DOCUMENTATION OF PROCESS

FOR CUSTOMIZATION OF
STANDARD TREATMENT GUIDELINES

AYUSHMAN BHARAT
PRADHAN MANTRI JAN AROGYA YOJANA (AB PM-JAY)
JANUARY 2021
SUDHA CHANDRASHEKAR | VIPUL AGGARWAL
AJAI AGARWAL | RIMY KHURANA | NEETIKA ASHWANI

OUR PARTNERS
Disclaimer: The main objective of this process document of National Health Authority (NHA) is to give an overview of
the process entailed in coming up with a set of Standard Treatment Guidelines (STGs) / guidance documents specific to
Health Benefit Packages under AB PM-JAY. These STGs have been prepared for guidance of processing team and
transaction management system of AB PM-JAY for processing claims of relevant procedures. It will also serve as a
guidance tool for the hospitals and the medical audit teams. However, these STGs don`t provide any guidance on
clinical and therapeutic management of patients. In that respect, the hospitals and physicians may refer to other
relevant material as per the extant professional norms. The content of the document may be reproduced / cited with
due acknowledgment of the original publication, AB PM-JAY and NHA.

Cite as: “Sudha Chandrashekar, Vipul Aggarwal, Ajai Agarwal, Rimy Khurana, Neetika Ashwani.
Documentation of Process for Customization of Standard Treatment Guidelines for Ayushman Bharat
Pradhan Mantri Jan Arogya Yojana (AB PM-JAY), National Health Authority. January 2021. Accessible
at: https://pmjay.gov.in/standard_treatment_guidelines”

Acknowledgements: Special thanks to Dr. R.S. Sharma, CEO, NHA; Dr Indu Bhushan, Former CEO, NHA; Dr Praveen
Gedam, Additional CEO, NHA; Dr JL Meena, Joint Director (SPE), NHA for their overall strategic guidance and
facilitating the process. We acknowledge with gratitude the contribution and support provided by Dr Balram Bhargava,
Secretary, Department of Health Research (DHR), Ministry of Health & Family Welfare, Government of India and Director
General, Indian Council of Medical Research (ICMR) and Dr CS Pramesh, Director, Tata Memorial Hospital (TMH),
Convener, National Cancer Grid (NCG), all NHA colleagues; the World Bank Team (Sheena Chhabra and Owen Smith);
for their feedback and suggestions.

Key contributors to the development and integration of the guidelines include Dr Sudha Chandrashekar, Advisor
(HP&QA) & Senior Consultant (World Bank); Dr Vipul Aggarwal, Deputy CEO, NHA; Dr Ajai Agarwal, Director (HP&QA),
NHA; Dr Rimy Khurana, Dy. Principal Consultant (NHA); Dr Neetika Ashwani, Consultant (World Bank), other team
members from NHA - Dr Ankit Batra, Dr Gaurav Mishra, Dr Kishor Mogulluru, Dr Nishu Sharma, Dr Aneesha Koul, Ms
Jayathra Datla, IT team, and supported by Experts from Tata Memorial Hospital/National Cancer Grid, Department of
Health Research-Indian Council of Medical Research (DHR-ICMR), Dr Deepika Saraf (ICMR), Expert group committees
on various Medical/Surgical Specialties, Experts of the Medical Cell (NHA), Ms Malti Jaswal, Dr Abhinav Suri, Dr Ankita
Chobisa and National Anti-Fraud Team (NAFU), Monitoring & Evaluation (M&E) team, Information, Education &
Communication (IEC) team at NHA. Special thanks to the State Health Agencies (SHAs) and their teams for continued
support.
 TABLE OF CONTENTS
1. ABBREVIATIONS 2
2. OUTLINE OF THE PROCESS DOCUMENT 3
2.1. Standard treatment guidelines (STGs) for Efficient Health Care 3
3. INTRODUCTION 3
3.1. Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (AB PM-JAY) 3-4
4. RATIONALE FOR STANDARD TREATMENT GUIDELINES 4
4.1.Purpose and Content 4-5
4.2. Advantages as stated by WHO (1) 6
4.3. Points considered while drafting the guidelines 6
4.4. Aim and Objectives 7
4.5. Process carried out at DHR/ICMR for developing STWs 7
5. DEVELOPMENT PROCESS OF STGs 7
6. CONCEPTUALIZATION 8
7. INKED MoU/ MoA 8
8. OVERALL PLANNING 8
8.1. Phase I 8
8.2. Phase II 9
8.2.1 Oncology STGs 9-10
9. COMMITTEE FORMULATION 10-11
10. ROLES AND RESPONSIBILITIES 12
11. STRUCTURE OF GUIDELINES 12
11.1. Standard treatment guideline (Structure) 12-13
11.2. Structure for Oncology STGs 14
12. DEVELOPMENT OF STGs 15-16
13. PILOT STUDIES 17
13.1. Training done with States 17-18
14. PUBLISH AND DISSEMINATE 18-20
15. MONITORING AND ANALYSIS 21
15.1. STG dashboard- Key analytics 22
16. REVISE AND UPDATE 22
16.1. Implementation/ compliance monitoring 23
17. CHALLENGES AND LESSONS LEARNT 23
17.1. Challenges 23-24
17.2. Lessons learnt 24
18. FUTURE VISION AND ROADMAP 25
18.1.Way Forward 25
19. REFERENCES 25
19.1. Link to STGs: 25
20. ANNEXURES 26-27
Annexure 1: Top 50 abuse prone & most utilised packages taken
up for implementation of 29 Standard Guidance documents
Annexure 2: Agenda for the State Workshop
21. DEVELOPMENT OF FREQUENTLY ASKED QUESTIONS (FAQs) FOR STGs 28
21.1 General FAQs 28-29
21.2 Process specific FAQs 30-32

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1. ABBREVIATIONS
AB PM-JAY Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana
CTVS Cardiothoracic and Vascular Surgery
COPD Chronic obstructive pulmonary disease
CPD Claims Processing Doctor
CABG Coronary artery bypass grafting
DHR Department of Health Research
D&C Dilation and curettage
EHCP Empanelled Health Care Providers
ENT Ear, Nose, Throat
FICCI Federation of Indian Chambers of Commerce & Industry
FAQ Frequently Asked Questions
HWCs Health and Wellness Centres
HP&QA Hospital Policy & Quality Assurance
ISA Implementation Support Agency
ICMR Indian Council of Medical Research
IEC Information Education Communication
IT Information Technology
IPD In-patient department
IDF Ipas Development Foundation
IABP Intra-Aortic Balloon Pump
IOL Intraocular Lens
MoA Memorandum of Association
MoU Memorandum of Understanding
MoH&FW Ministry of Health and Family Welfare
NAFU National Anti-Fraud Unit
NCG National Cancer Grid
NHA National Health Authority
NHS National Health Service
NICE National Institute of Health and Care Excellence
OPD Out-patient department
PTCA Percutaneous transluminal coronary angioplasty
PPD Pre-authorization Processing Doctor
PHCs Primary Health Centers
SFIOL Scleral-Fixated Intraocular Lens
SPE Service Provider Engagement
STG Standard Treatment Guidelines
STW Standard Treatment Workflows
SHA State Health Agency
SDGs Sustainable Development Goals
SHCs Sub health Centers
TMH Tata Memorial Hospital
TPA Third-party Administrators
TMS Transaction Management System
UT Union Territory
UK United Kingdom
USA United State of America
UHC Universal Health Coverage
UHCs Urban Health Centers
WHO World Health Organization

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2. OUTLINE OF THE PROCESS DOCUMENT

