Ayushman Bharat yojana Beneficiary Identification Process
Guidelines for Pradhan Mantri Rashtriya Swasthya Suraksha Mission (PMRSSM)
1. Guidelines on Process of Beneficiary Identification
1.1. Brief Process Flow
The core principle for finalising the operational guidelines for proposed PMRSSM is to construct a broad framework as guiding posts for simplifying the implementation of the Mission under the ambit of the policy and the technology while providing requisite flexibility to the States to optimally chalk out the activities related to implementation in light of the peculiarities of their own State/UT, as ownership of implementation of scheme lies with them.
A. PMRSSM will target about 10.74 crore poor, deprived rural families and identified occupational category of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data, both rural and urban. Additionally, all such enrolled families under RSBY that do not feature in the targeted groups as per SECC data will be included as well.
B. States covering a much larger population than the PMRSSM beneficiary list will need to
i) Provide a declaration that their eligibility criteria cover PMRSSM beneficiaries
ii) Setup a process to ensure any family in PMRSSM list who may be missed under the State’s criteria is covered when they seek care.
iii) Beneficiaries obtaining treatment should be tagged if they are PMRSSM beneficiaries. Reports to MoHFW/ NHA will need to be provided for these beneficiaries
iv) Link all PMRSSM beneficiaries with the State’s Scheme ID and Aadhaar in a defined time period
C. State/UT will be responsible for carrying out Information, Education and Communication (IEC) activities amongst targeted families such that they are aware of their entitlement, benefit cover, empanelled hospitals and process to avail the services under PMRSSM. This will include leveraging village health and nutrition days, making available beneficiary family list at Panchayat office, visit of ASHA workers to each target family and educating them about the scheme, Mass media, etc among other activities. The following 2 IEC activities are designed to aid in Beneficiary Identification
i) PMRSSM Additional Data Collection drive at Gram Sabha’s across India will take place on 30th April. MoHFW in collaboration with Ministry of Rural Development (MoRD) will drive collection of Ration Card, Mobile Number for each PMRSSM household.
ii) Government of India will send a personalised letter via mass mail to each targeted family through postal department in states launching PMRSSM. This letter will include details about the scheme, toll free helpline number and family details and their ID under PMRSSM
iii) States which are primarily covering PMRSSM beneficiaries are encouraged to create multiple service locations where beneficiaries can check if they are covered. These include
Contact points or kiosks set up at CSCs, PHCs, Gram Panchayat, etc
Empaneled Hospital
Self-check via mobile or web
Or any other contact point as deemed fit by States
D. Beneficiary identification will include the following broad steps:
i) The operator searches through the PMRSSM list to determine if the person is covered.
ii) Search can be performed by Name and Location, Ration Card No or Mobile number (collected during data drive) or ID printed on the letter sent to family or RSBY URN
iii) If the beneficiary’s name is found in the PMRSSM list, Aadhaar (or an alternative government ID) and Ration Card (or an alternative family ID) is collected against the Name / Family.
iv) The system determines a confidence score for the link based on how close the name / location / family members between the PMRSSM record and documents is provided.
v) The operator sends the linked record for approval to the Insurance company / Trust
vi) If the confidence score is high, the operator can immediately issue the e-Card and admit the patient for treatment. Otherwise, the patient must be advised to wait for approval from the insurance company/ trust
vii) The insurance company / Trust will setup a Beneficiary approval team that works on fixed service level agreements on turnaround time. The PMRSSM details and the information from the ID is presented to the verifier. The insurance company / Trust can either approve or recommend a case for rejection with reason.
viii) All cases recommended for rejection will be scrutinised by a State team that works on fixed service level agreements on turnaround time. The state team will either accept rejection or approve with reason.
ix) The e-card will be printed with the unique ID under PMRSSM and handed over to the beneficiary to serve as a proof for verification for future reference.
The beneficiary will also be provided with a booklet/ pamphlet with details about PMRSSM and process for availing services.
Presentation of this e-card (appendix 2: draft sample design) will not be mandatory for availing services. However, the e-card may serve as a tool for reinforcement of entitlement to the beneficiary and faster registration process at the hospital when needed.
E. Addition of new family members will be allowed. This requires at least one other family member has been approved by the Insurance Company/Trust. Proof of being part of the same family is required in the form of
i) Name of the new member is in the family ration card or State defined family card
ii) A marriage certificate to a family member is available
iii) A birth certificate to a family member is available.
