MoU with Health Care Provider under DKBSSY-Annexure 2.

Dr. Khoobchand Baghel Swastua Sahyta Yojana-Health Benefit Package.*

Procedure SHA - Stratification Reservation Reservation Auto
AB PM - JAY AB PM - JAY Level of Mandatory Documents - Pre Mandatory Documents - Claim
Specialty Code Package Criteria Public Hospitals Tertiary Hospitals LOS Approved
Package Name Procedure Name Care Authorization Processing
HBP 2.0 Price (Y/N) (Y/N) (Y/N) (Y/N)
Post procedure Imaging with film
(CT), Post procedure Clinical
Clinical notes and EEG,
Neurosurgery Epilepsy Surgery SN012A Epilepsy Surgery 99,000 No No No Tertiary 10 N photgraph showing scar, Detailed
Neurologist report, CT/MRI
discharge summary, Detailed
Procedure / Operative Notes.

Post procedure Imaging with film

(CT) showing clips, Post procedure
Aneurysm Clipping including Clinical notes and CT- Clinical photgraph showing scar,
Neurosurgery SN023A Aneurysm Clipping including angiogram 1,07,000 No No No Tertiary 12 N
angiogram angio/MRA/DSA Detailed discharge summary,
Detailed Procedure / Operative
Notes., invoice of all the clip(s) used

Histopathology, Post procedure

Imaging with film (X-ray/ CT), Post
Clinical notes and MRI supporting procedure Clinical photgraph
Neurosurgery Spine - Intramedullar Tumour SN043B Spine - Intramedullar Tumour with fixation 1,17,000 No No No Tertiary 7 N
surgery showing scar, Detailed Procedure /
Operative Notes. Detailed discharge
summary

Histopathology, Post procedure

Imaging with film (CT), Post
Excision of Brain Tumor procedure Clinical photgraph
Neurosurgery SN015C Brainstem 1,20,000 No No No Tertiary 10 N Clinical notes and CT/MRI
Supratentorial showing scar, Detailed discharge
summary, Detailed Procedure /
Operative Notes.
Histopathology, Post procedure
Imaging with film (CT), Post
Excision of Brain Tumor procedure Clinical photgraph
Neurosurgery SN015D C P Angle 1,20,000 No No No Tertiary 10 N Clinical notes and CT/MRI
Supratentorial showing scar, Detailed discharge
summary, Detailed Procedure /
Operative Notes.
CT/MRI, HPE within 15 days of
Neurosurgery Brain Tumour SN056CGA Fourth Ventricle Tumour/Infratentorial tumour 1,20,000 No No No Tertiary 10 N
CT/MRI discharge

Histopathology, Post procedure

Imaging with film (X-ray/ CT), Post
Clinical notes and MRI supporting procedure Clinical photgraph
Neurosurgery Spine - Intramedullar Tumour SN043A Spine - Intramedullar Tumour 1,27,000 No No No Tertiary 7 N
surgery showing scar, Detailed Procedure /
Operative Notes. Detailed discharge
summary

Admission Notes comprising of

Detailed Procedure / Operative
Obstetrics & Medical management of Secondar history and examination with
SO052A Medical management of ectopic pregnancy 1500 Yes No No 5 N Notes, Intraop. Stills, Progress
Gynecology ectopic pregnancy y indications for the
notes, Detailed discharge summary
procedure,Relavant Investigations
(establishing diagnosis),
Admission Notes comprising of
EUA for (minor girls / history and examination with Detailed Procedure / Operative
Obstetrics & EUA for (minor girls / unmarried sexually inactive / victims Secondar
unmarried sexually inactive / SO045A 2,000 No Yes No 1 N indications for the Notes, Intraop. Stills, Progress
Gynecology of sexual abuse) y
victims of sexual abuse) procedure,Relavant Investigations notes, Detailed discharge summary
(establishing diagnosis), and
parental
Admissionconsent
Notes(incase of minor
comprising of
history and examination with
Detailed Procedure / Operative
indications for the
Obstetrics & Medical Termination of Secondar Notes, Intraop. stills , HPE of
SO053A MTP upto 8 weeks 3,500 No Yes No 1 N procedure,Relavant Investigations
Gynecology Pregnancy y specimen,Progress notes, Detailed
(establishing diagnosis), USG -
discharge summary
Obstetric confirming the above
package. Has medicolegal
compliance been done?

Subject to change by National Health Authority, AB-PMJAY

Page 1 of 10124
 MoU with Health Care Provider under DKBSSY-Annexure 2.

Dr. Khoobchand Baghel Swastua Sahyta Yojana-Health Benefit Package.*

Procedure SHA - Stratification Reservation Reservation Auto
AB PM - JAY AB PM - JAY Level of Mandatory Documents - Pre Mandatory Documents - Claim
Specialty Code Package Criteria Public Hospitals Tertiary Hospitals LOS Approved
Package Name Procedure Name Care Authorization Processing
HBP 2.0 Price (Y/N) (Y/N) (Y/N) (Y/N)
Admission Notes comprising of
history and examination with Detailed Procedure / Operative
Obstetrics & Electro Cauterisation / Cryo Secondar
SO044A Electro Cauterisation / Cryo Surgery 4,000 No No No 1 N indications for the Notes, Intraop. Stills, Progress
Gynecology Surgery y
procedure,Relavant Investigations notes, Detailed discharge summary
(establishing diagnosis), pap smear-
optional
Detailed Procedure / Operative
Clinical notes with details of IUCD
Notes together with indication of
insertion (reason for non
Obstetrics & Secondar surgery, Intraop. stills with date &
Hysteroscopic IUCD removal SO017A Hysteroscopic IUCD removal 4,700 No Yes No 1 N availability of details), indication
Gynecology y patient ID, pic off gross specimen
for removing IUCD, USG showing
removed , HPE,Progress
misplaced IUD
notes,detailed discharge summary.

