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1. As you are aware, in recent years there has been a sizeable increase in the ESI beneficiary base subsequent to the expansion of schemes across the country and efforts are constantly being made to develop/strengthen ESI health infrastructure facilities to match the ground needs. It is observed that in the present circumstances ESI beneficiaries may, at times, be required to travel long distances for availing medical benefits from health from ESI health facilities which are located at relativity for distance.
2. Accordingly, in order to hardship to such ESI beneficiaries in availing medical services and as a stop-gap arrangement till the time ESI healthcare delivery system comes up in the vicinity, ESI Corporation during its 183^rd meeting held on 07.12.2020 has granted approval for the following such ESI Beneficiaries to avail medical services directly from ESIC empanelled hospitals as per following operational guidelines:-

• ESI beneficiaries of those areas (newly as well as already implemented) where on ESIC/ESIS health care delivery facility i.e. hospital, dispensary, IMP, etc. exists within the radius of KMs of IPs residence, shall be eligible.
• ESI beneficiaries of such areas my approach nearest ESIC empanelled hospital with ESI card or print out of online Health Passbook or ePehchaan Letter “issued by the employer for availing the required medical consultation.
• Once the ESI beneficiary attends the empanelled hospital, the prima facie verification regarding the identity of the beneficiary in terms of genuineness shall be ascertained by the empanelled Hospital cross verifying with Aadhaar card or any Govt. issued photo I Card. Additionally, the eligibility shall be verified through the UTI application by feeding in the IP Numbers. UTI portal has been integrated with panchdeep Module of ESIC. This verification shall be done by authorized by empanelled hospital for such a purpose.
• Once the OPD consultation of the beneficiary is carried out, the empanelled hospital shall be uploading the photo of the IP / beneficiary and photocopy of the Aadhaar on the UTI portal along with the bill raised at the CGHS rate. Further, as and when Aadhaar is implemented, an Aadhaar based online verification system shall be devised and incorporated in the system.
• Such beneficiaries may seek reimbursement of purchased medicines prescribed during OPD consultation through the nearest DCBO or regional office where DCBO is not available. Further, an online system shall be developed in due course for the processing and settlement of reimbursement claims.
• All the guidelines, process validation related to rendering health service, and various health service definitions of ESIC shall be applicable to the empanelled hospital of such area.
• In case, the patient requires investigation/hospital admission, the empanelled hospital will be required to seek permission from the respective RD/SMO office. Such permission shall be obtained online 24 hours as per existing ESIC guidelines for direct admission in emergency conditions.

3. In view of the above, you are requested to take cognizance of the decision of ESI Corporation for compliance and implementation. The issue, if any, may be brought to the notice of this office for smooth implementation of the above decision.

Process steps on ESI beneficiaries seeking Medical services from Nearby ESIC empanelled hospitals directly without referral in case of non-availability of ESI healthcare facility within a radius of 10 KM of IPS Residence.

1. Steps: Such beneficiary reports at nearest ESIC empanelled hospital for availing medical service without a referral from ESI dispensary/IMP etc.
2. Steps: Cross-Verification regarding the genuineness of the identity by the authorized person of empanelled hospital with ESI card/ ePehchaan Letter/Health Passbook along with Aadhaar or any other Government.
3. Steps: Eligibility checked through the appropriate field of UTI module linked to ‘Panchdeep’ module of ESIC
4. Steps: Beneficiary provided with OPD Consultation by empanelled hospital
5. Steps: Photo and Aadhaar uploaded on UTI portal along with consultation bill following all UTI portal/ ESIC process validation
6. Steps: Reimbursement of prescribed medicines from nearest DCBO or Regional office if DCBO is not available on bill submission by IP
7. Steps: In case the patient requires investigation/ hospitalization, online permission to be obtained by empanelled hospital within 24 hours from the nearest ESIC approving authority as per existing ESIC guidelines for direct admission in an emergency.

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