2.1. Standard treatment guidelines (STGs) for finger on the pulse to include newer developments in the
Efficient Health Care fields covering a plethora of diseases. The following
document covers the advantage of STGs, its methodology
A minimum standard of care is needed by every
in the application, and how it could prevent fraud
individual seeking medical treatment in a healthcare
treatments in high-risk areas.
facility or by a healthcare professional. For any clinical
conditions, it is imperative for health caregivers to be As has been detailed later in the document, many STGs/
guided by standard care guidelines/pathways to clinical guidelines/ clinical pathways have been
complement them to provide an acceptable level of formulated for years by various clinical bodies/
quality care to the patients. Hence formulating STGs federations/ organizations. However, this is the first
could be a beacon for health care. attempt made, especially through the largest
Government-funded public health insurance/assurance
Given the emphasis that is being placed on health under
scheme, to not just have package specific guidance
the various ministries of the Government of India,
documents but also have them integrated into the IT
methodical planning like STG could provide an umbrella
system to enable uptake and adherence to the
for medical professionals and for patients too. This is not
guidelines. Further, a dashboard specific to these STGs
just an ambitious step but an essential one that could
has also been developed for monitoring and analysis
revolutionize health care not only in India but probably in
purposes.
most developing countries. It would entail keeping the

3. INTRODUCTION Ayushman Bharat adopts a continuum of care approach,

comprising of two inter-related components, which are -
3.1. Ayushman Bharat Pradhan Mantri Jan
Aarogya Yojana (AB PM-JAY) • Health and Wellness Centres (HWCs)

Ayushman Bharat, a flagship scheme of Government of • Pradhan Mantri Jan Arogya Yojana (PM-JAY)
India, was launched as recommended by the National
Health Policy 2017, to achieve the vision of Universal Health and Wellness Centres (HWCs): These centers seek
Health Coverage (UHC). This initiative has been designed to promote individuals and communities to adopt healthy
to meet Sustainable Development Goals (SDGs) and its lifestyles and take control of their health by bringing
underlining commitment, which is to "leave no one services closer to the community. They are therefore free
behind". to users and provide a wide variety of services including
maternal and child health services, care for
Ayushman Bharat is an attempt to move from sectoral non-communicable diseases, palliative and rehabilitative
and segmented approach of health service delivery to a care, oral, eye and ENT care, mental health etc. To
comprehensive need-based health care service. This ensure continuum of care, 1,50,000 health and wellness
scheme aims to undertake path breaking interventions to centers will be set up with improved infrastructure,
holistically address the healthcare system (covering assured availability of drugs and diagnostic services
prevention, promotion and ambulatory care) at the along with strengthening of referral mechanisms and
primary, secondary and tertiary level. community linkages.

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The HWCs herald a whole new scene in increasing families (approximately 50 crore beneficiaries) that form
responsiveness of health care services and in reaching the bottom 40% of the Indian population.
the needs of marginalized sections of society with primary
The primary objectives for launching AB PM-JAY were to
health care teams. Several Sub health Centers (SHCs),
ensure comprehensive coverage for catastrophic
Primary Health Centers (PHCs) and Urban Health Centers
illnesses, reduce catastrophic out-of-pocket expenditure,
(UHCs) are going to be made into Health Wellness
improve access to hospitalisation care, reduce unmet
Centers by 2022.
needs, and to converge various health insurance schemes
The second component under Ayushman Bharat is the across the States.
Pradhan Mantri Jan Arogya Yojana or AB PM-JAY as
The benefit cover under the scheme includes INR
it is popularly known. This scheme was launched on 23rd
5,00,000 on a family floater basis which can be used by
September 2018 in Ranchi, Jharkhand by the Hon’ble
one or all members of the family. AB PM-JAY has been
Prime Minister of India, Shri Narendra Modi. National
designed in such a way that there is no cap on family size
Health Authority (NHA) is the Nodal Agency set up for
or age of members. In addition, pre-existing diseases are
scheme implementation and oversight.
covered from the very first day. This means that any
AB PM-JAY is the largest health assurance scheme in the eligible person suffering from any medical condition
world which aims at providing a health cover of Rs. 5 before being covered by AB PM-JAY will now be able to
lakhs per family per year for secondary and tertiary care get treatment for all those medical conditions as well
hospitalization to over 10.74 crores poor and vulnerable under this scheme right away without any waiting period.

4. RATIONALE FOR STANDARD TREATMENT the guidelines, including the group members, influence
GUIDELINES of opinions and clinical experience, and optimization of
patient`s perspective. The article emphasized on rigorous
“Standard Treatment Guideline (STG) is a systematically development of evidence-based guidelines minimizing
developed statement designed to assist practitioners and the potential risks, or it could lead to suboptimal,
patients in making decisions about appropriate health ineffective, or harmful practices.
care for specific clinical circumstances” – World Health
Organization (WHO) (1) STGs are currently in use in parts of the United States,
Europe, Latin America, Asia, Africa, and the Western
4.1. Purpose and Content Pacific. As has been seen that improper use or misuse of
medicines in the treatment of any medical condition is
An effectively implemented guidelines (STGs) is
rampant, which can be detrimental to people. The idea
advantageous for beneficiaries, healthcare providers,
behind having STG is to have standardisation in terms of
supply managers, and health policy makers.
treatment and promote effective and efficient treatment
Global Scenario options.

Back in 1999, when clinical guideline development was Such guidelines may be used at different stages of the
soaring in Europe, North America, Australia, New therapeutic process. It could include medical supplies as
Zealand, and Africa, a published article (2) mentioned also following prescribed treatments. It could assist in
the potential benefits and limitations of developing better diagnosis and look at preventive services. As STGs
clinical guidelines across health care professionals, are disease-specific, a publication of relevant documents
patients, and health systems. The focus was clinical and their proper updation would help medical
guidelines being the only way to improve quality of care, practitioners. If implemented properly, STGs can be
and limitations were on the quality in the development of inclusive in their application (1).

4
Even after two decades, we stand at the same platform Indian perspective
with an overwhelming minimal size of literature in some Studies from India explicated developing guidelines from
specialties. Guidelines are developed by the expert panel many States and authorities, but major limitations as
and are graded differently from evidence-based stated in KOLI et al. (5) in implementation included
practices, which increases the individual variability “multiplicity, paucity of Indian literature, failure to
among care providers and might have a difference of periodically revise guidelines, failure to tailor them
opinion. Developing homogenous clinical care can also according to the level of healthcare and a lack of
be considered difficult to implement as patients, and availability and accessibility” making India dependent on
clinical circumstances are heterogeneous. Hence, some the quality of evidence from developed countries. It was
variability and flexibility in the practices were productive. also noticed that in the UK, one statutory body (NICE)
The study focused on the importance of the following developed, promoted, and disseminated the guidelines
parameters, clearly defined scope of the guideline, nationally, whereas the USA, on the other hand, had
grading system of evidence-based practices, external multiple agencies framing the STGs based on
peer review, and regular updating (3). high-quality evidence. USA STGs and NICE guidelines did
not reveal the cost of treatment and nor strategized on
The Agency for Healthcare research and quality
levels of healthcare.
addressed the challenges in measuring care
co-ordination using electronic data. These included (4): Other studies (6,7) explained the main challenges for
initiating the STG development process itself, including a
1. Underutilization of health IT system capabilities and
vague understanding of the mechanism, onboarding
clinical workflow barriers.
expertise panel, challenges to streamline specialists and
2. Lack of data standardization and limited health IT generalists, international adaptation of pragmatic
system interoperability. approach, time constraint, lengthy process, and financial
support to sustain the task force. However,
3. Unknown clinical data quality in electronic data adapting/adopting evidence-based guidelines should be
sources. allaying to the local context tailored to diverse clinical
practice, varied resource settings, and acceptance by the
4. Limitations in linking data.
prescribers. Though there are many standardized
5. Technical hurdles to accessing data. adaptation frameworks available, a uniform global
approach, especially for developing countries, can ease
6. Business models that facilitate competition rather than the process to suit the local context. Investments in a
cooperation. National nodal agency to either adopt, adapt or develop
STGs along with dissemination, impact evaluation, and
Potential solutions addressed to the above-mentioned timely revision were considered crucial.
challenges included structured data fields into the IT
All in all, there is a substantial evidence on the benefits of
systems instead of text free writing and utilizing support
STGs focusing on rationalizing health care services,
staff to enter some information helps in care
thereby improving the quality of care. However,
co-ordination; mapping consistencies in the coding
standardization of developing frameworks, grading
system at the granular level example like medication
evidence-based practices, local context research for
units, laboratory results, diagnosis, etc. It also covered
effectiveness of interventions, peer review, easy
developing indicators for the evaluation of reliability and
availability of the guidelines, finance allocations,
accuracy of IT data; linking data to policymakers and
increasing awareness, multiple revisions, decreasing
public overcomes privacy barriers; designing the IT
multiplicity, feedback and update, standard electronic
system for easy accessibility of data to end-users, and
abstraction approach, and monitoring and evaluation are
financial support to help overcome business model
the key takeaways not only for the development but also
barriers that have hindered information sharing and care
for sustainability throughout the organizational strata
co-ordination.
including healthcare professionals, policymakers,
patients, and insurers.