Admission Notes comprising of

Detailed operative notes, discharge
Obstetrics & Vulvo vaginal cyst Secondar history and examination with
SO059A Vulvo vaginal cyst enucleation 4,700 No Yes No 1 N summary, histopathology report of
Gynecology enucleation / drainage y indications for the procedure,
tissue removed
Relavant Investigations
(establishing
Admission diagnosis)
Notes comprising of
history and examination with
Detailed Procedure / Operative
indications for the
Obstetrics & Medical Termination of Secondar Notes, Intraop. stills , HPE of
SO053B MTP 8 to 12 weeks 5,000 No Yes No 1 N procedure,Relavant Investigations
Gynecology Pregnancy y specimen,Progress notes, Detailed
(establishing diagnosis), USG -
discharge summary
Obstetric confirming the above
package. Has medicolegal
compliance
Clinical been
notes anddone?
Histopathology, Detailed Procedure
Obstetrics & Hysterectomy as part of VVF Cystoscopy+vaginoscopy+CT -
SU092A Hysterectomy as part of VVF / uterovaginal fistula repair 5,000 No No No Tertiary 0 N / Operative Notes, detailed discharge
Gynecology / uterovaginal fistula repair IVP/IVP +/- cystogram confirming
summary.
the diagnosis
Admission Notes comprising of
Obstetrics & Vulvo vaginal cyst Secondar history and examination with Detailed operative notes, discharge
SO059B Vulvo vaginal cyst drainage 5,500 No Yes No 1 N
Gynecology enucleation / drainage y indications for the procedure, summary
Relavant Investigations
(establishing diagnosis)
Detailed Procedure / Operative
Admission Notes comprising of
Notes together with indication of
history and examination, Relavant
Obstetrics & Secondar surgery, Intraop. stills with date &
Laparoscopic adhesiolysis SO023A Laparoscopic adhesiolysis 6,000 No No No 1 N Investigations (establishing
Gynecology y patient ID, pic off gross specimen
diagnosis), USG Abdomen/ Pelvis
removed , HPE, Progress
(CT abdomen- Optional)
notes,detailed discharge summary.

Admission Notes comprising of

history detailing when was first
Detailed Procedure / Operative
Obstetrics & Secondary suturing of Secondar surgery done? and examination
SO056A Secondary suturing of episiotomy 6,000 No No No 2 N Notes, Intraop. Stills, Progress
Gynecology episiotomy y with indications for the procedure,
notes, Detailed discharge summary
Physical examination findings with
indications for the procedure.
Admission Notes comprising of
history and examination with
Detailed Procedure / Operative
indications for the
Obstetrics & Medical Termination of Secondar Notes, Intraop. stills , HPE of
SO053C MTP > 12 weeks 6,500 No Yes No 1 N procedure,Relavant Investigations
Gynecology Pregnancy y specimen,Progress notes, Detailed
(establishing diagnosis), USG -
discharge summary
Obstetric confirming the above
package. Has medicolegal
complianceNotes
Admission been done?
comprising of
Detailed Procedure / Operative
history and examination with
Notes together with indication of
indications for the procedure,
Obstetrics & Secondar surgery, Intraop. stills with date &
Hysteroscopic adhesiolysis SO022A Hysteroscopic adhesiolysis 6,900 No No No 1 N Relavant Investigations
Gynecology y patient ID, pic off gross specimen
(establishing diagnosis),USG
removed , HPE,Progress
Abdomen Pelvis / CT/MRI
notes,detailed discharge summary.
Abdomen Pelvis

Subject to change by National Health Authority, AB-PMJAY

Page 2 of 10125
 MoU with Health Care Provider under DKBSSY-Annexure 2.

Dr. Khoobchand Baghel Swastua Sahyta Yojana-Health Benefit Package.*

Procedure SHA - Stratification Reservation Reservation Auto
AB PM - JAY AB PM - JAY Level of Mandatory Documents - Pre Mandatory Documents - Claim
Specialty Code Package Criteria Public Hospitals Tertiary Hospitals LOS Approved
Package Name Procedure Name Care Authorization Processing
HBP 2.0 Price (Y/N) (Y/N) (Y/N) (Y/N)
Admission Notes comprising of
Detailed Procedure / Operative
Obstetrics & Hymenectomy for Secondar history and examination with
SO029A Hymenectomy for imperforate hymen 7,000 No No No 1 N Notes, Intraop. Stills, Progress
Gynecology imperforate hymen y indications for the procedure and
notes, Detailed discharge summary
need of procedure
Admission Notes comprising of
Detailed Procedure / Operative
Obstetrics & Secondar history and examination with
Intrauterine transfusions SO021A Intrauterine transfusions 11,000 No No Yes 1 N Notes, Intraop. Stills, Progress
Gynecology y indications for the
notes, Detailed discharge summary
procedure,Relavant Investigations
(establishing diagnosis) Detailed Procedure / Operative
Admission Notes comprising of
Notes together with indication of
history and examination with
surgery, Intraop. stills with date &
Obstetrics & Secondar indications for the procedure,
Diagnostic hysteroscopy SO016B Without biopsy 12,000 No No No 1 N patient ID, pic off gross specimen
Gynecology y Relavant Investigations
removed , HPE of biopsy
(establishing diagnosis),USG uterus
specimen,Progress notes, Detailed
& adnexa
discharge summary

Admission Notes comprising of Detailed Procedure / Operative

history and examination with Notes together with indication of
Obstetrics & Secondar indications for the procedure, surgery, Intraop. stills with date &
Hysteroscopic polypectomy SO009A Hysteroscopic polypectomy 13,000 No No No 2 N
Gynecology y Relavant Investigations patient ID, pic off gross specimen
(establishing diagnosis),USG removed , HPE,Progress
showing polyp notes,detailed discharge summary.

Detailed Procedure / Operative

Admission Notes comprising of
Notes together with indication of
history and examination with
surgery, Intraop. stills with date &
Obstetrics & Secondar indications for the procedure,
Diagnostic hysteroscopy SO016A With biopsy 14,000 No No No 1 N patient ID, pic off gross specimen
Gynecology y Relavant Investigations
removed , HPE of biopsy
(establishing diagnosis),USG uterus
specimen,Progress notes, Detailed
& adnexa
discharge summary
Admission Notes comprising of
history and examination with Detailed Procedure / Operative
Obstetrics & Excision of Vaginal Septum Secondar
SO028A Excision of Vaginal Septum (vaginal route) 14,500 No No Yes 1 N indications for the Notes, Intraop. Stills, Progress
Gynecology (vaginal route) y
procedure,Relavant Investigations notes, Detailed discharge summary
(establishing diagnosis), need of
procedure (USG Abdomen + Pelvis)
Consulting notes giving the Detailed Procedure / Operative
Obstetrics & Secondar indication for amniocentesis; does Notes, Intraop. Stills, ; Amniotic
Amniocentesis SO047A Amniocentesis 14,500 No No Yes 1 N
Gynecology y the hospital have fetal medicine fluid analysis report; Progress notes,
expert? Detailed discharge summary

