This memorandum of understanding establishes an agreement between East West Assist TPA Pvt. Ltd., a third party administrator, and a hospital to provide medical services and cashless access to insurance clients. Key terms include East West Assist promoting the hospital as a preferred provider and facilitating cashless claims processing, while the hospital provides priority treatment and notifies East West Assist of admissions. The agreement is valid for three years and establishes procedures for authorization, billing, and dispute resolution under Indian law.
This memorandum of understanding establishes an agreement between East West Assist TPA Pvt. Ltd., a third party administrator, and a hospital to provide medical services and cashless access to insurance clients. Key terms include East West Assist promoting the hospital as a preferred provider and facilitating cashless claims processing, while the hospital provides priority treatment and notifies East West Assist of admissions. The agreement is valid for three years and establishes procedures for authorization, billing, and dispute resolution under Indian law.
This memorandum of understanding establishes an agreement between East West Assist TPA Pvt. Ltd., a third party administrator, and a hospital to provide medical services and cashless access to insurance clients. Key terms include East West Assist promoting the hospital as a preferred provider and facilitating cashless claims processing, while the hospital provides priority treatment and notifies East West Assist of admissions. The agreement is valid for three years and establishes procedures for authorization, billing, and dispute resolution under Indian law.
This memorandum of understanding establishes an agreement between East West Assist TPA Pvt. Ltd., a third party administrator, and a hospital to provide medical services and cashless access to insurance clients. Key terms include East West Assist promoting the hospital as a preferred provider and facilitating cashless claims processing, while the hospital provides priority treatment and notifies East West Assist of admissions. The agreement is valid for three years and establishes procedures for authorization, billing, and dispute resolution under Indian law.
This memorandum of understand is entered into on at
New Delhi between East West Assist TPA Pvt. Ltd, a third party administrator having it’s office.
East West Assist TPA Pvt. Ltd.
Plot No-172, J P House, Lane-2 Westend Marg, Saidulajab, Next to Saket Metro Station, New Delhi - 110030 Mob.9711779711, 011-47222666: Fax No. 29554130, 29553033 / 47222640-426 E-fax 022-66466-9006 Email: network@eastwestassist.com Website: www.eastwestassist.com
Represented by its C.E.O /M.D /C.O.O / DIRERCTOR’s
And
M/s Hospital, having its office
At herein after referred to as
The hospital /nursing home /clinic
Whereas the above two parties have decided to enter into an agreement to provide medical services to the health insurance sector and other corporations whereas the parties have decided to set out in writing the terms and procedures based on which the agreementbecomes operational for a validity of 3 years.
Now this memorandum of understanding shall witnessed as under
Purpose To enroll the hospital as a participating healthcare provider to the East West Assist(EWA) group of service provider.
I EWA will provide the following services by virtue of this agreement
1. To provide insurance companies and employees of corporations information
andaccess to quality health care. 2. To base with health insurance sector. 3. To offer cashless services to clients through the provider network. 4. To provide a twenty four hour alarm center 5. Being listed as a preferred care provider on the list of EWA 6. EWA will settle all approved, reasonable bills within 30 days of receipt of bills and supporting documents as details in the attached annexure
II The hospital/nursing home/clinic shall provide
The _______________________________ Hospital/nursing home/clinic by virtue of
being a preferred provider for EWA clients, theHospital will provide the following services.
1. All clients will be received and treated on a priority basis at all times. 2. Soon after admission or arrival of the patient and no later than 24 hours, the EWA alarm center will be notified of the patients admission so that authorization of services may be processed and communicated by EWA to the hospital at the earliest.
3. The hospital will provide cashless services to EWA clients on obtaining authorization 4. The procedure for obtaining authorization is set out on a separate document that isbeing provided with this Memorandum of understanding.
5. For payment after authorization by EWA; the hospital must supply all document aslisted in Annexure B. 6. All bills must be submitted promptly by the hospital but no later than seven days of discharge of the patient for prompt reimbursement.
7. No liability whatsoever shall develop on EWA in the event that facts have been concealed form EWA regarding the nature of the patients past or present history or on account of late submission or compliance of instructions as laid out and hence rejected by the insurance company.
8. The hospital shall always inform EWA in writing whenever their tariff is revised, some new services added or services/ facilities curtailed.
III
1. The role of EWA is to ensure that the best possible services to their clients at the most reasonable and competitive costs.
2. It is made explicitly clear that in so far that any services that maybe provided by networked hospital provider to its clients in so far as it leads to any negligence or deficiency in service on part of the hospital wherein the client or his or her family members has taken treatment, EWA shall not in any way be liable or responsible for anysuch negligence, deficiency or damages.
IV Laws and Jurisdiction
For all disputes that may arise by the virtue of this agreement, the laws of India shallapply and the jurisdiction shall be the courts at New Delhi, India.