5
4.2. Advantages as stated by WHO (1) • Supply management

The uses of STGs are multifarious and can take under its - Utilizes only formulary or essential medicines, therefore
wings health care givers, health care officials, supply the health care system needs to provide only medicines in
management personnel, and patients. the STGs

• Health care providers - Provides information for forecasting and ordering

(because medicines and quantities for common diseases
- Provides standardized guidance to practitioners will be known)

- Encourages high quality care by directing practitioners - Provides information for purchase of pre-packaged
to the most appropriate medicines for specific conditions medicines

- Encourages the best quality of care since patients are • Patients

receiving optimal therapy
- Patients receive optimal pharmaceutical therapy
- Utilizes only formulary or essential medicines, so the
health care system needs to provide only the medicines in - Enables consistent and predictable treatment from all
the STGs levels of providers and at all locations within the health
care system
- Provides valuable assistance to all practitioners,
especially to those with lower-level skills - Allows for improved availability of medicines because of
more consistent use and ordering
- Enables providers to concentrate on making the correct
diagnosis because treatment options will be provided for - Helps provide improved outcomes because patients are
them receiving the best treatment regimens available

• Health care officials - Lowers cost

- Provides a basis for evaluating quality of care provided

by the health care professionals 4.3. Points considered while drafting
AB PM-JAY guidelines
- Provides the most effective therapy in terms of quality
• Incomplete and inaccurate guidelines could provide
- Provides a system for controlling cost by using funds misinformation leading to wrong consequences. Care
more efficiently needs to be taken to shun misinformation for care
providers. Inappropriate or ambiguous guidelines would
- Provides information for practitioners to give to patients
do more harm than good. Hence, this aspect should
concerning the institution’s standards of care
receive attention while drafting proper guidelines.
- Can be a vehicle for integrating special programs (e.g.,
• STGs should not be limited to evaluation of a patient or
diarrhoea disease control, acute respiratory infection
a given fit of a standard treatment as it would give wrong
(ARI), tuberculosis control, malaria) at the primary health
signals of security.
care facilities using a single set of guidelines
• In a rapidly developing field of medical care with latest
developments in diagnostics and treatment, although
developing and updating guidelines at regular intervals is
a humongous task it must be done before they get
obsolete.

6
4.4. Aim and Objectives much higher than other smaller countries. This led to the
formulation of Standard Treatment Workflows (STWs) that
The aim of having STGs was to develop guidelines for AB were designed in such a manner that they were
PM-JAY Health Benefit Packages by adoption and user-friendly at the same time keeping in mind the
customization of available Standard Treatment Workflows feasibility of the country’s health system in the
developed by DHR/ICMR, National Cancer Grid (NCG), background. Department of Health Research-Indian
State Guidelines, Ministry guidelines, and other globally Council of Medical Research (DHR-ICMR) created a
accepted standard treatment protocols as per the three-peer review mechanism to give a concrete shape to
scheme’s requirement. the workflows. Subject expert group committees were
formed by inviting clinical experts from Premier Medical
The objectives of STGs are to aid the Pre-authorization
Institutes, Medical Colleges and private sector. A
Processing Doctor (PPD) and Claims Processing Doctor
Secretariat was created staffed by clinical scientists and
(CPD) at the time of pre-authorization and claims
lead by a Public Health Expert with sound clinical
processing by specifying the mandatory documentation
background to navigate the discussions in a format that
required and specific things to look for in these
was resource stratified. An Editorial Board was created to
documents for the prescribed procedure; to help prevent
streamline the care pathways. The Advisory Committee
and control fraud and abuse; to provide quality care to
gave supportive supervision to the whole exercise.
the beneficiaries by bringing uniformity in documentation
across empanelled healthcare providers; and to serve as ICMR STWs were developed to formulate treatment
a Guidance Tool for treating doctors, Empanelled Health algorithms for common and serious medical and surgical
Care Providers (EHCPs), Third-party Administrators conditions for both Out-patient Department (OPD) and
(TPAs), Implementing Support Agency (ISAs), State Health In-patient department (IPD) management at primary,
Agencies (SHAs) and medical auditors. secondary and tertiary levels of India’s healthcare system
that are scientific, robust, and locally contextual (8). The
4.5. Process carried out at DHR/ICMR for
objective of these STWs was to ensure appropriate
developing STWs
disease management and quality services through
It was felt that various prevailing treatment guidelines judicious use of hospital-based interventions and the
were not easy to follow and hence were not properly creation of stronger referral linkages with other levels
utilized by the busy clinicians in India as the workload is of care.

5. DEVELOPMENT PROCESS OF AB PM-JAY STGs

Establishing STGs is a long-drawn process that involved basic methodical practice that was adopted by all
deliberations and discussions, onboarding experts, etc., a practitioners

Figure 1: The process flow adapted by NHA from conceptualization to rolling out the STGs

01 02 03 04 05 06

Conceptualization Inked MoU/MoA Overall Setting up Mapping HBP Development

Planning medical cell packages

07 08 09 10 11

Customization Review and Integration and Trainings and Monitoring and

of STGs Approvals Roll out Feedback Analysis

7
6. CONCEPTUALIZATION

With the vision of Universal Health Coverage, the The STGs would enable standardization of treatment
National Health Authority (NHA) worked in collaboration protocols across all empanelled healthcare providers,
with Department of Health Research (DHR/ICMR) and control fraud and abuse, deliver cost effective and quality
Tata Memorial Hospital (TMH)/ National Cancer Grid care to the patients under the scheme. Starting with the
(NCG) to rationalize the Health Benefit Packages (HBPs) most abuse prone packages, the aim was to have in place
and to have STGs in place for better implementation of guidelines for all the Health Benefit Packages under
the AB PM-JAY scheme. AB PM-JAY.

7. INKED MoU/ MoA

• NHA had inked a Memorandum of Association (MoA) • Subsequently, NHA also signed a Memorandum of
with DHR/ ICMR to provide support inter alia, in Understanding (MoU) with Ipas Development Foundation
developing STWs for various disease conditions / benefit (IDF) as they approached to volunteer in providing
packages under AB PM-JAY and undertake costing for support in drafting some of the Obstetrics and
rationalisation of health benefit packages studies. Gynaecology STGs in their area of expertise and
field experience.
• Simultaneously, MoA was also signed with Tata Memorial
Hospital (TMH) lead NCG to provide guidance for developing
Oncology packages and guidelines.

8. OVERALL PLANNING

For the development and execution of the STGs, the process was strategically divided in two phases.

8.1.Phase I

In Phase-I of the development, STGs were conceptualized customized for the AB PM-JAY packages and STGs were
and introduced only for the most abuse prone packages developed. The developed STGs underwent extensive
(Annexure 1). These were identified with the help of internal and external expert review and were approved
National Anti-Fraud Unit (NAFU) team at NHA. Sixty such for piloting in six volunteering States. The feedbacks
packages were identified; duplicates were removed and shared by these States during the orientation and pilot
were mapped with the 53 Standard Treatment Workflows were considered and documents were revised.
released by ICMR. These guidelines and workflows were

Figure 2: Process of developing and piloting abuse prone packages

Abuse prone packages Mapping DHR/ICMR’s

were identified with the STG Development
released 53 STW’s
help of NAFU tream

Pilot in 6 Internal &

NHA approval
volunteering states Expert review

8
8.2. Phase II

During the pilot, many States had put up requests for World Bank, Federation of Indian Chambers of
developing STGs for more packages and the exercise was Commerce & Industry (FICCI) guidelines etc. were
extended to all Health Benefit Packages in Phase-II. Since referred. Similar to phase-I, these were mapped with AB
only 53 ICMR STWs were available, other sources of PM-JAY packages and STGs were developed. The STGs
guidelines were explored for reference. Various national underwent internal and external expert review. The STGs
and international guidelines such as those of Ministry of approved by NHA were then integrated in the Transaction
Health and Family Welfare (MoH&FW), State guidelines, Management System (TMS) and rolled out nationally
NCG guidelines, WHO, NHS / NICE guidelines, in batches.