Admission Notes comprising of Procedure / Operative Notes with

Obstetrics & Secondar history and examination with report of chorionic villi sampling;
Chorionic villus sampling SO048A Chorionic villus sampling 14,500 No No Yes 1 N
Gynecology y indications for the Progress notes, Detailed discharge
procedure,Relavant Investigations summary
(establishing diagnosis),
Admission Notes comprising of Detailed Procedure / Operative
Obstetrics & Secondar history and examination with Notes, Intraop. Stills, report of
Cordocentesis SO049A Cordocentesis 14,500 No No Yes 1 N
Gynecology y indications for the cordocentesis; Progress notes,
procedure,Relavant Investigations Detailed discharge summary
(establishing
Admission diagnosis),
Notes comprising of
Detailed Procedure / Operative
Obstetrics & Secondar history and examination with
Manchester Repair SO012A Manchester Repair 15,000 No No No 5 N Notes, Intraop. Stills, Progress
Gynecology y indications for the
notes, Detailed discharge summary
procedure,Relavant Investigations
(establishing
Admission diagnosis),
Notes comprising of
Detailed Procedure / Operative
Obstetrics & Vaginal Sacrospinus fixation Secondar history and examination with
SO027A Vaginal Sacrospinus fixation with repair 15,000 No No No 5 N Notes, Intraop. Stills, Progress
Gynecology with repair y indications for the
notes, Detailed discharge summary
procedure,Relavant Investigations
(establishing
Admission diagnosis),
Notes comprising of
history and examination with Detailed Procedure / Operative
Obstetrics & Anterior & Posterior Secondar
SO030A Anterior & Posterior Colpoperineorrhapy 15,000 No No No 5 N indications for the Notes, Intraop. Stills, Progress
Gynecology Colpoperineorrhapy y
procedure,Relavant Investigations notes, Detailed discharge summary
(establishing diagnosis), clinical pic
if feasible

Subject to change by National Health Authority, AB-PMJAY

Page 3 of 10126
 MoU with Health Care Provider under DKBSSY-Annexure 2.

Dr. Khoobchand Baghel Swastua Sahyta Yojana-Health Benefit Package.*

Procedure SHA - Stratification Reservation Reservation Auto
AB PM - JAY AB PM - JAY Level of Mandatory Documents - Pre Mandatory Documents - Claim
Specialty Code Package Criteria Public Hospitals Tertiary Hospitals LOS Approved
Package Name Procedure Name Care Authorization Processing
HBP 2.0 Price (Y/N) (Y/N) (Y/N) (Y/N)
Detailed Procedure / Operative
Admission Notes comprising of Notes together with indication of
Obstetrics & Diagnostic / Staging Secondar history and examination, Relavant surgery, Intraop. stills with date &
SO039A Diagnostic / Staging laparoscopy 15,000 No No No 3 N
Gynecology laparoscopy y Investigations patient ID, pic off gross specimen
(establishing diagnosis) removed , HPE, Progress
notes,detailed discharge summary.

Admission Notes comprising of

Detailed Procedure / Operative
history and examination with
Obstetrics & Trans - vaginal tape / Trans- Secondar Notes, Barcode of TVT/TOT tape
SO024A Trans-vaginal tape 15,200 No No No 1 N indications for the
Gynecology obturator tape y used; progress notes,Detailed
procedure,Relavant Investigations
discharge summary
(establishing diagnosis)
Admission Notes comprising of
Detailed Procedure / Operative
history and examination with
Obstetrics & Trans - vaginal tape / Trans- Secondar Notes, Barcode of TVT/TOT tape
SO024B Trans-obturator tape 15,200 No No No 1 N indications for the
Gynecology obturator tape y used; progress notes,Detailed
procedure,Relavant Investigations
discharge summary
(establishing diagnosis)
physical examination findings with Detailed Operative notes, HPE,
Obstetrics & Secondar
Hysteroscopic myomectomies SO007A Hysteroscopic myomectomies 16,900 No Yes No 1 N indications for the procedure. USG Intraop stills with date & patient ID,
Gynecology y
pelvis / MRI Pelvis Detailed discharge summary
Admission Notes comprising of
history and examination with Detailed Procedure / Operative
indications for the Notes, Intraop. stills with date &
Obstetrics & Secondar
Hysterotomy SO014A Hysterotomy 16,900 No No No 1 N procedure,Relavant Investigations patient ID, HPE of
Gynecology y
(establishing diagnosis), USG - specimen,Progress notes, Detailed
Obstetric confirming the above discharge summary
package. Has medicolegal
compliance been done? Detailed Operative notes,HPE, Pic
Clinical notes establishing
Obstetrics & Secondar of specimen removed- Gross and
Abdominal Myomectomy SO006A Abdominal Myomectomy 20,000 No Yes No 5 N indication, USG Abdomen Pelvis/
Gynecology y Histopathology, Detailed discharge
MRI abdomen. Pap smear
summary
Clinical notes with planned line of
treatment (including System
Histopathology, Detailed Discharge
Obstetrics & Secondar Examination) and Relavant
Hysterectomy SO010A Abdominal Hysterectomy 20,000 No Yes No 5 N Summary with Procedure /
Gynecology y Investigations (USG Abdomen +
Operative Notes
Pelvis/ CT abdomen+ Pelvis)
confirming the indication
Admission Notes comprising of
history and examination with
indications for the
procedure,Clinical notes with
planned line of treatment (clearly Detailed Procedure / Operative
indicating medical management Notes together with indication of
Obstetrics & Secondar tried and failed or not indicated. If surgery, Intraop. stills with date &
Hysterectomy SO010B Abdominal Hysterectomy + Salpingo-oophorectomy 20,000 No Yes No 5 N failed documents proving duration
Gynecology y patient ID, pic off gross specimen
of treatment and failure. The removed , HPE,Progress
medical management should have notes,detailed discharge summary.
been tried for atleast 4-6 months
covering 1 course of hormone
cycle) and USG Abdomen + Pelvis/
CT/ MRI abdomen+ Pelvis
confirming the indication, Pap
Clinical notes with planned line of
treatment (clearly indicating
medical management tried and Detailed Procedure / Operative
failed or not indicated. If failed Notes together with indication of
Obstetrics & Secondar documents proving duration of surgery, Intraop. stills with date &
Hysterectomy SO010C Non descent vaginal hysterectomy 20,000 No Yes No 4 N treatment and failure. The medical
Gynecology y patient ID, pic off gross specimen
management should have been tried removed , HPE, Progress
for atleast 4-6 months covering 1 notes,detailed discharge summary.
course of hormone cycle), USG
Abdomen + Pelvis, Pap smear,
EB/EAC

Subject to change by National Health Authority, AB-PMJAY

Page 4 of 10127
 MoU with Health Care Provider under DKBSSY-Annexure 2.

