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Tender for Medical Audit of Bills of CGHS Recognized

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									            TENDER     DOCUMENT



                 FOR



        Medical Audit of Bills of CGHS

Recognized Private Hospitals/Diagnostic Centres

                     By TPAs.
                              F.NO.I.25012/3/2008-CGHS Desk.II
                                 GOVERNMENT OF INDIA
                         MINISTRY OF HEALTH & FAMILY WELFARE
                                      CGHS DIVISION


                                         TENDER DOCUMENT

                                                  FOR

      MEDICAL AUDIT OF BILLS OF PRIVATE HOSPITALS/DIAGNOSTIC CENTRES
                        RECOGNISED UNDER THE CGHS


                                         Revised Bidding Schedule


1. Price of blank Bid Document   :           Rs.1000/- (Rs. One Thousand Only) Payable
                                             Through Demand Draft in the name of “Pay
                                             and Accounts Officer, CGHS, Delhi” from
                                             any Nationalised/Scheduled Bank.

2. Last date for submission of
   completed sealed Bid Documents :          16.03.2009 upto 4.00 pm.

3. Amount of Earnest Money Deposit:          Rs.2,00,000/-

4. Address of Receiving Office       :       Director, CGHS, Room No.545-A Wing,
                                             Nirman Bhawan, New Delhi.

5. Date and Time of Opening of
   Bid Documents.                    :       19.03.2009 at 3.00 pm (Room No.545-A
                                             Wing, Nirman Bhawan, New Delhi.
                                             I N D E X



Sr.No.                   Description                             Page No.

1        Scope of work                                           1
         Eligibility

2        Earnest Money                                           2
         Conditions of Tender
         Technical Bid

3        Financial Bid                                           3

4        Period of Validity of Bids                              4
         Period of Contract

5        Performance Security Guarantee
         Penalties                                               5
         Bidders Declaration

6        List of CGHS Cities (Group-wise)                        6

7        Tender Format                                           7

8        Documents Required (Annexure-1)                         8

9        Declaration of the Bidder (Annexure-2)                  9

10        Letter of Authority (Annexure-3)                       10

11       Bid Letter (Annexure-4)                                 11

12        Price Schedule (Annexure-5)                            12

13        Financial Capability of the Bidder (Annexure-6)        13

14        Bank Guarantee for Performance Security (Annexure-7)   14
                         Tender for Medical Audit of Bills of CGHS Recognized
                            Private Hospitals/Diagnostic Centres by TPAs.



Terms and Conditions


1.       Scope of Work

The Third Party Administrators (TPAs) will medically audit the bills of CGHS Private Recognised
Hospitals/Diagnostic Centres in all the CGHS cities (as per Annexure-A) for the treatment/services taken
by the CGHS beneficiaries in those Hospitals/Diagnostic Centres to determine/see:

     a) Appropriateness of treatment / line of treatment including screening of patients records to identify
        unnecessary admission and unwarranted treatment.
     b) Whether investigations/treatment carried out by the hospital were necessary for the treatment and
        as per the approved CGHS rates and package rates.
     c) Whether the duration of stay of the patient in the hospital was justified for the treatment.
     d) Whether the planned treatment has been shown as emergencies.
     e) Whether the Procedures investigation that were not required were conducted by the Hospital
        including unnecessary investigation.
     f) Verify the calculation.
     g) Whether the number of visits of the doctors/specialists was necessary for the treatment and as per
        the norms of CGHS.
     h) Disallow payments for unnecessary/inapproprite treatment and restrict the amount payable to
        CGHS approved rates.
     i) Provide the final calculation sheet in soft copy also to be hosted on the website.

The TPA shall provide Management Information System reports whereby CGHS will be provided
information regarding the number of claim files received for audit, number of cases audited and number of
cases pending. The reports will be submitted by the TPA to the CGHS on regular weekly basis.

2.       Eligibility

              1) The TPA should be registered with the Insurance Regulatory and Development
                 Authority (IRDA) for not less than 03 years as a TPA for health/medical insurance.


               2) The TPA should have at least one of its CEO/CAO/COO/CFO as professionally qualified
                  Chartered Accountant/Cost Accountant with a minimum experience of at least 10 years
                  and out of which he/she should have had at least two years‟ experience in conducting
                  medical audit of similar type covered by this Tender. A satisfactory certificate from the
                  organization(s) for which it conducted the medical audit must be attached along with
                  copy of the medical audit report.
            3) The TPA should have at least one Director as a qualified medical practitioner, with at
              least two years‟ continuous experience in conducting medical audit. List of organizations
              for whom medical audit has been conducted must be attached.