Figure 3: Exploring and adapting wide range of guidelines for further integration

PACKAGE STG REVIEW & IT STATE FINALIZATION

MAPPING DEVELOPMENT APPROVAL INTEGRATION FEEDBACK & ROLL-OUT
Primary reference:
AB PM-JAY package Expert review IT integration National/State level Required updation
DHR/ICMR and NCG
mapping with & approval UAT testing workshop Release in TMS
DHR/ICMR and NCG Secondary Reference:
guidelines States guidelines,
National, International
guidelines

8.2.1 Oncology STGs

Simultaneously, for the rationalization of Oncology STG documents. A similar process was followed for
packages, TMH lead NCG in co-ordination with NHA Oncology packages and a roadmap was established
worked parallely for development of Oncology for implementation.

Figure 4: Systematic roadmap for development and implementation of Oncology STGs

PACKAGE STG REVIEW & IT STATE FINALIZATION

MAPPING DEVELOPMENT APPROVAL INTEGRATION FEEDBACK & ROLL-OUT
Primary reference:
AB PM-JAY Oncology NCG review & IT integration National level Required updation
NCG
package mapping approval UAT testing workshop & release
Secondary Reference: in TMS
with NCG guidelines State guidelines,
National, Internal
guidelines

9
After repeated discussions and meetings with the TMH and medical oncology reviewed the AB PM-JAY STG's and
team, the procedures/diseases for STGs were divided provide guidance and support in finalising the documents
based on anatomical sites and drafted accordingly. The as per the extant NCG guidelines, prevailing treatment
respective teams of surgical oncology, radiation oncology norms and best practices in the field.

Guidelines covering relevant HBP 2.0 Radiation / Surgical / Medical

Oncology packages classified as per Anatomical sites

Bone & Soft tissue tumour Neuro-oncology

Breast cancer Paediatric

Gastrointestinal Thoracic

Gynaecological Urological

Head & Neck Miscellaneous

Leukaemia and lymphomas

9. COMMITTEE FORMULATION
A Medical Cell was constituted by onboarding a set of A formal process for onboarding was put in place and the
Specialty Experts, with the approval of competent experts were finalized to support and guide NHA.
authority at NHA.

Figure 5: Comprehensive process adopted for committee formation

1 HBP 2.0 rationalisation specialist committee considered for medical call

2 Committee chair/co-chair/active member/nominated expert were selected

3 Formal letter sent from director HPQA for onboarding and sharing their undertaking CV’s

4 Referrals sort from experts from institutes of national eminence for few specialities

5 Documentation completed for consenting experts

6 List of experts finalised and put up for formal engagement

10
The main objective of medical cell was for engaging experts in the overall development and rationalisation of HBPs' and
review of STG documents.

Figure 6: Engagement of Specialists

EMAIL CONSULTATIONS COMMITTEE MEETINGS

MODE OF ENGAGEMENT
(FOR QUERIES) (VIRTUAL/PHYSICAL)

ENGAGEMENT

HBP QA
Unspecified surgical
Quality standards
packages
Revision of packages Hospital infrastructure
Scheme convergence & empanelment criteria
Clinical queries STG Policy design &
review
Development of STGs
Review and Updates
on STGs

Overall objectives of the Medical Cell include:

a. Provide expert guidance in the field of their clinical c. Aid NHA in identification and monitoring of fraud/
practice for supporting NHA in Health Benefit abuse during claims adjudication process and in
Packages, STGs, Quality Assurance, Hospital designing package specific fraud prevention
empanelment, etc. guidelines.
b. Advise NHA in developing specialty specific d. Support research and analytics activities of NHA by
policies/ treatment guidelines for seamless providing technical guidance in their subject areas.
implementation of the Health Benefit Packages.

11
10. ROLES AND RESPONSIBILITIES
The roles and responsibilities for implementation & roll Once reviewed and approved, the HP&QA and the IT
out of STGs are divided across NHA and SHA. Implemen- team at NHA integrated them in the TMS (one of the IT
tation of STGs is a collaborative effort of all stakeholders. platform of NHA). Once integrated, it is the responsibility
The Hospital Policy & Quality Assurance (HP&QA) of NHA, SHA, EHCPs, ISA and TPAs to ensure that these
division at NHA referred to the available guidelines and are implemented in the field and monitored by NHA
literature for adapting them to the AB PM-JAY packages and SHA.
and developed package specific guidelines.

Figure 7: Multi-Stakeholder collaboration for seamless application

11. STRUCTURE OF GUIDELINES

The NHA team had deliberations with experts of varied lab for performing Coronary Angiography, etc. and a
specialties and with consensus designed a format for the Disclaimer which states that this document has been
developing guidelines. The structure was broadly divided prepared for guidance of MEDCO, PROCESSING TEAM
into four different parts and an introduction. and TRANSACTION MANAGEMENT SYSTEM of AB
PM-JAY for the Pre-auth and claims of all AB PM-JAY
11.1. Standard treatment guideline (Structure)
packages. The hospitals can also refer to this document
The Introductory part which comprises of Package and to have an insight on how the pre-auth and claims will be
procedure along with its HBP2.0 and HBP1.0 code processed. However, this document doesn’t provide any
covered under the STG, Minimum qualifications guidance on clinical and therapeutic management of
(Essential and Desirable) of the treating doctor, the patient. In that respect the hospitals and physicians may
empanelment criteria such as those pertaining to refer to other relevant material as per the extant
minimum essential infrastructure required for professional norms and the professional judgment of the
performing that procedure for example a Cardiac Cath healthcare professionals should be used for management
of the patient.

12
Part-I
For Empanelled Healthcare providers – It gives the CPD. It will guide them to determine the mandatory
Guidelines for Clinicians and Healthcare Providers. This documents like relevant investigations, clinical notes,
includes key clinical pointers such as signs, symptoms, past history, etc. to look for in the case. The questions in
indications, contraindications, admission, discharge and it are specific to the procedure/package selected.
referral criteria, etc. It will also guide the MEDCO to
select the appropriate package by guiding on what to Part-3
look for in the documents/ clinical notes of the patient IT guidance document - It includes one or more most
and give a glimpse of the standard treatment workflow significant alert question(s) at the hospital level. This part
referred. This part also lists down the mandatory has been incorporated in the TMS in MEDCO
documents required to be submitted by the EHCPs both questionnaire. It will help in setting up cross check
at the time of pre-auth and claims submission. This will mechanisms/ rule engines and prevent booking of wrong
help reduce the number of queries raised to the hospital package.
and the processing time as well if all the documents are In very few Obstetrics & Gynecology STGs, a Part 4 has
complete and submitted on time. It aims to ensure been included that contains guidelines for Medical
uniformity of documentation and quality of care to the Auditors for some abuse prone packages.
beneficiaries.

Part-2
For processing doctor (PPD/ CPD) - this section contains
the guidelines for the processing team i.e. the PPD and

Figure 8: Four segments of STG structure

13
11.2. Structure for Oncology STGs
The structure for Oncology guidance documents was neurology, head & neck, urology, etc. The applicable
developed with the support of TMH/NCG on similar lines medical, surgical and radiation oncology packages were
as those for other specialties with a few modifications as mapped and clubbed together in one document for each
these were developed site wise such as breast, of these sites.

