{ "stages": { "preauth": "Pre-Authorization (before treatment)", "claim": "Claim Submission (after treatment)" }, "packages": [ { "code": "SG039A", "name": "Cholecystectomy", "procedure": "Without Exploration of CBD – Open", "specialty": "General Surgery / Pediatric Surgery", "price": "₹22,800", "documents": { "preauth": [ { "id": "clinical_notes", "label": "Clinical notes", "verify": "Detailed history, signs & symptoms, and indication for the procedure" }, { "id": "usg_abdomen", "label": "USG Upper Abdomen", "verify": "Confirms presence of gall stone. If CBD exploration is planned, MRCP/USG should show large (>1cm) or multiple CBD stones" }, { "id": "lft", "label": "LFT (Liver Function Test)", "verify": "Report showing serum bilirubin, transaminase and alkaline phosphatase levels" } ], "claim": [ { "id": "operative_notes", "label": "Operative notes", "verify": "Detailed operative notes with indications and outcomes of the procedure" }, { "id": "pre_anesthesia", "label": "Pre-anesthesia check-up report", "verify": "Pre-anesthesia evaluation / fitness report" }, { "id": "discharge_summary", "label": "Detailed Discharge Summary", "verify": "Discharge summary including follow-up advice at the time of discharge" }, { "id": "intraop_photo", "label": "Intra-operative photograph & gross specimen pictures", "verify": "Intra-operative image and picture(s) of gross specimen removed. If CBD stones detected/suspected, photo/video of stones removed from CBD" }, { "id": "histopathology", "label": "Histopathology report", "verify": "Histopathology report of the specimen removed", "note": "Can be submitted within 7 days of discharge" } ] }, "rules": [ { "id": "usg_calculi", "check": "USG shows presence of calculi in the gall bladder" }, { "id": "pain_site", "check": "Patient has complaint of right hypochondrium or epigastric pain" }, { "id": "no_prior_chole", "check": "No prior cholecystectomy done in the past" } ] }, { "code": "SG039B", "name": "Cholecystectomy", "procedure": "With Exploration of CBD – Open", "specialty": "General Surgery / Pediatric Surgery", "price": "₹22,800", "documents": { "preauth": [ { "id": "clinical_notes", "label": "Clinical notes", "verify": "Detailed history, signs & symptoms, and indication for the procedure" }, { "id": "usg_abdomen", "label": "USG Upper Abdomen", "verify": "Confirms presence of gall stone. If CBD exploration is planned, MRCP/USG should show large (>1cm) or multiple CBD stones" }, { "id": "lft", "label": "LFT (Liver Function Test)", "verify": "Report showing serum bilirubin, transaminase and alkaline phosphatase levels" } ], "claim": [ { "id": "operative_notes", "label": "Operative notes", "verify": "Detailed operative notes with indications and outcomes of the procedure" }, { "id": "pre_anesthesia", "label": "Pre-anesthesia check-up report", "verify": "Pre-anesthesia evaluation / fitness report" }, { "id": "discharge_summary", "label": "Detailed Discharge Summary", "verify": "Discharge summary including follow-up advice at the time of discharge" }, { "id": "intraop_photo", "label": "Intra-operative photograph & gross specimen pictures", "verify": "Intra-operative image and picture(s) of gross specimen removed. If CBD stones detected/suspected, photo/video of stones removed from CBD" }, { "id": "histopathology", "label": "Histopathology report", "verify": "Histopathology report of the specimen removed", "note": "Can be submitted within 7 days of discharge" } ] }, "rules": [ { "id": "usg_calculi", "check": "USG shows presence of calculi in the gall bladder" }, { "id": "pain_site", "check": "Patient has complaint of right hypochondrium or epigastric pain" }, { "id": "no_prior_chole", "check": "No prior cholecystectomy done in the past" } ] }, { "code": "SG039C", "name": "Cholecystectomy", "procedure": "Without Exploration of CBD – Lap.", "specialty": "General Surgery / Pediatric Surgery", "price": "₹22,800", "documents": { "preauth": [ { "id": "clinical_notes", "label": "Clinical notes", "verify": "Detailed history, signs & symptoms, and indication for the procedure" }, { "id": "usg_abdomen", "label": "USG Upper Abdomen", "verify": "Confirms presence of gall stone. If CBD exploration is planned, MRCP/USG should show large (>1cm) or multiple CBD