Dr. Khoobchand Baghel Swastua Sahyta Yojana-Health Benefit Package.*

Procedure SHA - Stratification Reservation Reservation Auto
AB PM - JAY AB PM - JAY Level of Mandatory Documents - Pre Mandatory Documents - Claim
Specialty Code Package Criteria Public Hospitals Tertiary Hospitals LOS Approved
Package Name Procedure Name Care Authorization Processing
HBP 2.0 Price (Y/N) (Y/N) (Y/N) (Y/N)
Clinical notes with planned line of
treatment (clearly indicating
medical management tried and
failed or not indicated with reason. Detailed Procedure / Operative
If failed documents proving Notes together with indication of
Obstetrics & Vaginal hysterectomy with anterior and posterior Secondar duration of treatment and failure. surgery, Intraop. stills with date &
Hysterectomy SO010D 20,000 No Yes No 5 N The medical management should
Gynecology colpoperineorrhaphy y patient ID, pic off gross specimen
have been tried for atleast 4-6 removed , HPE, Progress
months covering 1 course of notes,detailed discharge summary.
hormone cycle), Photographic
documentation with patient’s
consent, Pap smear ( EB/EAC is
optional )
Clinical notes with planned line of
Histopathology, Detailed Discharge
Obstetrics & Secondar treatment and USG Abdomen +
Hysterectomy SO010E Laparoscopic hysterectomy (TLH) 20,000 No Yes No 5 N Summary with Detailed operative
Gynecology y Pelvis/ CT abdomen+ Pelvis
notes
confirming the indication
Admission Notes comprising of
history and examination(clearly
indicating medical management
tried and failed or not indicated, Detailed Procedure / Operative
with reason. If failed documents Notes together with indication of
Obstetrics & Secondar proving duration of treatment and surgery, Intraop. stills with date &
Hysterectomy SO010F Laparoscopically assisted vaginal hysterectomy (LAVH) 20,000 No Yes No 5 N failure. The medical management
Gynecology y patient ID, pic off gross specimen
should have been tried for atleast 4- removed , HPE, Progress
6 months covering 1 course of notes,detailed discharge summary.
hormone cycle) , USG Abdomen +
Pelvis/ MRI abdomen+ Pelvis
confirming the indication, Pap
smear, EB/EAC
Admission Notes comprising of
Detailed Procedure / Operative
Obstetrics & Secondar history and examination with
Pyometra drainage SO020A Pyometra drainage 20,000 No No No 3 N Notes, Intraop. Stills, Progress
Gynecology y indications for the
notes, Detailed discharge summary
procedure,Relavant Investigations
(establishing diagnosis)
Admission Notes comprising of
history and examination with Detailed Procedure / Operative
Obstetrics & Abdomino Perineal repair for Secondar
SO037A Abdomino Perineal repair for Mullerian Anomaly 20,000 No No Yes 5 N indications for the Notes, Intraop. Stills, Progress
Gynecology Mullerian Anomaly y
procedure,Relavant Investigations notes, Detailed discharge summary
(establishing diagnosis), (USG/ CT/
MRI) Procedure / Operative Notes, Post
Obstetrics & Clinical notes with planned line of Procedure Photographs of surgical
Bilateral salpingoophorectomy SC030A Open 21,000 No No No Tertiary 5 N
Gynecology treatment, HPE site, HPE report, Detailed Discharge
Summary
Procedure / Operative Notes, Post
Obstetrics & Clinical notes with planned line of Procedure Photographs of surgical
Bilateral salpingoophorectomy SC030B Lap. 21,000 No No No Tertiary 5 N
Gynecology treatment, HPE site, HPE report, Detailed Discharge
Summary

Detailed Procedure / Operative

Admission Notes comprising of
Notes together with indication of
history and examination, Relavant
Obstetrics & Secondar surgery, Intraop. stills with date &
Laparoscopic cystectomy SO041A Laparoscopic cystectomy 22,000 No No No 5 N Investigations (establishing
Gynecology y patient ID, pic off gross specimen
diagnosis), USG Abdomen Pelvis/
removed , HPE, Progress
CT abdomen.
notes,detailed discharge summary.

Admission Notes comprising of Detailed Procedure / Operative

history and examination with Notes, Intraop. stills with date &
Obstetrics & Secondar
Sacrocolpopexy (Abdominal) SO025A Open 23,900 No No No 7 N indications for the patient ID, Barcode of mesh used;
Gynecology y
procedure,Relavant Investigations progress notes,Detailed discharge
(establishing diagnosis) , summary summary
Photographic documentation with

Subject to change by National Health Authority, AB-PMJAY

Page 5 of 10128
 MoU with Health Care Provider under DKBSSY-Annexure 2.

