Subject: Empanelment Policy of
Original Issue Date: 1 Aug 2022 Effective Date: 01-Apr-2024
Network Providers
Policy on Revision Dates: 30-Apr-2024 Version No: 2.0
;
Magma HDI General Insurance
Company Limited
The purpose of this document is to describe
the Product Management and management
policy to be followed and details around the
Empanelment
same.
Policy of Cashless
Network Hospitals
Product Management and Management
Policy
EffectiveDate:
Effective Date:01.04.2017
1 Aug 2022
ApprovalDate:
Approval Date: 30/04/2024
VersionNo.:
Version No.:1.0
2.0
ApprovedBy:
Approved By:PMC
Board of Directors
PolicyOwner:
Policy Owner: Mr. Amit Bhandari
1
Subject: Empanelment Policy of
Original Issue Date: 1 Aug 2022 Effective Date: 01-Apr-2024
Network Providers
Policy on Revision Dates: 30-Apr-2024 Version No: 2.0
Base Document : IRDAI Circular ‘Standard and Benchmarks for Hospitals in the Provider Network’
vide Circular no: IRDAI/HLT/CIR/MISC/150/7/2022, dated 20th July 2022
IRDAI Circular: ‘Guidelines on providing AYUSH coverage in Health Insurance
policies’ vide circular no: IRDAI/HLT/CIR/GDL/31/01/2024, dated 31st Jan 2024
Initial Document : Vikram Singh
Prepared by
Functional aspects : Dr Sunil Gala/Nirmal Gupta
Checked by
Governing : NA
Guideline/Policy
Legal aspects checked : Compliance team
by
Policy owner : Amit Bhandari
INDEX
Objective 3
2
Subject: Empanelment Policy of
Original Issue Date: 1 Aug 2022 Effective Date: 01-Apr-2024
Network Providers
Policy on Revision Dates: 30-Apr-2024 Version No: 2.0
Regulations Governing the Policy 3
Empanelment Philosophy 3
Current Network Status 3
Empanelment Process 4
Empanelment Criteria 4
Change Control Record 6
Objective:
The main objective of empanelment policy of cashless network hospitals (herein after referred to as “the
Policy”) of Magma HDI General Insurance Co. Ltd. (herein after referred to as “Magma HDI or Company”) is to
comply with IRDAI circular on ‘Standards and Benchmarks for the Hospitals in the Provider Network’ dated 20th
July 2022(hereinafter referred as “the Circular”).
This circular specifies as below:
“with an objective to enhance the scope of cashless facility across the nation, Insurers are now empowered to
empanel the network providers that meet the standards and benchmarks criteria as specified by their respective
Boards.”
The Circular further stipulates the following conditions for the Insurers:
• While specifying the criteria, board shall, amongst others, consider especially the minimum manpower
and healthcare infrastructure facilities
• While empaneling network providers for cashless facility, insurers are also advised to focus on the
delivery of quality healthcare services.
Regulations Governing the Policy:
IRDAI Circular ‘Standard and Benchmarks for Hospitals in the Provider Network’ vide Circular no:
IRDAI/HLT/CIR/MISC/150/7/2022, dated 20th July 2022
Empanelment Philosophy
Magma HDI offers Health Insurance products to various segments viz. retail, corporate and mass population.
Therefore, the Company regularly empanels number of network Hospitals across India to provide cashless
facility to Magma HDI policyholders.
For the empanelment of Hospitals on network, focus shall remain on:
• Wide geographical distribution
• Quality infrastructure
• Cost effectiveness
Current Network Status
Magma HDI has a network base of 8608 empaneled hospitals as on Feb 2024. Hospitals are either empaneled
via a bipartite agreement (direct) or a tripartite agreement (through various partner TPA).
Network list comprises of Hospitals under primary care, secondary care, and tertiary care categories spread
across India.
Empanelment Process
Hospitals are empanelled through a bipartite or a bipartite agreement. While tripartite empanelment is
executed through TPA, Bipartite empanelment is executed directly by Magma HDI. Decision to empanel a
certain hospital/Group is taken basis the following:
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Subject: Empanelment Policy of
Original Issue Date: 1 Aug 2022 Effective Date: 01-Apr-2024
Network Providers
Policy on Revision Dates: 30-Apr-2024 Version No: 2.0
• Request for empanelment of a particular Hospital, from distribution team
• Request for empanelment of hospitals in a certain geography, from distribution team
• Empanelment request from a certain Provider/Hospital Group
• Suo-moto empanelment decision by Zonal head – Provider Management Team (PMT), basis the
following:
o To empanel a critical provider/ hospital chain
o To expand the network in certain geographies
o Basis competition benchmarking
On account of high reimbursement cases/pay-out
Empanelment Criteria
Empanelment criteria is specified under following two broad categories:
• Healthcare Infrastructure facilities
• Minimum Manpower requirements
Separate empanelment criteria has been put in place for AYUSH hospitals and AYUSH day care centers
Empanelment criteria for Hospitals:
Mandatory
Category Minimum Criteria for Empanelment
requirement
Minimum Beds: 15 beds in Urban, and 10 beds in Rural areas Yes
Has a fully equipped operation theatre of its own where surgical
Yes
procedures are carried out
Registration Certificate from local authorities (active status) Yes
Bio-Medical Waste Management certificate (active contract) Yes
Healthcare Infra
Registration under PC PNDT for USG Yes
facilities
Maintains daily records of patients and makes these accessible to the
Yes
insurance company’s authorized personnel
Safe and hygiene environment Yes
ROHINI registration Preferred
HFR id (Health Facility Registry) Preferred
Has qualified medical practitioner(s) in charge round the clock Yes
Minimum
Has qualified nursing staff under its employment round the clock Yes
Manpower
Availability of Housekeeping staff round the clock Preferred
Empanelment criteria for AYUSH Centres/Hospitals:
AYUSH treatment refers to the medical and/or hospitalization treatments given under ayurveda, yoga and
naturopathy, unani, siddha and homeopathy systems.