stones" }, { "id": "lft", "label": "LFT (Liver Function Test)", "verify": "Report showing serum bilirubin, transaminase and alkaline phosphatase levels" } ], "claim": [ { "id": "operative_notes", "label": "Operative notes", "verify": "Detailed operative notes with indications and outcomes of the procedure" }, { "id": "pre_anesthesia", "label": "Pre-anesthesia check-up report", "verify": "Pre-anesthesia evaluation / fitness report" }, { "id": "discharge_summary", "label": "Detailed Discharge Summary", "verify": "Discharge summary including follow-up advice at the time of discharge" }, { "id": "intraop_photo", "label": "Intra-operative photograph & gross specimen pictures", "verify": "Intra-operative image and picture(s) of gross specimen removed. If CBD stones detected/suspected, photo/video of stones removed from CBD" }, { "id": "histopathology", "label": "Histopathology report", "verify": "Histopathology report of the specimen removed", "note": "Can be submitted within 7 days of discharge" } ] }, "rules": [ { "id": "usg_calculi", "check": "USG shows presence of calculi in the gall bladder" }, { "id": "pain_site", "check": "Patient has complaint of right hypochondrium or epigastric pain" }, { "id": "no_prior_chole", "check": "No prior cholecystectomy done in the past" } ] }, { "code": "SG039D", "name": "Cholecystectomy", "procedure": "With Exploration of CBD – Lap.", "specialty": "General Surgery / Pediatric Surgery", "price": "₹22,800", "documents": { "preauth": [ { "id": "clinical_notes", "label": "Clinical notes", "verify": "Detailed history, signs & symptoms, and indication for the procedure" }, { "id": "usg_abdomen", "label": "USG Upper Abdomen", "verify": "Confirms presence of gall stone. If CBD exploration is planned, MRCP/USG should show large (>1cm) or multiple CBD stones" }, { "id": "lft", "label": "LFT (Liver Function Test)", "verify": "Report showing serum bilirubin, transaminase and alkaline phosphatase levels" } ], "claim": [ { "id": "operative_notes", "label": "Operative notes", "verify": "Detailed operative notes with indications and outcomes of the procedure" }, { "id": "pre_anesthesia", "label": "Pre-anesthesia check-up report", "verify": "Pre-anesthesia evaluation / fitness report" }, { "id": "discharge_summary", "label": "Detailed Discharge Summary", "verify": "Discharge summary including follow-up advice at the time of discharge" }, { "id": "intraop_photo", "label": "Intra-operative photograph & gross specimen pictures", "verify": "Intra-operative image and picture(s) of gross specimen removed. If CBD stones detected/suspected, photo/video of stones removed from CBD" }, { "id": "histopathology", "label": "Histopathology report", "verify": "Histopathology report of the specimen removed", "note": "Can be submitted within 7 days of discharge" } ] }, "rules": [ { "id": "usg_calculi", "check": "USG shows presence of calculi in the gall bladder" }, { "id": "pain_site", "check": "Patient has complaint of right hypochondrium or epigastric pain" }, { "id": "no_prior_chole", "check": "No prior cholecystectomy done in the past" } ] }, { "code": "MG006A", "name": "Enteric fever", "procedure": "Enteric fever (medical management)", "specialty": "General Medicine / Pediatric Medical Management", "price": "₹1,800 (Gen) – ₹4,500 (ICU+vent)", "documents": { "preauth": [ { "id": "clinical_notes", "label": "Clinical notes with detailed history", "verify": "Detailed clinical notes documenting history of fever and symptoms" }, { "id": "cbc_panel", "label": "CBC, ESR, Peripheral smear, LFT", "verify": "Baseline CBC, ESR, peripheral smear and LFT reports" } ], "claim": [ { "id": "indoor_case_papers", "label": "Detailed Indoor case papers & treatment details", "verify": "Indoor case papers with vitals and full treatment details" }, { "id": "post_cbc_panel", "label": "Post-treatment CBC, ESR, Peripheral smear, LFT", "verify": "Repeat CBC, ESR, peripheral smear and LFT after treatment" }, { "id": "discharge_summary", "label": "Detailed Discharge Summary", "verify": "Discharge summary including date of follow-up" } ] }, "rules": [ { "id": "fever_threshold", "check": "Patient had fever >= 38.3°C / 101°F for more than 2 days (documented)" } ] }, { "code": "MG064A", "name": "Severe Anemia", "procedure": "Severe anemia (medical management)", "specialty": "General Medicine / Pediatric Medical Management", "price": "₹1,800 (Gen) – ₹4,500 (ICU+vent)", "documents": { "preauth": [ { "id": "clinical_notes", "label": "Clinical notes", "verify": "Evaluation findings, indications for the procedure, and planned line of treatment" }, { "id": "cbc_hb", "label": "CBC, Hb report", "verify": "Complete blood count and hemoglobin level report" } ], "claim": [ { "id": "indoor_case_papers", "label": "Detailed Indoor case papers & treatment details", "verify": "Indoor case papers with indications and treatment details. Should mention blood transfusion and ferrous sulphate injection" }, { "id": "post_cbc_hb", "label": "Post-treatment CBC, Hb report", "verify": "Repeat CBC / hemoglobin report after treatment" }, { "id": "discharge_summary", "label": "Detailed Discharge Summary", "verify": "Detailed discharge summary" } ] }, "rules": [ { "id": "hb_below_7", "check": "Patient hemoglobin level was less than 7 g/dl" }, { "id": "transfusion", "check": "Patient underwent blood transfusion treatment" } ] }, { "code": "SB039A", "name": "Total Knee Replacement (Primary)", "procedure": "Primary - Total Knee Replacement", "specialty": "Orthopedics", "price": "₹80,000", "documents": { "preauth": [ { "id": "clinical_notes", "label": "Clinical notes with indication for surgery", "verify": "Clinical notes documenting the indication for knee replacement surgery" }, { "id": "knee_xray", "label": "X-ray / CT of Knee (labelled)", "verify": "X-ray or CT of the knee, labelled with patient ID, date and side (Left/Right)" } ], "claim": [ { "id": "indoor_case_papers", "label": "Indoor case papers", "verify": "Indoor case papers for the admission" }, { "id": "postop_photo", "label": "Post-op clinical photograph", "verify": "Post-operative clinical photograph" }, { "id": "postop_xray", "label": "Post-op X-ray showing implant", "verify": "Post-op X-ray of the operated knee showing the implant, labelled with patient ID, date and side (Left/Right)" }, { "id": "implant_invoice", "label": "Implant invoice / barcode", "verify": "Invoice or bar code of the implant used" }, { "id": "operative_note", "label": "Detailed operative / procedure note", "verify": "Detailed operative note" }, { "id": "discharge_summary", "label": "Discharge Summary", "verify": "Discharge summary" } ] }, "rules": [ { "id": "postop_implant", "check": "Post-op X-ray of the knee shows presence of the implant" }, { "id": "primary_age", "check": "If indication is primary osteoarthritis (no trauma / systemic joint disease), patient age is > 55 years" } ] }, { "code": "SB039B", "name": "Total Knee Replacement (Revision)", "procedure": "Revision - Total Knee Replacement", "specialty": "Orthopedics", "price": "₹1,30,000", "documents": { "preauth": [ { "id": "clinical_notes", "label": "Clinical notes with indication for surgery", "verify": "Clinical notes documenting the indication for revision knee replacement" }, { "id": "knee_xray", "label": "X-ray / CT of Knee (labelled)", "verify": "X-ray or CT of the knee, labelled with patient ID, date and side (Left/Right)" }, { "id": "preop_xray_implant", "label": "Pre-op X-ray showing existing implant", "verify": "Pre-op X-ray of the affected knee showing the existing implant (required for revision cases)" } ], "claim": [ { "id": "indoor_case_papers", "label": "Indoor case papers", "verify": "Indoor case papers for the admission" }, { "id": "postop_photo", "label": "Post-op clinical photograph", "verify": "Post-operative clinical photograph" }, { "id": "postop_xray", "label": "Post-op X-ray showing implant", "verify": "Post-op X-ray of the operated knee showing the implant, labelled with patient ID, date and side (Left/Right)" }, { "id": "implant_invoice", "label": "Implant invoice / barcode", "verify": "Invoice or bar code of the implant used" }, { "id": "operative_note", "label": "Detailed operative / procedure note", "verify": "Detailed operative note" }, { "id": "discharge_summary", "label": "Discharge Summary", "verify": "Discharge summary" } ] }, "rules": [ { "id": "postop_implant", "check": "Post-op X-ray of the knee shows presence of the implant" }, { "id": "preop_implant", "check": "Pre-op X-ray shows presence of the existing implant" } ] } ] }