1.2. Detailed Steps for Beneficiary Identification and Issuance of e-card
PMRSSM will target about 10.74 crore poor, deprived rural families and identified occupational category of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data, both rural and urban. Additionally, all such enrolled families under RSBY that do not feature in the targeted groups as per SECC data will be included as well.
The main steps for the above exercise are as follows:
A. Preparatory Activities for State/ UT’s:
Responsibility of – State Government
Timeline – within a period of 15 days, after receiving the approval from MoHFW/NHA, the State/UT may complete the preparatory activities to initiate the implementation and beneficiary identification process.
The State will need to:
i) Ensure the availability of requisite hardware, software and allied infrastructure required for beneficiary identification and PMRSSM e-card printing. Beneficiary Identification Software/ Application/ platform will be provided free of cost by MoHFW/NHA. Specifications for these will be provided by MoHFW/NHA.
ii) Availability of printed booklets, in abundant quantities at each Contact point, which will be given to beneficiaries along with the PMRSSM e-cards after verification. The booklet/pamphlet shall provide the following details:
Details about the PMRSSM benefits
Process of taking the benefits under PMRSSM and policy period
List of the empanelled network hospitals in the district along with
address and contact details (if available)
The names and details of the key contact person/persons in the
district
Toll-free number of PMRSSM call centre (if available)
Details of DNO for any further contact
iii) State/State Health Agency (SHA) shall identify and set-up team(s) which shall have the capacities to handle hardware and basic software support, troubleshooting etc.
iv) Training of trainers for this purpose will be organised by MoHFW/NHA.
The State shall ensure availability of above, in order to carry out all the activities laid down
in this guideline.
B. Preparation of PMRSSM target data
Responsibility of – MoHFW
Timeline – Preparation of SECC data by 15th March
MoHFW has decided to use latest Socio-Economic Caste Census (SECC) data as a
source/base data for validation of beneficiary families under the PMRSSM. Based on SECC
data, number of families in each State, that will be eligible for central subsidy under the
PMRSSM, will be identified. The categories in rural and urban that will be covered under
PMRSSM are given as follows:
For Rural
Total deprived Households targeted for PMRSSM who belong to one of the six deprivation criteria amongst D1, D2, D3, D4, D5 and D7:
Only one room with kucha walls and kucha roof (D1)
No adult member between age 16 to 59 (D2)
Female headed households with no adult male member between age 16 to 59 (D3)
Disabled member and no able-bodied adult member (D4)
SC/ST households (D5)
Landless households deriving major part of their income from manual casual labour
(D7)
Automatically included
Households without shelter
Destitute/ living on alms
Manual scavenger families
Primitive tribal groups
Legally released bonded labour
For Urban
Occupational Categories of Workers
Rag picker
Beggar
Domestic worker
Street vendor/ Cobbler/hawker / Other service provider working on streets
Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/
Coolie and another head-load worker
Sweeper/ Sanitation worker / Mali
Home-based worker/ Artisan/ Handicrafts worker / Tailor
Transport worker/ Driver/ Conductor/ Helper to drivers and conductors/ Cart
puller/ Rickshaw puller
Shop worker/ Assistant/ Peon in small establishment/ Helper/Delivery assistant /
Attendant/ Waiter
Electrician/ Mechanic/ Assembler/ Repair worker
Washer-man/ Chowkidar
The following activities will be carried out for identifying target families for PMRSSM:
i) PMRSSM data in defined format by applying inclusion and exclusion criteria shall be
prepared.
ii) Preparation of Rashtriya Swasthya Bima Yojana (RSBY) beneficiary family list (based on
existing RSBY enrolled families) for such families where premium has been paid by
Government of India and data finalized by MoHFW with inputs of States.
iii) AHL_HH_ID will be considered as Family ID for PMRSSM targeted families.
iv) Final data will be accessible in a secure manner to only authorised users who will be
allowed to access it online and use it for beneficiary verification.
Example:
A. State implementing RSBY –the scenario could be as follows:
Number of eligible families in SECC Data = 50 lakhs
Number of families currently enrolled in RSBY = 52 lakhs
Total Number of eligible families for PMRSSM = 52 lakhs
B. State/ UT not implementing RSBY – the scenario could be as follows:
Number of eligible families in SECC data = 50 lakhs
Total number of eligible families for PMRSSM = 50 lakhs
C. State implementing their own scheme – the scenario could be as follows:
Number of eligible families in SECC Data = 50 lakhs
Number of families currently covered in State Scheme = 75 lakhs
Total Number of eligible families for PMRSSM = 50 lakhs
C. Informing Beneficiaries on what to bring for Identification
Responsibility of – SHA
Timeline – Ongoing
The process requires that Beneficiaries bring
Aadhaar
Any other valid government id(s) decided by the State if they do not have an
Aadhaar
Ration Card or any other family id decided by the State.