An AYUSH hospital is a healthcare facility wherein medical/surgical/para-surgical treatment procedures and
interventions are carried out by AYUSH medical practitioner(s) comprising of any of the following:
1. Central or state government AYUSH Hospital; or
2. Teaching hospital attached to AYUSH college recognized by the Central government/central council of
Indian medicine/central council for homeopathy; or
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Subject: Empanelment Policy of
Original Issue Date: 1 Aug 2022 Effective Date: 01-Apr-2024
Network Providers
Policy on Revision Dates: 30-Apr-2024 Version No: 2.0
3. AYUSH hospital, standalone or co-located with in-patient healthcare facility of any recognized system of
medicine, registered with the local authorities, wherever applicable, and is under the supervision of a
qualified registered AYUSH medical practitioner and must comply with all the following criterion:
a) Having at least 5 in-patient beds
b) Having qualified AYUSH medical practitioner in charge round the clock;
c) Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre
where surgical procedures are to be carried out;
d) Maintaining daily records of the patients and making them accessible to the insurance company’s
authorized representative
e) Additionally, AYUSH day care centers to have:
i. Active Bio-Medical Waste Management contract (mandatory)
ii. Be preferably ROHINI registered (non-mandatory) and have HFR id/Health facility
registry (non-mandatory)
4. Considering the quality of Infrastructure, maintenance of Hygiene factors, customer wellbeing and quality
of care imparted, empanelment of AYUSH hospitals to be done preferably with either pre-entry level
certificate (or higher level of certificate) issued by National Accreditation Board for Hospitals &
Healthcare Providers (NABH) or State Level Certificate (or higher level of certificate) under National
Quality Assurance Standards (NQAS), issued by National Health Systems Resources Centre (NHSRC).
AYUSH day care centre means and includes community health centre (CHC), primary health centre (PHC),
dispensary, clinic, polyclinic or any such health centre which is registered with the local authorities, wherever
applicable and having facilities for carrying out treatment procedures and medical or surgical/para-surgical
interventions or both under the supervision of registered AYUSH medical practitioner (s) on day care basis without
in-patient services and must comply with all the following criterion:
1. Having qualified registered AYUSH medical practitioner(s) in-charge
2. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where
surgical procedures are to be carried out
3. Maintaining daily records of the patients and making them accessible to the insurance company’s
authorized representative
4. Additionally, AYUSH day care centers to have:
a) Active Bio-Medical Waste Management contract (mandatory)
b) Be preferably ROHINI registered (non-mandatory) and have HFR id/Health facility registry (non-
mandatory)
Medical Practitioner (not applicable for Overseas Travel Insurance) : Medical Practitioner means a person who
holds a valid registration from the Medical Council of any State or Medical Council of India or Council for Indian
Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby entitled to
practice medicine within its jurisdiction; and is acting within its scope and jurisdiction of license. (Insurance
companies may specify additional or restrictive criteria to the above e.g. that the registered practitioner should
not be the insured or close member of the family. Insurance Companies may also specify definition suitable to
overseas jurisdictions where Indian policyholders are getting treatment outside India as per the terms and
conditions of a health insurance policy issued in India).
Network Provider (not applicable for Overseas Travel Insurance) : Network Provider means hospitals or health
care providers enlisted by an insurer, TPA or jointly by an Insurer and TPA to provide medical services to an
insured by a cashless facility.
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Subject: Empanelment Policy of
Original Issue Date: 1 Aug 2022 Effective Date: 01-Apr-2024
Network Providers
Policy on Revision Dates: 30-Apr-2024 Version No: 2.0
Change Control Record
Version Change Requested Approval
Memorandum of Change
No by Date
Addition of separate empanelment criteria for AYUSH
Hospitals/AYUSH Day care centers.
2.0 Vikram Singh Addition of definition of Medical Practitioner and Network 30/04/2024
Provider
Source - Master Circular on Standardization of Health Insurance Products
dated 22/07/2020