Figure 9: STG framework for Oncology guidance documents

14
 suggestions for cross-specializations and changes in costs
12. DEVELOPMENT OF STGs
and package name/procedure for respective packages
A systematic, rigorous process flow was adhered to were added to proposed amendments. Simultaneously,
finalize the STG guidance document, as shown in Table many packages/procedures that were under
2. Once developed by the NHA team, the drafts were cross-specialty underwent review and approval of
overseen by an in-house medical expert, modified, and multiple experts.
thereafter shared with the respective specialty Expert for
vetting and approval. Revisions were based on expert The last step in the process, the expert-approved
feedback that included length of stay, minimum document, was then put up to the competent authority at
qualifications and infrastructure, clinical content, NHA for final approval and roll-out.
mandatory documents, questionnaire, and triggers. The

Table 2: Extensive review process and finalization of STGs

DOCUMENT DRAFT VERSION

First version prepared by the NHA Team V1

Version reviewed by the NHA internal Medical Expert V2

Version revised and sent to Specialty Expert for review V3

Version approved by the Specialty Expert V4

Version approved at NHA, uploaded on website and released V5

Table 3 summarizes the work done in the STG Since the launch of first set of STGs that was made live on
development. A total number of 625 STGs were 15th August, 2020, subsequent sets have been regularly
developed by aligning complex systems of the process integrated and released in AB PM-JAY IT platform.
covering 1572 procedures from 24 different specialties.

15
 Table 3: Total number of STGs developed

S. NO. SPECIALITY TOTAL NO. OF STGS TOTAL NO. OF PROCEDURES

DEVELOPED COVERED

1 Burns 6 20

2 Cardiology 18 21

3 CTVS 62 117

4 Emergency Medicine 5 6

5 ENT Surgery 22 47

6 General Medicine 66 102

7 General Surgery 45 89

8 Intervention Neuroradiology 11 15

9 Mental disorders 7 7

10 Neonatology 9 10

11 Neurosurgery 33 65

12 Obstetrics & Gynaecology 48 76

13 Oncology (Medicine)

14 Oncology (Surgery) 80 540

15 Oncology (Radiation)

16 Ophthalmology 20 51

17 Oral & Maxillofacial Surgery 8 15

18 Orthopaedics 52 137

19 Paediatric Medicine 19 31

20 Paediatric Surgery 17 35

21 Plastic & Reconstructive Surgery 12 22

22 Polytrauma 11 20

23 Urology 72 128

24 Infectious diseases 2 4

Total 625 1572

16
13. PILOT STUDIES
Pilots were initiated in some States (Table-4) to roll out During the orientation session, feedback of States and
the STGs and have first-hand feedback from the States hospitals were taken and were considered for further
on their acceptability and any suggestions on the initia- development of STGs. States were encouraged to share
tive. Initially, abuse prone packages were oriented to the continuous feedback on the STGs. Subsequently, the
teams. For the pilot the pre-final version was considered release of STGs was initiated with the first batch released
to receive State feedback. Capacity building and pilot of on 15th August 2020.
the STGs as given in table-4 were conducted.

Table 4: Summary of pilot testing

PILOTS INITIATED STATUS STATE

Cataract Pilot completed Assam

Haemodialysis / peritoneal dialysis Pilot completed Manipur

Coronary artery bypass grafting (CABG) Pilot completed Kerala

& Percutaneous transluminal coronary
angioplasty (PTCA)

Respiratory failure due to any cause Pilot completed Haryana

Haemodialysis / peritoneal dialysis Pilot completed Andhra Pradesh

Feedback from clinicians on overview Session conducted Chandigarh

of Standard Treatment Guidelines
and Haemodialysis package

Severe sepsis and Septic shock Suspended due to lockdown Punjab

Acute exacerbation of Chronic Obstructive Suspended due to lockdown Tripura

Pulmonary Disease (COPD)

13.1. Training done with States The orientation was carried out pan-India and had an
encouraging feedback. Orientation and training of
As a constructive step forward, training sessions were States/ UTs/ EHCPs were undertaken before the launch
conducted during the piloting phase which gave better and is a continuing exercise. For continuous training
insight for operationalization of the roll out. The training and updates for the States, presentations, online
module included orientation about the STGs, its training videos, Frequently Asked Questions (FAQs),
significance and how to process them. Teams across user manuals, and modules were developed
India were given instructions about how to upload files & and are available on the AB PM-JAY
related data, other requirements. website https://pmjay.gov.in/standard_treatment_guidelines
under a separate heading of STGs.

17
 Photograph 1: Extensive training sessions during piloting stage

14. PUBLISH AND DISSEMINATE

As planned, an official launch was done on 15th August 2020 by CEO, NHA, wherein the first batch of 10 STGs was
launched and rolled out nationwide.

Photograph 2: Virtual Official Launch of STGs by Dr. Indu Bhushan, Former CEO, NHA

18
 Figure 10: Snapshot of STG portal on AB PM-JAY website

Post launch feedback sessions were conducted with the take feedback from the States during field visit such as
States of Kerala, Jharkhand, Gujarat. NHA continued to Assam, Bihar, Tamil Nadu, Jharkhand, etc. in a structured
format as given in figure 11.

Photograph 3: Post launch Kerala Feedback

19
 Figure 11: Captured feedback from the States

After the successful launch and roll out of the STGs of AB PM-JAY States, prior to the launch of Oncology STGs.
various specialties, parallelly, an exclusive training A detailed process flow of Oncology STGs was
session in collaboration with the NCG was undertaken demonstrated as integrated in the IT platform through a
for all empaneled Oncology Specialty hospitals in the training module and the SHAs along with their teams
were also walked through the STG dashboard.

Photograph 4: An orientation and interaction session with AB PM-JAY

empaneled hospitals by the NHA and NCG representatives

20
15. MONITORING AND ANALYSIS
NHA plans to continuously monitor the adherence to teams was conducted online before the dashboard was
these guidelines through data analytics and artificial made live in December 2020.
intelligence tools. STG dashboard was developed for
Moving forward, the States using their own IT software
overviewing the utilization of packages for which STG
(some of the Brown field States) have been requested to
had been launched, highlighting areas of further
have the STGs integrated in their State specific IT system
analysis and monitoring. With the objective of
to have uniform implementation across the country. STG
monitoring the level of compliance, improvement in
dashboard is open to States for continuous
quality of mandatory documents, areas that need
self-monitoring at their level. NAFU team also utilises the
trainings, inputs from M&E team, NAFU team and IT
inputs from this dashboard as triggers to monitor flagged
team were taken. M&E team helped in finalizing the
cases by either desk audit/field audit. The idea is to
design and data points to monitor on the dashboard.
infuse not only efficient adoption of STGs but also to set
Currently, the dashboard shows data only for States that
exemplary patterns for inclusion of modern technologies
use AB PM-JAY IT system and the packages in which STG
(IT platform for recording and monitoring, Artificial
have been launched. The SHAs have also been given
Intelligence (AI) /Machine Learning (ML)) for delivering
access to this dashboard through their State specific
better quality health care and providing better insights to
dashboard IDs. An orientation training of SHAs and their
policy recommendations.

Figure 12: Overview of STG dashboard

21
15.1. STG dashboard- Key analytics • Responses with deviations provides visibility into the
• Overall summary page will depict monitoring the reasons for which there are deviations. Analysis of
trends in utilization, level of compliance at responses help in realizing the areas of training
State/user level, and the reasons for deviation from needs or relaxation of mandatory document based on
the expected answer. level of care. It will also help in identifying gaps in
• Treatment summary page of the dashboard will help package design, renaming, and infrastructural
the users to monitor the trends in utilization across challenges highlighted by respondents in case of
state/district, specialty/procedure, and hospitals. deviating from the expected answer
• Response Summary page of the dashboard helps
users in monitoring the level of compliance by This data will be utilized to undertake impact evaluation
states/hospitals/PPDs/CPDs. It does so by studies on the use of STGs for certain packages in
highlighting the highest deviation from the expected selected States/Districts and as evidence/inputs for future
response to the questions in guidance documents. policy decisions.
Deviation refers to the response which is different
than the specified answer to each question.