V Modification
This agreement can be modified from time to time by mutual consent of both parties
Signed for EWA Signed for Hospital
Signature Signature Name Name Title/Designation Title/Designation Name of Hospital/Nursing home/clinic Date Date Annexure A
The hospital must provide the following information for the purpose of efficient functioning of the relationship with EWA and rapid processing of the claim.
1. A recent brochure of the hospital with current tariff list of services and procedures that are carried out at the hospital/nursing home/clinic.
2. List of various specialties available in your hospital
3. Name and phone number of persons who may be contacted on an
emergency basis on holidays and at night, the contact details of the physician in charge of the patient should be given.
4. Any suggestions you may have for smooth functioning of this relationship.
5. Phone number, mobile number, all contact details of the owner, medical director or person with authority in charge of handing insurance formalities at the hospital Email address to be included if present. 6. Bank details of the hospital to be provided for a rapid wire transfer for payment.
7. If there is any change in address, contact phone number, fax, email,
address, of the hospital, personal email, accounts section or contact person of the hospital, it should be intimated in writing by fax, post or email to EWA at the earliest. Annexure B
When the hospital submits bills, kindly ensure that all the following documents are attached:
1. Hospital bill in original with bill breakups; to be signed by signed by the
patient before discharge from the hospital whenever possible,
2. Original reports of all investigations such as, ECG, X-ray, Ultrasound, CT
scan etc., even if the test has been repeated, all repeat reports to be attached , All the reports should be signed by the treating physician or the medical superintendent.
3. Photocopy of the insurance policy of patient and their identification card
(both sides of the card).
4. In case investigations are done at a place other than the hospital/nursing
home/clinic, kindly provides original bills along with the original reports 5. Discharge Summary in original.
6. Pharmacy bills and breakups of the bill.
7. Doctor prescriptions in original.
8. Operation theater & OT consumables breakups
9. Claim form with signatures of patient.
This list may be modified from time to time for efficient processing of claims and shall be intimated to you in writing. Annexure C
When requesting authorization from the alarm center of EWA, kindly provide the following Information by phone call which should be promptly followed by fax or email.
1. Full name of patient
2. Age 3. Sex 4. Residential address 5. Name of insurance company/ corporation 6. Policy number 7. Identification card number 8. Dates of validity from to 9. Name of Hospital 10. Name of treating doctor 11. Contact phone numbers of treating physician/surgeon 12. Patients location in the hospital/ bed number/ room number 13. With extension number of bedside telephone 14. Date and time of admission 15. Working diagnosis 16. Medication given and investigations done at the time of informing EWA 17. Approximate daily cost 18. Likely number of days the patient may be hospitalized 19. If any family members or companion is with the patient. East West Assist TPA Pvt. Ltd. Plot No-172, J P House, Lane-2 , Westend Marg, Saidulajab, Next to Saket Metro Station. New Delhi - 110030 Mob.9711779711,011-47222666: Fax No.29554130, 29553033, 47222640-426 E-fax 022-66466-9006 Email: network@eastwestassist.com Website:www.eastwestassist.com
DETAILS OF PRIVATE NURSING HOME / HOSPITAL
Name of hospital
Address
Phone numbers
Fax
Email
Website Total number of beds
Double room (approx.
charge) Single room
(approx. charge) Name of Medical Director
Contact number / Mobile :
Name of medical superintendent
Contact number / Mobile :
In case of emergency / notification calls from our organization to your hospital, the Person to contact : Name and contact number / Mobile : Name of Financial Officer / Accounts officer Contact number / Mobile :
Laboratory Hematology Biochemistry Serology If in-house ABG (arterial blood gas examination) not available. Is it possible to send the sample elsewhere? Histopathology HIV 1 HIV 2 Cardiology Electrocardiograph Echo Defibrillator Cardiac monitor Pacing – Temporary -Permanent TMT Holter Respiratory Spirometry Nebulizer Ventilator Oximetry BIPAP Pharmacy 24 hours and only for inpatients? Available to general public? Blood bank – In house? In house – is blood checked for - HIV 1 HIV 2 Hepatitis B Hepatitis C If not in hospital, which blood bank’s is used Please provide name and phone number of the bank. Surgery Operation theater ( number minor/major) C arm available CTVS (cardio thoracic vascular surgery) Cardiac Bypass General surgery Neurosurgery Please add other if available
Emergency Ambulance- size and type of vehicle available Emergency room 24 hour resident in the hospital Specialists on call
Pediatrics Yes No Ventilator Nursery Incubator Neonatologist
Other departments Please add other specialties, services, facilities available in Your institution Dentistry Dietitian Dermatology Endocrinology Hematology Psychiatry Physiotherapy Oncology Other information Food for patients available Private duty nurses available Oxygen MOU signing date Validity till
Form filled by:
Signature: Designation: Please attach hospital/nursing home/clinic brochure, charge schedules of laboratory, Investigation, Room charges etc. Please add additional sheets if required.