Dr. Khoobchand Baghel Swastua Sahyta Yojana-Health Benefit Package.*

Procedure SHA - Stratification Reservation Reservation Auto
AB PM - JAY AB PM - JAY Level of Mandatory Documents - Pre Mandatory Documents - Claim
Specialty Code Package Criteria Public Hospitals Tertiary Hospitals LOS Approved
Package Name Procedure Name Care Authorization Processing
HBP 2.0 Price (Y/N) (Y/N) (Y/N) (Y/N)
Admission Notes comprising of Detailed Procedure / Operative
history and examination with Notes, Intraop. stills with date &
Obstetrics & Secondar
Sacrocolpopexy (Abdominal) SO025B Lap. 23,900 No No No 7 N indications for the patient ID, Barcode of mesh used;
Gynecology y
procedure,Relavant Investigations progress notes,Detailed discharge
(establishing diagnosis) , summary summary
Photographic
Clinical notes documentation
with physical with Detailed discharge summary;
Obstetrics & Laparotomy for broad Secondar
SO005A Laparotomy for broad ligament haematoma 25,000 No No No 3 N examination findings supported by Detailed Operative notes. Intra
Gynecology ligament haematoma y
evidence of hematoma (USG) procedure clinical photograph
Admission Notes comprising of
history and examination with
Detailed Procedure / Operative
indications for the
Obstetrics & Surgeries for Prolapse - Sling Notes, Intraop. stills ,Barcode of
SO013A Surgeries for Prolapse - Sling Surgeries 28,900 No No Yes Tertiary 5 N procedure,Relavant Investigations
Gynecology Surgeries sling used; progress notes,Detailed
(establishing diagnosis) ;
discharge summary
Photographic documentation of
degree/severity of prolapse with
patient’s
Admission consent,Pap smear. of
Notes comprising
Detailed Procedure / Operative
history and examination with
Obstetrics & Secondar Notes, Intraop. stills with date &
Rectovaginal fistula repair SO033A Rectovaginal fistula repair 29,000 No No Yes 3 N indications for the
Gynecology y patient ID, Progress notes,detailed
procedure,Relavant Investigations
discharge summary.
(establishing diagnosis)
Admission Notes comprising of
history and examination with Detailed Procedure / Operative
Obstetrics & Vaginoplasty (McIndoe Secondar
SO031A Vaginoplasty (McIndoe procedure) 30,000 No Yes Yes 3 N indications for the Notes, Intraop. Stills, Progress
Gynecology procedure) y
procedure,Relavant Investigations notes, Detailed discharge summary
(establishing diagnosis), need of
procedure
Admission(USG
NotesAbdomen
comprising+ Pelvis)
of
history and examination with Detailed Procedure / Operative
Obstetrics & Secondar
Burch SO043A Abdominal 30,000 No No Yes 5 N indications for the Notes; Intraop. stills ,progress
Gynecology y
procedure,Relavant Investigations notes,Detailed discharge summary
(establishing diagnosis) ;
UrodynamicNotes
Admission studies are optional.
comprising of
history and examination with Detailed Procedure / Operative
Obstetrics & Secondar
Burch SO043B Laparoscopic 30,000 No No Yes 5 N indications for the Notes; Intraop. stills ,progress
Gynecology y
procedure,Relavant Investigations notes,Detailed discharge summary
(establishing diagnosis) ;
Urodynamic
Clinical notesstudies are optional.
and urethro
Obstetrics & Detailed Procedure / Operative
Urethrovaginal fistula repair SU075A Urethrovaginal fistula repair 30,000 No No No Tertiary 2 N Cystoscopy +vaginoscopy +USG
Gynecology Notes, detailed discharge summary.
confirming the diagnosis

Obstetrics & Vulvectomy + reconstruction Clinical notes with planned line of Procedure / Operative Notes, HPE
SC034A Vulvectomy + reconstruction procedures 36,000 No No No Tertiary 11 N
Gynecology procedures treatment, Biopsy/HPE report, Detailed Discharge Summary

Clinical notes and USG/CT / Histopathology, Detailed discharge

Obstetrics & Radical Retroperitoneal
SU090A Open 36,500 No No No Tertiary 3 N Biopsy confirming bilateral summary, detailed Procedure /
Gynecology lymph node dissection
testicular cancer Operative Notes
Clinical notes and USG/CT / Histopathology, Detailed discharge
Obstetrics & Radical Retroperitoneal
SU090B Lap. 36,500 No No No Tertiary 3 N Biopsy confirming bilateral summary, detailed Procedure /
Gynecology lymph node dissection
testicular cancer Operative Notes
Clinical notes and Clinical Histopathology report, post
Obstetrics & Secondar
Biopsy SG096A Lymph Node 8,500 No No No 1 Y Photograph of Enlarged lymph procedure clinical photograph,
Gynecology y
nodes +/- FNAC report Detailed Operative notes
Obstetrics & Secondar Clinical notes with supporting Pic of specimen, Histopathology
Biopsy SG096B Endometrial Aspiration 2,000 No No No 1 Y
Gynecology y investigations report, discharge summary
Obstetrics & Secondar Clinical notes with supporting Pic of specimen, Histopathology
Biopsy SG096C Cervix Cancer screening (PAP + Colposcopy) 3,000 No No No 1 Y
Gynecology y investigations report, discharge summary
Obstetrics & Secondar Clinical notes with supporting Pic of specimen, Histopathology
Biopsy SG096D Cervical (Neck) 1,500 No No No 1 Y
Gynecology y investigations report, discharge summary
Obstetrics & Secondar Clinical notes with supporting Pic of specimen, Histopathology
Biopsy SG096E Vulval 1,500 No No No 1 Y
Gynecology y investigations report, discharge summary
Indication of the procedure Detailed discharge summary;
Obstetrics & Procedure on Fallopian Tube Secondar
SO004A Procedure on Fallopian Tube for establishing Tubal Patency 38,000 No No No 5 N preferably with record of previous Detailed Operative notes. Intra
Gynecology for establishing Tubal Patency y
sterilization/ reason for non- procedure clinical photograph

Subject to change by National Health Authority, AB-PMJAY

Page 6 of 10129
 MoU with Health Care Provider under DKBSSY-Annexure 2.

Dr. Khoobchand Baghel Swastua Sahyta Yojana-Health Benefit Package.*

Procedure SHA - Stratification Reservation Reservation Auto
AB PM - JAY AB PM - JAY Level of Mandatory Documents - Pre Mandatory Documents - Claim
Specialty Code Package Criteria Public Hospitals Tertiary Hospitals LOS Approved
Package Name Procedure Name Care Authorization Processing
HBP 2.0 Price (Y/N) (Y/N) (Y/N) (Y/N)
Admission Notes comprising of Detailed Procedure / Operative
history and examination with Notes together with indication of
Radical Vulvectomy with
Obstetrics & Radical Vulvectomy with Inguinal and Pelvic lymph node Secondar indications for the procedure, surgery, Intraop. stills with date &
Inguinal and Pelvic lymph SO036A 38,500 No No Yes 3 N
Gynecology disection y Relavant Investigations patient ID, pic off gross specimen
node disection
(establishing diagnosis),vulval removed , HPE, Progress
biopsy, CT/MRI for staging notes,detailed discharge summary.