All IEC activities (see detailed IEC guidelines) must work towards education of the above to
ensure it is easy for the beneficiaries to receive care.
D. Beneficiary identification Contact Points – Infrastructure and Locations
Any resident must be able to easily find out if they are covered under the scheme. This is
especially critical in States that are launching only on the basis of PMRSSM list (SECC +
RSBY). These states are encouraged to create a large number of resident contact points
where they can easily check if they are eligible and obtain a e-card.
The Beneficiary identification contact point will require
A computer with the latest browser
A QR code scanner
A document scanner to scan requisite documents
A printer to print the e-Card
A web camera for photos
Internet connectivity
Aadhaar registered device for fingerprint and iris biometrics (only at Hospital
Contact Points)
Only Hardware and software as prescribed by MoHFW/NHA shall only be used. Detailed
specifications will be provided in a separate document. Beneficiary identification will be
available as a web and mobile application. Availability as a mobile app will make it easy to
be deployed at larger number of contact points. The DNO shall be responsible for choosing
the locations for contact centres within each village/ward area that is easily accessible to a
maximum number of beneficiary families including the following:
CSC
PHCs
Gram Panchayat Office
Empanelled Hospital
Or any other contact point as deemed fit by States/UTs
Require hardware and software must be setup in these contact points which will be
authorized to perform Beneficiary identification and issue e-cards.
SHA/ District Nodal Agency will organize training sessions for the operators so that they are
trained in the Beneficiary identification, Aadhaar seeding and PMRSSM e-card printing
process. Operators are registered entities in the system. All beneficiary verification requests
are tagged to the operator that initiated the request. If the insurer (Insurance Company/
Trust) rejects multiple requests from a single operator – the system will bar the operator till
further training / remedial measures can be undertaken.
1.3. Process Flow Chart for Beneficiary Identification
1.4. Identity Document for a Family Members
Aadhaar will be primary identity document for a family member that has to be produced
under the PMRSSM scheme. When the beneficiary comes to a contact point, the QR code on
the Aadhaar card is scanned (or an e-KYC is performed) to capture all the details of the
Aadhaar. A demographic authentication is performed with UIDAI to ensure the information
captured is authentic. A live photograph of the member is taken to be printed on the e-card.
If the PMRSSM family member does not have an Aadhaar card and the contact point is a
location where no treatment is provided, the operator will inform the beneficiary that he is
eligible and can get treatment only once without an Aadhaar or an Aadhaar enrolment slip.
They may be requested to apply for an Aadhaar as quickly as possible. A list of the closest
Aadhaar enrolment centres is provided to the beneficiary
The PMRSSM family member does not have an Aadhaar card and the contact point is a
Hospital or place of treatment then
A. A signed declaration is taken from the Beneficiary that he does not possess an
Aadhaar card and understands he will need to produce an Aadhaar or an Aadhaar
enrolment slip prior to the next treatment
B. The beneficiary must produce an ID document from the list of approved ids by the
State
C. The operator captures the type of ID and the fields as printed on the ID including the
Name, Father’s Name (if available), Age, Gender and Address fields.
D. A scan of the ID produced is uploaded into the system for verification.
E. A photo of the beneficiary is taken
F. The information from this alternate ID is used instead of Aadhaar for matching
against the PMRSSM record.
1.5. Searching the PMRSSM Database
The PMRSSM database will be searched based on the information provided in the Member
Identity document. PMRSSM is based on SECC and it is likely that spellings for Name, Fathers
Name and even towns and villages will be different between the PMRSSM record and the
identity document. A beneficiary will be eligible for PMRSSM if the Name and Location
parameters in the beneficiary identity document can be regarded as similar to the Name
and Location parameters in the PMRSSM record.
The Search system automatically provides a confidence score between the two.