16. REVISE AND UPDATE

To keep abreast with the revision and rationalization of continuous process. STGs should be updated regularly to
AB PM-JAY Health Benefit Packages and the changes in reflect changes in accepted treatment strategies. If a
treatment/clinical recommendations, it is imperative that regular schedule for updating the STGs is not used, they
Standard treatment guideline development remains a might quickly lose their credibility.

Figure 13: Devised plan for STGs regular review and update

22
16.1. Implementation/ compliance monitoring
• Other options for cardiology/CTVS/ on cology
• The compliance monitoring of STGs is open to monitoring are also being planned in consonance
States/UTs through STG dashboard. with the discussion with certain volunteering
• NAFU would monitor flagged cases-desk audit/ field institutions/organizations of National repute
audit in order to assess the efficacy. especially using recent technological capabilities
such as Artificial Intelligence / Machine Learning, etc.

17. CHALLENGES AND LESSONS LEARNT

Especially during the current pandemic and due
17.1. Challenges to their engagement in additional tasks
/responsibilities, the feedback from experts took a lot
1. Limited availability of MoH&FW & DHR-ICMR of time for review and finalization of the documents.
reference documents Specialty prioritization had to be done based on
ICMR had recently released only 53 Standard availability of experts. Online discussions and
Treatment Workflows (STWs). Similarly, limited personal follow-up were also done to ensure speedy
guidelines were available under Clinical review by experts.
establishment act/ MoH&FW/state guidelines that
could be mapped with AB PM-JAY packages. Some 4. State wise auto-approved and government reserved
of them were old and not updated. Thus, publicly packages
available information/ protocols/ guidelines in Many States have different packages as
many national and international journals were also auto-approved and government reserved in contrast
referred for getting relevant information and to the national master. The STGs for these States had
ensuring updated guidelines are shared with experts to be integrated in IT system accordingly.
for their review and approval.
5. Pilots couldn’t be completed due to limitation on
2. Disease/ Diagnosis to procedure mapping travel due to pandemic
Most of the STWs/ clinical protocols of ICMR / Pilots & orientation were conducted in 6 States/UTs
MoH&FW/ NCG were disease/ diagnosis based. only-Assam, Manipur, Kerala, Haryana, Andhra
These had to be mapped with the procedures under Pradesh and Chandigarh. Rest of the planned pilots
AB PM-JAY. Many a times, for developing one STG, had to be aborted due to the pandemic.
multiple procedures and multiple disease-based
guidelines had to be mapped. 6. Limited implementation in States using their own IT
system
3. Non availability of many experts for timely feedback Some States are still using their State specific IT
especially during pandemic platform which limits the utilization of integrated
Most of the experts are nationally / internationally STGs in these States except for portability cases. A
acclaimed clinicians from some of the most reputed separate orientation was held, and the IT documents
medical hospitals and colleges in the country. required for customization were shared and followed
up by sending communications to these States to
integrate at the earliest.

23
7. Initial plan for 30 abuse prone and 100 most 2. Only most essential mandatory documents to be
utilized procedures was scaled up to all packages included for public hospitals
Development of STGs was conceptualized with an Some relaxation has been given to public hospitals
intent to develop the guidelines for only 30 most for mandatory documents for each procedure
abuse prone packages and 100 most utilized considering the limited resources available and
procedures. However, this was later extended to all patient load in these hospitals at the time of
packages under HBP2.0 and corresponding HBP1.0 pre-authorization. For private hospitals, mandatory
packages. The sudden increase in the requirement documents have been kept stringent to prevent fraud
of STGs for all procedures was coupled with limited and ensure quality care is given to the beneficiaries.
dedicated human resource for undertaking this task
for development, review and integration in IT for 3. Interlinkages of different IT modules (TMS with HEM)
which the team was later expanded. Interlinkages within the AB PM-JAY IT modules- TMS
and HEM are being worked out to ensure that the
8. Packages for most of the specialties were packages are booked and carried out in the hospitals
non-rationalized having minimum required infrastructure and by
Many of the specialties where the packages were doctors having minimum required qualifications.
not rationalized in HBP2.0 and were adopted as it is
at HBP1.0 rates including duplicacy in some 4. Developing FAQs, online training sessions and
packages across specialties. As a result of this some modules for States
of the specialized mandatory investigations required Due to the requirements of continuous capacity
could not be justified in the existing packages rates. building of hospitals/processing teams due to turn
While making STGs it was observed that, the over of staff in each State/ district, online training
non-rationalized packages of HBP 1.0 duplicating videos and modules have been developed for
especially across specialties also had different rates. Training of Trainers (ToTs) for States and hospitals. All
This also led to issues in mapping procedures as queries received during online orientation have been
well. These will be addressed in the next revision of translated to Frequently asked questions (FAQs)
health benefit packages 3 (HBP3.0). Many States are which are readily available on the AB PM-JAY
still transitioning to HBP2.0 and STGs had to be website. With a view to ensure quality care for
mapped with non-rationalized packages of HBP1.0. COVID-19 testing & treatment, immediate
development of Standard Treatment Guidelines for
these packages has also been done.
17.2. Lessons learnt
5. Comprehensive rationalisation of all health benefit
1. Customisation of the available guidelines to match packages
the available on-ground resources Given the feedback from experts and other
Many guidelines referred for developing STGs had stakeholders while developing the STGs, a process to
limited information pertaining to aspects like rationalize the health benefit packages has been
minimum infrastructure and qualifications of the initiated.
treating doctors. Also, at times these were too ideal,
which had to be matched with the on-field
availability of the resources while striking a
balancing between essential and ideal.

24
 18. FUTURE VISION AND ROADMAP

The teams involved in formulating comprehensive STGs This is indeed an ambitious venture under AB PM-JAY and
understand the necessity of the programme not as a concerted efforts can make it successful for better
one-time effort but a continuous process. With this healthcare delivery and attain global standardisation.
objective, empanelment of hospitals (Hospital
empanelment module (HEM 2.0)) which would be 18.1. Way Forward
empowered to synchronise with the STGs has already The trajectory ahead lies to complete integration and
begun. The empanelment criteria have been drawn from release of remaining STGs. It will be imperative to have
the guidance documents and the minimum requirements periodic orientation and training in States/UTs/EHCPs.
for hospitals to get into this criterion is formulated. Systematic review of feedback from States/ hospitals/
TPAs & ISA (through States) will go a long way for
Based on the inputs received from Experts and States strengthening of STG implementation. There is also a
(SHAs) an interim revision has been done in HBP 2.0 with necessity of monitoring adherence and conducting
the addition of a few more packages (now termed as HBP impact evaluation to these guidelines through data
2.1) which is in the process of being integrated so as to analytics entailing IT platforms on certain specific pack-
include new packages and procedures for common ages in selected states. This will help modifications and
diseases. After consulting speciality experts, the updating of the STG development process in the
packages would be finalized and drafted accordingly due course.
and STGs for the same would be developed.

19. REFERENCES

1. Management Sciences for Health and World Health 5. https://www.ahrq.gov/research/findings/

Organization. 2007. Drug and Therapeutics final-reports/prospectscare/prospects1.html
Committee Training Course. Submitted to the U.S. 6. Sharma S, Sethi GR, Gupta U, Chaudhury RR.
Agency for International Development by the Rational Barriers and facilitators to development of standard
Pharmaceutical Management Plus Program. Arlington, treatment guidelines in India. WHO South East Asia
VA: Management Sciences for Health. J Public Health. 2015 Jan-Jun;4(1):86-91. doi:
2. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw 10.4103/2224-3151.206626. PMID: 28607279.
J. Clinical guidelines: potential benefits, limitations, 7. Mehndiratta A, Sharma S, Gupta NP, Sankar MJ,
and harms of clinical guidelines. BMJ. Cluzeau F. Adapting clinical guidelines in India-a
1999;318(7182):527-530. pragmatic approach. BMJ. 2017;359:j5147.
doi:10.1136/bmj.318.7182.527 Published 2017 Nov 17. doi:10.1136/bmj.j5147
3. Polin RA, Lorenz JM. Value and limitations of clinical 8. https://stw.icmr.org.in/
practice guidelines in neonatology. Semin Fetal
Neonatal Med. 2015 Dec;20(6):416-23. doi: 19.1. Link to STGs:
10.1016/j.siny.2015.09.004. Epub 2015 Sep 26. https://pmjay.gov.in/resources/documents or
PMID: 26412690. https://pmjay.gov.in/standard_treatment_guidelines
4. Koli PG, Kshirsagar NA, Shetty YC, Mehta D, Mittal Y, Please share your queries at : stg.hnqa@nha.gov.in
Parmar U. A systematic review of standard treatment
guidelines in India. Indian J Med Res.
2019;149(6):715-729.doi:10.4103/ijmr.IJMR_902_17