Procedure / Operative Notes, Post

Obstetrics & Class I radical hysterectomy + bilateral Clinical notes with planned line of Procedure Photographs of surgical
Radical Hysterectomy SC032A 40,000 No No No Tertiary 11 N
Gynecology salpingoophorectomy + BPLND - Lap. treatment and Biopsy, CECT/ MRI site, HPE report, Detailed Discharge
Summary
Procedure / Operative Notes, Post
Obstetrics & Class I radical hysterectomy + bilateral Clinical notes with planned line of Procedure Photographs of surgical
Radical Hysterectomy SC032B 40,000 No No No Tertiary 11 N
Gynecology salpingoophorectomy + BPLND - Open treatment and Biopsy, CECT/ MRI site, HPE report, Detailed Discharge
Summary
Procedure / Operative Notes, Post
Obstetrics & Class I radical Hysterectomy +/- bilateral Clinical notes with planned line of Procedure Photographs of surgical
Radical Hysterectomy SC032C 40,000 No No No Tertiary 6 N
Gynecology salpingoophorectomy - Lap. treatment and Biopsy, CECT/ MRI site, HPE report, Detailed Discharge
Summary
Procedure / Operative Notes, Post
Obstetrics & Class I radical Hysterectomy +/- bilateral Clinical notes with planned line of Procedure Photographs of surgical
Radical Hysterectomy SC032D 40,000 No No No Tertiary 6 N
Gynecology salpingoophorectomy - Open treatment and Biopsy, CECT/ MRI site, HPE report, Detailed Discharge
Summary
Procedure / Operative Notes, Post
Obstetrics & Clinical notes with planned line of Procedure Photographs of surgical
Radical Hysterectomy SC032E Class II radical hysterctomy + BPLND 40,000 No No No Tertiary 11 N
Gynecology treatment and Biopsy, CECT/ MRI site, HPE report, Detailed Discharge
Summary
Procedure / Operative Notes, Post
Obstetrics & Clinical notes with planned line of Procedure Photographs of surgical
Radical Hysterectomy SC032F Class III radical hysterctomy + BPLND 40,000 No No No Tertiary 11 N
Gynecology treatment and Biopsy, CECT/ MRI site, HPE report, Detailed Discharge
Summary
Procedure / Operative Notes, Post
Obstetrics & Hysterectomy + bilateral salpingoophorectomy + Clinical notes with planned line of Procedure Photographs of surgical
Radical Hysterectomy SC032G 40,000 No No No Tertiary 13 N
Gynecology omentectomy + peritonectomy and organ resections treatment and Biopsy, CECT/ MRI site, HPE report, Detailed Discharge
Summary

HPE report, detailed Procedure /

Obstetrics & Operative Notes. Detailed discharge
Radical Trachelectomy SC035A Radical Trachelectomy 40,000 No No No Tertiary 11 N Clinical notes and CECT, biopsy
Gynecology summary , Post procedure Clinical
photgraph showing scar

Admission Notes comprising of

Detailed Procedure / Operative
history and examination with
Notes, Intraop. stills with date &
Obstetrics & Vaginal repair for vesico- Secondar indications for the
SO032A Vaginal repair for vesico-vaginal fistula 40,000 No No Yes 5 N patient ID, Progress notes,detailed
Gynecology vaginal fistula y procedure,Relavant Investigations
discharge [Link]
(establishing diagnosis) and
discharge summary.
Cystoscopy/ Cystourethroscopy.
Voiding Cystourethrogram
Clinical notes is +
and IVP/ CT-IVP Intra procedure still
Obstetrics & Uretero-vaginal / Uterine cystoscopy and vaginoscopy Scopy photograph,Detailed discharge
SU029A Uretero - vaginal fistula repair - Open 40,000 No No No Tertiary 3 N
Gynecology fistula repair confirming the diagnosis for which summary, detailed Procedure /
the surgery is done, Operative Notes
Clinical notes and IVP/ CT-IVP + Intra procedure still
Obstetrics & Uretero-vaginal / Uterine cystoscopy and vaginoscopy Scopy photograph,Detailed discharge
SU029B Uretero - Uterine fistula repair - Open 40,000 No No No Tertiary 3 N
Gynecology fistula repair confirming the diagnosis for which summary, detailed Procedure /
the surgery is done, Operative Notes
Clinical notes and IVP/ CT-IVP + Intra procedure still
Obstetrics & Uretero-vaginal / Uterine cystoscopy and vaginoscopy Scopy photograph,Detailed discharge
SU029C Uretero - vaginal fistula repair - Laparoscopic 40,000 No No No Tertiary 2 N
Gynecology fistula repair confirming the diagnosis for which summary, detailed Procedure /
the surgery is done, Operative Notes

Subject to change by National Health Authority, AB-PMJAY

Page 7 of 10130
 MoU with Health Care Provider under DKBSSY-Annexure 2.

Dr. Khoobchand Baghel Swastua Sahyta Yojana-Health Benefit Package.*

Procedure SHA - Stratification Reservation Reservation Auto
AB PM - JAY AB PM - JAY Level of Mandatory Documents - Pre Mandatory Documents - Claim
Specialty Code Package Criteria Public Hospitals Tertiary Hospitals LOS Approved
Package Name Procedure Name Care Authorization Processing
HBP 2.0 Price (Y/N) (Y/N) (Y/N) (Y/N)
Clinical notes and IVP/ CT-IVP + Intra procedure still
Obstetrics & Uretero-vaginal / Uterine cystoscopy and vaginoscopy Scopy photograph,Detailed discharge
SU029D Uretero - Uterine fistula repair - Laparoscopic 40,000 No No No Tertiary 2 N
Gynecology fistula repair confirming the diagnosis for which summary, detailed Procedure /
the surgery is done, Operative Notes

Laparotomy and proceed for Histopathology, Detailed Operative

Clinical notes and USG Abdomen
Obstetrics & Ovarian Cancers. Omentomy Laparotomy and proceed for Ovarian Cancers. Omentomy Secondar notes, per op pic of specimen
SO002A 42,500 No No Yes 5 N + Pelvis/ CT abdomen+ Pelvis
Gynecology with Bilateral Salpingo- with Bilateral Salpingo-oophorectomy y removed, Detailed Discharge
establishing indication
oophorectomy Summary.

