Surgery
Surgery
17 Polytrauma MS/DNB/Equivalent (General Surgery);
MS/DNB/Equivalent
(Orthopaedic surgery)
18 Urology MS/DNB or equivalent in Urology
*****
39