The Search system will provide multiple ways to find the PMRSSM beneficiary record. If
there are no results based on Name and Location, the operator should
A. Search by Ration Card and Mobile No (Information captured during the Additional
Data Collection Drive)
B. Search using the ID printed on the letter sent by post to Beneficiaries (AHL_HH_ID)
C. Reduce some of the parameters like Age, Gender, Sub district, etc and trial with
variation in the spelling of the Name if there are no matching results
D. Try adding the name of the father or family members if there are too many results.
The Search system will show the number of results matched if > 5. The operator is expected
to add more information to narrow results. The actual results will be displayed when the
number matched is 5 or less. The operator has to select the correct record from the list
shown.
1.6. Searching the PMRSSM Database for Valid RSBY Beneficiaries
The operator is unable to find the person using PMRSSM search using Name and other
methods described above, then he can search from the valid RSBY database. The RSBY URN
printed on the beneficiary card is used to perform the search. The system fetches the record
from the RSBY database. The operator is presented with the confidence score between the
Beneficiary Identity document and the RSBY record.
1.7. Linking Family Identification document with the PMRSSM Family
One or more Family Identity Cards can be linked with each PMRSSM Family. While Ration
cards will be the primary family document, States can define additional family documents
that can be used. SECC survey was conducted on the basis of households and there are
possibilities where the household could have multiple ration cards.
Linking a family identification document strengthens the beneficiary identification process
as we can create a confidence score based on the names in family identification document
and PMRSSM record.
Linking the family identification document will be mandatory ONLY if the same document
(Ration Card) is also the ID used by the state to cover a larger base. Operators are
encouraged to upload the family document if the name match confidence score is low but
they believe the 2 records are the same
Integration with an online family card database is recommended. In this scenario, the
operator will enter the Family ID No (Ration Card No) and will be able to fetch the names of
the family members from the online database.
If an integration is not possible, the operator will enter the names of the family members as
written in the ID card and upload a scan of the ID card for verification.
1.8. Approval by Insurance Company/Trust
The State can appoint either the Insurance company or Trust to perform the verification of
the data of identified beneficiaries. The team needs to work with a strong Service Level
Agreements (SLA) on turnaround time. Approvals are expected to be provided within 30
minutes back to the operator on a 24×7 basis.
The Approver is presented the Beneficiary Identity Document and the PMRSSM (or RSBY)
record side by side for validation along with the confidence score. The lowest confidence
score records are presented first.
If the operator has uploaded the Family Identity document it is also displayed along with the
Confidence Score.
The Approver has only 2 choices for each case – Approve or Recommend for Rejection with
Reason
The System maintains a track of which Operator is Approving / Recommending for
rejection. The Insurance Company/Trust can analyze the approval or rejection pattern of
each of the operators.
A. Acceptance of Rejection Request by State (applicable only in case of Insurance
Company mode of implementation)
The State should setup a team that reviews all the cases recommended for Rejection. The
team reviews the data provided and the reason it has been recommended for rejection. If
the State agrees with the Insurer it can reject the case.
If the State disagrees with the Insurer it can approve the case. The person in the state
making the decision is also tracked in the system. The State review role is also SLA based
and a turnaround is expected in 24 hours on working hour basis.
B. Addition of Family Members
The PMRSSM scheme allows addition of new family members if they became part of the
family either due to marriage or by birth. In order to add a family member, at least one of
the existing family members needs to be verified and the identity document used for the
verification must be Aadhaar.
To add the additional member the family must produce
– The name of the additional member in a State approved family document like
Ration Card OR
– A birth certificate linking the member to the family OR
– A marriage certificate linking the member to the family.
In order to add a family member, at least one of the existing family members needs to be
verified and the identity document used for the verification must be Aadhaar.
C. Monitoring of Beneficiary identification and e-card printing process
Responsibility of – State Government/ SHA
Timeline – Continuous
SG/ SHA will need to have very close monitoring of the process in order to ascertain
challenges, if any, being faced and resolution of the same. Monitoring of verification process
may be based on following parameters:
Number of contact points and manpower deployed/ Number and type of manpower
Time taken for issuance of e-card of each member
Percentage of families with at least one member having issued e-card out of total
eligible families in PMRSSM
Percentage of members issued e-cards out of total eligible members in PMRSSM
Percentage of families with at least one member verified out of total eligible families
in RSBY data (if applicable)
Percentage of members issued e-card out of total eligible members in RSBY data (if
applicable)
Percentage of total members where Aadhaar was available and captured and
percentage of members without Aadhaar number
Percentage of total members where mobile was available and captur
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