Detailed Operative notes,HPE Pic of

Clinical notes establishing
Obstetrics & Secondar specimen. Intraop stills with date &
Lap. Salpingo-oophrectomy SO001A Lap. Salpingo-oophrectomy 14,000 No Yes No 3 Y indication, USG Abdomen Pelvis/
Gynecology y patient ID, Detailed discharge
CT/ MRI abdomen Pelvis
summary
Admission Notes comprising of
history and examination (clearly
indicating medical management
tried and failed or not indicated Detailed Procedure / Operative
with reason. If failed documents Notes. Histopath of uterus removed,
proving duration of treatment and per op pic of specimen removed;
Obstetrics & Secondar
Caesarean hysterectomy SO011A Caesarean hysterectomy 30,000 No No No 5 Y failure. The medical management status of the child at the time of
Gynecology y
should have been tried for atleast 4- delivery and at the time of discharge;
6 months covering 1 course of progress notes,Detailed discharge
hormone cycle), detailed Ante natal summary
care records/ reasons for non-
availability of ANC records. Per op
clinical pic is optional
Admission Notes comprising of
history and examination with Detailed Procedure / Operative
Obstetrics & Dilation and Evacuation Secondar indications for the Notes, Intraop. Stills,Histopathology
SO019A Dilation and Evacuation (D&E) 6,000 No No No 1 Y
Gynecology (D&E) y procedure,Relavant Investigations of evacuated material, Progress
(establishing diagnosis),USG notes, Detailed discharge summary
abdomen and pelvis)
Admission Notes comprising of
history and examination with Detailed Procedure / Operative
indications for the Notes, Intraop. stills with date &
Obstetrics & LLETZ (including PAP Secondar
SO026A LLETZ (including PAP smear and colposcopy) 11,000 No No No 3 Y procedure,Relavant Investigations patient ID, HPE of
Gynecology smear and colposcopy) y
(establishing diagnosis) , Evidence specimen,Progress notes, Detailed
of cervical pre-cancer (PAP smear) discharge summary
Colposcopiy. Cervical Biopsy is
optional Notes comprising of
Admission
Detailed Procedure / Operative
Obstetrics & Secondar history and examination with
Vulval Hamatoma drainage SO034A Vulval Hamatoma drainage 5,500 No No No 1 Y Notes, Intraop. Stills, Progress
Gynecology y indications for the
notes, Detailed discharge summary
procedure,Relavant Investigations
(establishing
Admission diagnosis),
Notes comprising of
Detailed Procedure / Operative
history and examination with
Obstetrics & Pelvic Abscess Management Secondar Notes, Intra procedure clinical
SO038A Pelvic Abscess Management including Colpotomy 12,000 No No No 1 Y indications for the
Gynecology including Colpotomy y photograph/ stills; progress
procedure,Relavant Investigations
notes,Detailed discharge summary
(establishing diagnosis) , USG
Abdomen & Pelvis
Admission Notes comprising of Detailed Procedure / Operative
history and examination with Notes together with indication of
Obstetrics & Laparotomy for benign Secondar indications for the surgery, Intraop. stills with date &
SO040A Ectopic 25,000 No No No 5 Y
Gynecology disorders y procedure,Clinical notes patient ID, pic off gross specimen
establishing ruptured ectopic with removed , HPE,detailed discharge
Evidence of beta hCG & USG summary.

Admission Notes comprising of

Detailed Procedure / Operative
Obstetrics & Secondar history and examination with
Cystocele - Anterior repair SO042A Cystocele - Anterior repair 12,000 No Yes No 3 Y Notes, Intraop. Stills, Progress
Gynecology y findings establishing Cystocoele .
notes, Detailed discharge summary
Clinical pic if feasible

Subject to change by National Health Authority, AB-PMJAY

Page 8 of 10131
 MoU with Health Care Provider under DKBSSY-Annexure 2.

Dr. Khoobchand Baghel Swastua Sahyta Yojana-Health Benefit Package.*

Procedure SHA - Stratification Reservation Reservation Auto
AB PM - JAY AB PM - JAY Level of Mandatory Documents - Pre Mandatory Documents - Claim
Specialty Code Package Criteria Public Hospitals Tertiary Hospitals LOS Approved
Package Name Procedure Name Care Authorization Processing
HBP 2.0 Price (Y/N) (Y/N) (Y/N) (Y/N)
Admission Notes comprising of
Detailed Procedure / Operative
Obstetrics & Hospitalisation for Antenatal Secondar history and examination with
SO046A Hospitalisation for Antenatal Complications 1500 Yes No No NA Y Notes, Intraop. Stills, Progress
Gynecology Complications y indications for the
notes, Detailed discharge summary
procedure,Relavant Investigations
(establishing
Admission diagnosis),
Notes comprising of
Detailed Procedure / Operative
Obstetrics & Secondar history and ANC findings justifying
McDonald's stitch SO050A McDonald's stitch 8,000 No No No 1 Y Notes, Intraop. Stills, Progress
Gynecology y cervical incompetence and the
notes, Detailed discharge summary
procedure.
Admission Notes comprising of
Detailed Procedure / Operative
Obstetrics & Secondar history and ANC findings justifying
Shirodkar's stitch SO051A Shirodkar's stitch 6,000 No No No 1 Y Notes, Intraop. Stills, Progress
Gynecology y cervical incomptenecs and the
notes, Detailed discharge summary
procedure.
Admission Notes comprising of
Detailed delivery notes, PNC notes
history and detailed Ante natal care
along with relevant investigation
records/ reasons for non-availability
Obstetrics & Secondar details; status of the child at the time
High risk delivery SO054A Pre-mature delivery 11,500 No Yes No 3 Y of ANC records. Obstetric USG.
Gynecology y of delivery and at the time of
All high risk deliveries are to be
discharge; progress notes, Detailed
clubbed & case specific documents
discharge summary.
required.
Admission Notes comprising of
Detailed delivery notes, PNC notes
history and detailed Ante natal care
along with relevant investigation
records/ reasons for non-availability
Obstetrics & Mothers with eclampsia / imminent eclampsia / severe pre- Secondar details; status of the child at the time
High risk delivery SO054B 11,500 No Yes No 3 Y of ANC records. Obstetric USG.
Gynecology eclampsia y of delivery and at the time of
All high risk deliveries are to be
discharge; progress notes, Detailed
clubbed & case specific documents
discharge summary.
required.
Admission Notes comprising of
Detailed delivery notes, PNC notes
history and detailed Ante natal care
along with relevant investigation
records/ reasons for non-availability
Obstetrics & Major Fetal malformation requiring intervention Secondar details; status of the child at the time
High risk delivery SO054C 11,500 No Yes No 3 Y of ANC records. Obstetric USG.
Gynecology immediately after birth y of delivery and at the time of
All high risk deliveries are to be
discharge; progress notes, Detailed
clubbed & case specific documents
discharge summary.
required.
Admission Notes comprising of
Detailed delivery notes, PNC notes
history and detailed Ante natal care
along with relevant investigation
records/ reasons for non-availability
Obstetrics & Secondar details; status of the child at the time
High risk delivery SO054D Mothers with severe anaemia (<7 g/dL) 11,500 No Yes No 3 Y of ANC records. Obstetric USG.
Gynecology y of delivery and at the time of
All high risk deliveries are to be
discharge; progress notes, Detailed
clubbed & case specific documents
discharge summary.
required.
Admission Notes comprising of
history and detailed Ante natal care Detailed delivery notes, PNC notes
records with special reference to along with relevant investigation
Other maternal and fetal conditions as per guidelines-eg investigations supporting the
Obstetrics & Secondar details; status of the child at the time
High risk delivery SO054E previous caesarean section, diabetes, severe growth 11,500 No Yes No 3 Y diagnosis/ reasons for non-
Gynecology y of delivery and at the time of
retardation, etc that qualify for high risk delivery. availability of ANC records. discharge; progress notes, Detailed
Obstetric USG. All high risk discharge summary.
deliveries are to be clubbed & case
specific documents
Clinical [Link] of
notes documenting Detailed Procedure / Operative
Obstetrics & Secondar manual removal of placenta/ use of Notes,stills of placenta, progress
Manual removal of placenta SO055A Manual removal of placenta 8,500 No No No 2 Y
Gynecology y Active Management of Third Stage note Detailed discharge summary;
of Labor (AMTSL) Post natal course
Admission Notes comprising of
history and examination with
Detailed Procedure / Operative
detailed Ante natal care records/
Notes, status of the child at the time
Obstetrics & Secondar reasons for non-availability of ANC
Caesarean Delivery SO057A Caesarean Delivery 11,500 No No No 5 Y of delivery and at the time of
Gynecology y records. Indications for the
discharge; progress notes,Detailed
procedure. USG Obstetrics with
discharge summary
Doppler is case specific & optional.
Labor charting, CTG if available.