25
20. ANNEXURES
Annexure 1: Top 50 abuse prone & most utilised packages taken up for implementation of initial 30
Standard Guidance documents

S. NO. PACKAGE/ PROCEDURE SPECIALTY HBP 2.0 PACKAGES

COVERED

1 Cataract Ophthalmology 2
2 Iris Prolapse repair, Secondary Intraocular Lens (IOL), Ophthalmology 4
Endophthalmitis, Scleral-Fixated IOL (SFIOL)
3 Acute exacerbation of COPD General Medicine 1
4 Hysterectomy OBS & GYN 6
5 Caesarean Hysterectomy OBS & GYN 1
6 Respiratory failure due to any cause General Medicine 1
7 PTCA Cardiology 1
8 Systemic Thrombolysis Cardiology 1
9 CABG CTVS 1
10 Low cardiac output Intra-aortic Balloon Pump (IABP) CTVS 1
insertion post-operatively
11 Acute glomerulonephritis General Medicine 1
12 Urinary Tract Infection General Medicine 1
13 Asthma General Medicine 2
14 Acute severe malnutrition General Medicine 1
15 D&C (Dilatation & curettage) OBS & GYN 1
16 Polypectomy OBS & GYN 2
17 Epistaxis treatment - packing ENT 1
18 Atrial Fibrillation General Medicine 1
19 Hemodialysis/ peritoneal dialysis General Medicine/ nephrology 3
20 Emergency management of Ureteric Stones Urology 1
21 Epilepsy General medicine/ neurology 2
22 Stroke General medicine/ neurology 4
23 Pneumonia General Medicine 1
24 Severe pneumonia General Medicine 1
25 Acute bronchitis General Medicine 1
26 Dengue General Medicine 3
27 Severe sepsis General Medicine 2
28 Acute encephalitis syndrome General medicine/ neurology 1
29 Diarrhoea General Medicine 2
30 Total Knee Replacement Orthopaedics 2

26
Annexure 2: Agenda for the State Workshop

State: Manipur
Location: Imphal, Manipur
Day: 3rd - 4th January 2020
Who all should participate: State Staff from SHA, IT team, ISA (PPD, CPD), Staff (PMAM, Medco, AB PM-JAY nodal staff)
from 2 Hospitals (preferably 1 private and 1 public, selected for undertaking pilot of Dialysis Standard Treatment
Guidelines (STG)).

S. NO. TOPIC TIME SESSION

CONDUCTED BY
DAY 1: 3RD JANUARY 2020

1 Health Benefit Packages

HBP 2.0 orientation 9:30 AM -1:00 PM Dr Sudha
Discussion on Rationalising health benefit packages in Manipur

LUNCH 1:00 PM-2:00 PM

2. STG orientation
Presentation / brief overview on the STGs
Orientation on ‘Dialysis STG’ Dr Sudha &
2:00 PM – 4:00 PM
Discussion on the IT document of Dialysis STG STG team
Demo of the IT module for Dialysis STG
Discussion on STG

3. Presentation & Discussion by State SHA on

4:00 PM – 5:00 PM SHA
implementation of scheme in Manipur- (Current status,
Challenges and way forward)

DAY 2: 4TH JANUARY 2020

1. Presentation & Discussion on AB PM-JAY Quality

Certification Guidelines for Achieving Bronze/Silver/Gold
Certification (Online Registration Process for AB PM JAY
9:30 AM - 11.30 AM Dr Rimy Khurana
Certification)

2. Hospital Empanelment online certification process

27
Annexure 3: Development of Frequently Asked Questions (FAQs) for STGs
Based on the pilots, trainings and feedback received from the States, FAQs were developed and published on the website.

5. What is the structure of the AB PM-JAY STG

21. GENERAL FAQS
document?
AB PM-JAY STG comprise of 4 parts:
1. What are AB PM-JAY STGs?
A) Introductory part:
Standard Treatment Guidelines (STGs) are being
a. Package & procedure description
introduced for each health condition/procedure
b. Min. qualifications of treating doctor
under the Ayushman Bharat Pradhan Mantri Jan
c. Empanelment criteria
Arogya Yojana Health Benefit Packages. AB PM-JAY
d. Disclaimer
has customized the available clinical protocols/-
B) Part I: Guidelines for Clinical and
Standard treatment workflows from Department of
Healthcare providers
Health Research/Indian council of Medical research
a. Objectives
(DHR/ICMR), National Cancer Grid, State &
b. Clinical key pointers
MoH&FW guidelines, professional specialty associa-
c. Standard treatment workflow
tions guidelines, International guidelines e.g. WHO,
d. Mandatory documents for EHCPs
World Bank, relevant specialty journal publications.
(pre-auth & claims)
C) Part II: Guidelines for processing team
2. What is the alternate name given to these
a. Guidance document for processing team
documents?
(PPD&CPD)
These are also called as Guidance documents for
D) Part III: Guidelines for IT
AB PM-JAY packages.
a. Alert questions to be answered by
EHCPs/Medco
3. Who all need to refer to these guidelines?
These are advisory guidelines primarily for the
6. Where are these guidelines available?
empaneled hospitals, Medical coordinators
The released guidelines are available on AB PM-JAY
(MEDCO), Pre-auth panel doctor (PPD), Claims
website at link: https://pmjay.gov.in/standard_treat-
Panel doctor (CPD), audit teams to give them an
ment_guidelines or https://pmjay.gov.in/resources/-
idea on package specific key clinical pointers, man-
documents (under Standard Treatment Guidelines)
datory documents, questionnaire in the form of a
check list.
7. Can the guidelines be downloaded?
Yes the guidelines can be downloaded from
4. What is the purpose of these guidelines?
AB PM-JAY website at the following link: https://pm-
These guidance documents are prepared with the
j a y. g o v. i n / s t a n d a r d _ t r e a t m e n t _ g u i d e l i n e s
following purpose:
or https://pmjay.gov.in/resources/documents (under
a. Aid in processing of pre-authorization & claims
Standard Treatment Guidelines)
document
b. Prevention & control of fraud and abuse
8. How many STGs will be released & integrated?
c. Provide quality care to the patients
The STGs for 1572 AB PM-JAY HBP2.0 packages and
d. Guidance tool for treating doctors, empaneled
corresponding HBP1.0 packages have been devel-
health care providers (EHCPs), Third Party Adminis-
oped and are being integrated and released in
trators (TPAs)/Implementing support agencies (ISAs),
batches. The first batch of 10 STGs was made live on
State health agencies (SHAs) and medical auditors
15th August 2020 in AB PM-JAY IT system.

