Guidelines On Hospital Empanelment And De-Empanelment

This guide summarises the National Health Authority’s (NHA) Guidelines on Hospital Empanelment and De-Empanelment under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY), issued in December 2021. The guideline sets out the processes, criteria, roles, and responsibilities that help beneficiaries receive quality healthcare services. States can adapt it to local conditions and state laws, so always check your State Health Agency’s (SHA) current rules as well.

Overview Of Ayushman Bharat PM-JAY

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) was launched by the Government of India in September 2018. The core aim of this scheme is to reduce the financial burden on the poorest and most vulnerable population and ensure their access to quality health services, thereby accelerating India’s progress towards Universal Health Coverage (UHC).

Empanelment Of Healthcare Providers

1 Approach For Empanelment

• States/Union Territories can empanel healthcare providers only within their own State/UT.
• If an SHA needs a hospital outside its state, it can send a request with reasons to NHA, which may ask the hospital’s home state to empanel it.
• Government facilities with 5 or more beds that provide inpatient services are deemed empanelled, but they must still register on the web portal.

2 Criteria For Empanelment

• Healthcare providers must meet minimum eligibility requirements, such as infrastructure, staffing, and equipment standards. For a private network hospital this includes at least 10 inpatient beds, with exemptions for dental and day-care hospitals and relaxations for aspirational districts.
• Specialty-specific eligibility criteria apply for providers offering specialized services like oncology or neurology.

3 Incentive Structure For Empanelment

• Empanelled healthcare providers are encouraged to earn PM-JAY quality certifications (Bronze, Silver, Gold), which bring higher prices for health benefit packages.
• Hospitals empanelled on the basis of a quality certification or accreditation go through renewal every 3 years, or when their PM-JAY Bronze or NABH certification expires, whichever is earlier.

Institutional Set-Up For Empanelment

Four bodies share responsibility for empanelment and monitoring:

1. Role Of National Health Authority (NHA)

The NHA develops guidelines, supports SHAs, and gives states the flexibility to adapt them. It may directly empanel providers in states that do not implement PM-JAY, National Healthcare Providers (NHCPs, hospitals and medical colleges under the Union Health Ministry) and public hospitals under other ministries.

2. Role Of State Health Agency (SHA)

SHAs are responsible for creating awareness, verifying applications, and approving or rejecting healthcare provider applications. SHAs conduct district-level analyses to ensure equity and access to healthcare services.

3. State Empanelment Committee (SEC)

The SEC monitors the overall empanelment process, supervises DEC activities, and handles application rejections or pendency.

4. District Empanelment Committee (DEC)

DECs validate and scrutinize application documents, conduct field and desktop-based verifications, and recommend approval or rejection to the SHA. Some states also hire a Third Party Empanelment Agency (TPEA) to carry out verification.

Process Of Empanelment For Healthcare Providers

1. Application And Registration On the Portal

Healthcare providers must register on the Hospital Empanelment Module (HEM) portal (hospitals.pmjay.gov.in) and complete the detailed application form. Only providers registered as an establishment under the relevant central or state law, where applicable, can be empanelled.

2. Approval Process Of the Application

Under the standard route, the DEC completes desktop and physical verification within 15 working days of receiving the application, and the final decision on empanelment should be taken within 30 working days. States may instead choose fast-track empanelment for hospitals with PM-JAY Bronze certification, NABH accreditation or certification, or CGHS or ECHS empanelment, and for hospitals already empanelled under a state scheme, with physical verification carried out afterwards. A rejected hospital can approach the State Empanelment Committee within 15 working days.

3. On-Boarding Processes After Approval

Upon approval, healthcare providers sign an MoU with the SHA (within 7 working days, as per the guideline), designate a nodal officer, and receive training on PM-JAY systems and processes.

Disciplinary Proceedings And De-Empanelment

1. Rationale For Disciplinary Actions

Disciplinary proceedings and de-empanelment are conducted to ensure quality care and prevent fraud and abuse in the scheme.

2. Investigation Of Suspect Claims

Suspect claims are identified through ongoing data analytics and complaints, then investigated through desk audits and hospital visits. The guideline asks for the investigation report within 10 working days of the case being flagged. The hospital is then given a show-cause notice and a short window, usually 5 working days, to respond.

3. Suspension And De-Empanelment

Healthcare providers may be suspended for a specified period of up to 6 months, or until a decision is taken on the proceedings. During suspension, the hospital cannot raise new pre-authorisations under PM-JAY, but patients already admitted continue to be treated until discharge. The SHA can then present the case to the State Empanelment Committee, which may order de-empanelment along with penalties or an FIR. De-empanelment normally lasts 1 year; for serious offences the committee can de-empanel a hospital for more than 2 years or blacklist it. In a hospital chain, only the branch at fault is de-empanelled. Either party can then approach the competent authority under the grievance redressal guidelines.

Annexures For Healthcare Providers

Detailed annexures provide additional information and criteria for empanelment, verification processes, and other specific requirements:

1. Criteria For Empanelment

Detailed criteria for minimum standards and speciality-specific requirements are provided, along with relaxations for aspirational districts.

2. Additional Documents

Annexures include the list of X and Y class cities, the process for desktop-based verification, the list of aspirational districts, and self-declaration forms for standalone and outsourced dialysis centres.

Official source: National Health Authority, Guidelines on Hospital Empanelment and De-Empanelment, AB PM-JAY (December 2021) (PDF). Timelines and penalties may have been adapted by your state, so confirm the current rules with your State Health Agency.

Conclusion

For a hospital seeking empanelment, the practical sequence is: confirm you meet the minimum and speciality criteria, register on the HEM portal, prepare for desktop and physical verification, and sign the MoU promptly once approved. After empanelment, clean claims and good documentation are what keep a hospital clear of suspension and de-empanelment.

Frequently Asked Questions