Subject to change by National Health Authority, AB-PMJAY

Page 9 of 10132
 MoU with Health Care Provider under DKBSSY-Annexure 2.

Dr. Khoobchand Baghel Swastua Sahyta Yojana-Health Benefit Package.*

Procedure SHA - Stratification Reservation Reservation Auto
AB PM - JAY AB PM - JAY Level of Mandatory Documents - Pre Mandatory Documents - Claim
Specialty Code Package Criteria Public Hospitals Tertiary Hospitals LOS Approved
Package Name Procedure Name Care Authorization Processing
HBP 2.0 Price (Y/N) (Y/N) (Y/N) (Y/N)
Admission Notes comprising of
Detailed Procedure / Operative
Re exploration after history and examination with
Obstetrics & Secondar Notes, Intra procedure clinical
laparotomy / Caesarean SO058A Re exploration after Caesarean Section 14,000 No No No 5 Y indications for the
Gynecology y photograph/ stills; progress
Section procedure,Relavant Investigations
notes,Detailed discharge summary
(establishing diagnosis) , USG
Admission Notes comprising of
Detailed Procedure / Operative
Re exploration after history and examination with
Obstetrics & Secondar Notes, Intra procedure clinical
laparotomy / Caesarean SO058B Re exploration after laparotomy 14,000 No No No 5 Y indications for the
Gynecology y photograph/ stills; progress
Section procedure,Relavant Investigations
notes,Detailed discharge summary
(establishing diagnosis) , USG

Obstetrics & Normal Delivery / Breach / Secondar

SO060CGA Normal Delivery / Breach / Vaccum / Forcep 1,000 No Yes No 1 Y Clinical Notes Clinical Notes
Gynecology Vaccum / Forcep y

Clinical notes detailing when was

cataract surgery was done and
procedure notes, Detailed discharge
notes mentioning indication for this
Ophthalmology Capsulotomy (YAG) SE022A Capsulotomy (YAG) 1,000 No No No Tertiary 1 N summary, Still image of the the
procedure with vision and fundus.
procedure with pt. ID and date
Clinical photo of patient before
procedure

Clinical notes showing Indication Still image of the the procedure

Secondar
Ophthalmology Iridectomy SE026A Iridectomy 1,000 No No No 1 N for Iridectomy(Laser), Tonometry, with pt. ID and date, procedure
y
Gonioscopy,and clinical photo notes. Detailed discharge summary

discharge summary, clinical notes,

Retinal Laser Secondar clinical notes and or supportive
Ophthalmology SE029A For retinal tear repair Per Eye Per Sitting 1,500 No No No 1 N Still image of the the procedure
Photocoagulation y documents
with pt. ID and date

Discharge notes, pathology report,

Secondar Patient details, diagnosis, doctors
Ophthalmology Chalazion Removal SE007A Chalazion Removal 2,000 No Yes No 1 N Still image of the patient undergoing
y notes, photo
the procedure with date stamp

Clinical Notes for the associated

GA / EUA separate add on Secondar Clinical Notes justifying the need surgery / disease along with Pre OP,
Ophthalmology SE040A GA / EUA separate add on package 2,000 No No No 1 N
package y for GA in the associated surgery Operative and Anesthesia, Post OP
notes
Indication for Evisceration and Detailed discharge summary, Still
supporting investigation report, image of the the procedure with pt.
Clinical Photograph, ID and date,operative notes,
Secondar
Ophthalmology Evisceration SE036A Evisceration 2,800 No No No 1 N Recommendation/opinion of 2 Confirmation/declaration that
y
ophthalmologists for the procedure, specimen sent for lab
stated plan for lab investigation of investigationmicrobio/path and
host tissue (HP/ Microbiology/other) report will be submitted
operative notes, Still image of the
Ophthalmology Corneal / Scleral Patch Graft SE016A Corneal / Scleral Patch Graft 3,000 No No No Tertiary 3 N preoperative clinical photo patient undergoing the procedure
with date stamp
Clinical notes establishing Intra procedure clinical photograph,
Indication and justifying detailed discharge summary,
Ophthalmology Enucleation SE035A Without implant 3,000 No No No Tertiary 2 N enucleation and supporting ,operative notes, confirmation that
investigation, Clinical Photograph; specimen was sent for
Recommendation/opinion of 2 histopathology.
ophthalmologists
Clinical for the procedure
notes establishing long
standing history of Glaucoma with Detailed Procedure / Operative
Ophthalmology Glaucoma Surgery SE027A Cyclocryotherapy / Cyclophotocoagulation 3,500 No No No Tertiary 1 N
recent documentation of vision and Notes and discharge summary.
reports of field of vision.

Detailed discharge summary, Still

Secondar Clinical notes and Clinical
Ophthalmology Entropion correction SE002A Entropion correction 4,000 No No No 1 N image of the the procedure with pt.
y Photograph
ID and date,operative notes.

Clinical notes and Retinoscopy, Still image of the the procedure

Pterygium + Conjunctival Corneal topography (not with pt. ID and date, detailed
Ophthalmology SE014A Pterygium + Conjunctival Autograft 4,000 No No No Tertiary 1 N
Autograft mandatory), keratometry, Clinical discharge summary, detailed
Photograph operative notes.

Subject to change by National Health Authority, AB-PMJAY

Page 10 of 10133