28
9. Is it mandatory to follow these guidelines? 12. Will the deployment of STGs have an impact on
This document has been prepared for guidance of a States policy with the insurance company?
MEDCO, PROCESSING TEAM and TRANSACTION STGs should not have any impact on the policy with
MANAGEMENT SYSTEM of AB PM-JAY for the the insurance company, since the package rates are
Pre-auth and claims of all AB PM-JAY packages. The not impacted. In fact, it intends to help prevent fraud
hospitals can also refer to this document so that they and abuse, improve quality of care of the patients
may have the insight on how the pre-auth and and reduce the number of queries raised to the
claims will be processed. However, this document hospitals.
doesn’t provide any guidance on clinical and
therapeutic management of patient. In that respect 13. Some State sponsored schemes are
the hospitals and physicians may refer to other implementing Standard treatment protocols?
relevant material as per the extant professional Then what is new in AB PM-JAY STGs?
norms. The decision for admission, discharge, Yes, some State sponsored schemes are
approving/ disapproving the case will depend on implementing Standard Treatment protocols.
the decision of the treating doctor, the hospital and However, all those are manually being referred so
the processing team. Ultimately the professional far. Under AB PM-JAY, STGs have been integrated in
judgment of the healthcare professionals should be the IT system in the form of mandatory documents,
used. Deviations from the guidelines may be questionnaire. Minimum qualifications of the
monitored and enquired into by experts to check if treating doctor and minimum infrastructure
these were justified or not. requirement have also been clarified which will be
linked to the empanelment module soon. Our
10. Are there any training documents/ manual guidelines also have drawn upon the existing state
available on use of STGs? guidelines wherever available.
Yes, the STG presentation and STG IT training
manual is available on AB PM-JAY website link: 14. Are these STGs also applicable to State schemes
https://pmjay.gov.in/standard_treatment_guidelines. also?
Training videos and online training module have States can consider adopting it for their other state
also been developed and are available at the AB schemes as well.
PM- JAY website on the above link.
15. Will the STGs be applicable to government
11. What will be the use/ benefits of these STGs? reserved packages also?
a. It will help standardize the documents being Yes. STGs will be applicable to all government
submitted by the hospitals reserved packages also.
b. Lead to reduction in number of queries and
repeat transactions
c. Decrease unnecessary delay in processing of
pre-auth and claims and aid timely payment to
hospitals
d. Bring in more accountability at all
levels- MEDCO, PPD, CPD
e. Improve quality of care by avoiding unnecessary
treatment with focus on appropriateness of care
f. Promote choosing the relevant package as per
the patient requirement
g. Prevent fraud and abuse

29
21.1. Process specific FAQs 6. Already some questions are asked at PPD/ CPD
level? How is STG questionnaire different from
1. What are the key changes in TMS workflow those existing?
with the introduction of STGs? The questions that were asked so far at the PPD/
a. The guidelines are available for download CPD level were medical audit questions by the
b. The mandatory documents have been auditors. The STG questionnaires are for MEDCO,
rationalized PPD and CPD and are integrated in the IT system.
c. A mandatory checklist (in the form of a The response to these questions may be monitored
questionnaire) has been included by the auditors.

2. Is it mandatory to fill the questionnaire or Can 7. Will the STGs enable introduction of auto query
MEDCO/ PPD/ CPD proceed the case in TMS feature for PPD/ CPD?
without filling the questionnaire? No. Currently the auto query feature is not enabled
Filling the questionnaire in the TMS is a mandatory for PPD/ CPD with the introduction of STG.
step for raising a pre-auth, initiating claim and
processing a pre-auth and claim for both public and 8. How does one confirm that they have opened/
private hospitals. referred/ read the STG?
Currently this feature is not enabled. We hope that
3. What happens if the answer filled is opposite the pop up will remind the concerned to open and
to the expected answer? Will it lead to rejection refer the STGs as this will come for each case of the
of the case? specific package whenever it is booked/processed.
If the answer filled is opposite to the expected
answer it will not lead to rejection but the PPD/ CPD 9. Can the SHA decide to make certain mandatory
should raise a query to the MEDCO in case of any documents non-mandatory?
concerns and seek clarification. In case SHA decides to make any document
non-mandatory it must intimate, giving justification
4. Are the mandatory documents same for public and take concurrence of NHA. (email:
and private hospitals? stg.hnqa@nha.gov.in)
Yes. For public hospitals, for certain packages,
requirement of mandatory documents has been 10. Can a State/ UT opt for using STGs for a few
reduced. In case SHA decides to make any packages only as per the requirement of the
document non-mandatory it must intimate, giving State/ UT?
justification and take concurrence of NHA. No. The STGs for all packages will be integrated in
the IT system in a phased manner. States cannot pick
5. Will the questionnaire differ with each and choose only for specific packages.
procedure?
Yes, the questionnaire is different for each 11. Can a State/ UT do away with STGs for
procedure. Few questions may be common to all, government reserved packages?
but most are customized as per the requirement of No. We are moving towards quality of care across
the procedure. both public and private hospitals and would be
For e.g. Barcode for implant is asked only in those working towards standardized approaches. The
cases where implant has been used. Similarly, public hospitals are also paid at par in most states so
specific investigations are asked for each procedure. accountability to public funds is uniform across type
of hospitals to ensure quality of care to beneficiaries.

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 will also be done at the national level by NHA and
12. Can the State/ UT start to implement STGs with
necessary directions to concerned states/hospitals
only private hospitals?
will also be issued as and when any major deviations
Yes if absolutely needed for a short time-frame but
are noticed.
eventually it has to be extended to all hospitals, but
the same has to be officially conveyed to NHA with
16. Mandatory documents were required earlier
justification- e-mail: stg.hnqa@nha.gov.in and
also. Then what is the change after the
obtain concurrence.
introduction of STGs?
Mandatory documents have been rationalized with
13. Some States have changed the mandatory
the introduction of STGs.
document requirement for certain packages.
What about uploading mandatory documents
17. Can the PPD/ CPD reject a case if the mandatory
for such packages in these States?
document hasn’t been uploaded/ a wrong
document has been uploaded?
The SHA may share details of such packages
PPD/ CPD must raise a query in such a case and
through e-mail: stg.hnqa@nha.gov.in and the
clarify from the hospital and then follow the rejection
reason for their decision to NHA for concurrence.
process as established by the States/ National Health
However, the change will only be made at the State
authority under Claims Adjudication. The claims
level if NHA approves and not at the national level.
adjudication manual is available at
For portability cases the national mandatory
https://pmjay.gov.in/resources/documents (under
documents will still continue to be applicable.
Claim Adjudication)

14. Are these STGs also applicable to those States

18. Will there be an autogenerated standard
who are using their own IT software (other than
remark of the case being rejected if the
NTMS)?
relevant mandatory document is not uploaded?
The adoption of STGs by all States/UTs is
No such remark will be generated. The PPD/ CPD
mandatory. NHA recommends that all SHAs migrate
must raise a query in such a case and clarify from the
to IT system developed and maintained by the NHA.
hospital. If even after such query, the document is
Till this is done, the States which are using their own
not submitted in 7 days, the claim may be rejected.
IT software are encouraged to adopt these in their
system as well, at the earliest. NHA has initiated
time-bound facilitation of this process. However, for
portability cases for specific packages it will be
applicable as and when they are integrated
in NTMS.

15. What are the implications for non-compliance?

It is mandatory to upload the mandatory documents
and fill the questionnaire. The steps have to be
followed to initiate the pre-auth, discharge or
process the case. It will lead to accountability on the
person filling the questionnaire. If the answer filled
in is opposite of the expected answer without due
justification may lead to raising a query by the PPD/
CPD. The monitoring of adherence to STGs

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19. What is the significance of questionnaire tab? 22. Are STGs available for surgical complications also?
Selecting the questionnaire tab will open the STGs will be made available only for those surgical
questionnaire list. It is a check list for hospitals, PPD complication package that are available in HBP2.0
and CPD to confirm that all required documents and corresponding HBP1.0 packages. For e.g.
have been uploaded and checked for necessary ‘Excessive bleeding requiring re-exploration’, etc.
details.
23. How will the PPD questions appear in auto
20. Will there be a warning sign/ pop-up alert for approved cases?
MEDCO at the time of blocking any package if For auto approved cases, the PPD questions will
there is any mismatch between the package appear in CPD questionnaire.
booked and age/ gender of the patient?
This feature is currently available for gender in TMS 24. Government reserved packages and auto
for MEDCO as well as PPD & CPD. Further, certain approved packages may vary from State to
questions for some packages have also been State. What about such cases?
included in specific STGs to verify this mismatch. In such cases the STGs will be deployed as per the
State specific government reserved and auto
21. Will the STGs and its questionnaire be approved packages.
applicable for Bulk approval at SHA level as
well?
This is not applicable currently for bulk approval by
SHA. The SHA may use the STGs for further
guidance in individual cases.

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