             4) The TPA should have a net worth of not less than Rs.1.00 Crore for the last three
              financial years (Statement to be filed in the Format at Annexure-6)


3.    Earnest Money

           The Bidders are required to submit a Demand Draft of Rs.2,00,000/- (Rupees Two Lakhs) as
           Earnest Money from any Scheduled/Nationalized Bank in the name of “Pay and Accounts
           Officer, CGHS Delhi” along with the bid documents.


4. Conditions of Tender


      i.        Tender documents can be downloaded from the website of Ministry of Health & Family
                Welfare at www.mohfw.nic.in .

      ii.       Tender documents should be submitted in two separately sealed envelopes - one each
                for Technical Bid and Financial Bid subscribed as „Tender for Medical Audit of the
                bills of CGHS empanelled Private Hospitals/Diagnostic Centres‟ at the office of the
                Director, CGHS. Both the sealed envelopes shell be kept in the third envelope.

      (A) Technical Bid

      (A) iii. The Technical Bid envelope shall contain the earnest money of Rs.2, 00,000/-(Rs. Two
               Lakhs Only) in the form of a Demand Draft in the name of “Pay and Accounts Officer,
               CGHS Delhi” from any Scheduled/Nationalized Bank and also the documents
               establishing the bidders eligibility.

      (A) iv. Cost of Tender document Rs.1000/- in the form of Demand Draft in name of “Pay and
              Accounts Officer, CGHS Delhi” from any Scheduled Nationalized Bank.

      (A) v. Tender Format along with Documents as mentioned in Annexure -1 with proper seal
             and signature of the authorized person on each (each page is to be serially numbered).




                                                       2
(B) Financial Bid

       (B) vi. The Financial Bid envelope shall contain the rates in the form of Price Schedule (
               Annexure-5) indicating the total cost in figures as well as in words (Group-wise).

       (B) vii. The Technical Bid will first be opened on a date to be specified and the Financial
                Bid will be opened only of those tenderers who qualify in the Technical Bid.

             viii. In the event that two or more bidders have quoted same rates, CGHS may.

                        (a).    Invite fresh proposals only from the bidders quoting the same rates.
                                However, the fresh rates should not be higher than the one quoted
                                originally

                                       Or

                        (b)     Take any such measure as may be deemed fit in its sole discretion,
                                including annulment of the bidding process.

ix.          The tender is liable to be ignored if the information given in eligibility criteria is not
             complete.

x.           The tender document must be accompanied with the set of necessary substantiating
             Documents as given in Annexure-1

xi           Every page of tender document and enclosures must be serially numbered and signed
             by the competent person. The signatory must mention as to whether he/she is the sole
             proprietor or partner. In case of partnership, a copy of the partnership agreement duly
             attested by a Notary should be furnished. Similarly, in case of authorized signatory,
             appropriate legal document should be furnished.

xii.         The CGHS will declare a Bidder firm ineligible, either indefinitely or for a stated
             period of time, to be awarded a contract if it at any time determines that the firm
             has engaged in corrupt and fraudulent practices in competing for, or in executing the
             Contract.

     xiii.    The Director, CGHS reserves the right to accept or reject any bid, and to annul the
              bidding process and reject all bids at any time without thereby incurring any liability
              to the affected Bidder or Bidders or any obligation to inform the affected Bidder or
              Bidders of the grounds for the CGHS‟ action

     xiv.     Nothing under the contract shall be construed as establishing or creating between the
              parties any relationship of Master and Servant or Principal and Agent between the
              CGHS and TPA.

                                               3
      xv.     The TPA shall not represent or hold itself out as agent of the CGHS except to the
              extent of its duties or activities provided under the Contract.


      xvi.    The employees of the TPA will not have any relation or relationship with the
              CGHS/Govt. in any way. They will be treated as the employees of the TPA for all the
              purposes.

      xvii.   The CGHS will not be responsible in any way to the employees of TPA for any
              accident, injury, or damage sustained or suffered by them or their agent or any third
              party resulting from or by any operation conducted by and on behalf of the TPA or in
              the course of doing this work.

      xviii. The TPA shall notify the Government of any material change in their status and their
             shareholdings or that of any Guarantor of the TPA in particular where such change
             would have an impact on the performance of obligation under this contract.

      xix.    Tenders shall be opened at the office of the Director, CGHS. Every tenderer or his
              authorized agent can be present at the time of opening of the tenders.

      xx.     If the bid submitted by a TPA does not fulfill any one or all other conditions of the
              tender, the bid is liable to be rejected straight away without any liability on
              CGHS/Ministry of Health & Family Welfare.

      xxi.    The Director (CGHS) reserves the right to award the work at L1 rates to more than
              one TPA in addition to the bidders whose L1 rates have been accepted by the CGH S,
              if the lowest acceptable bidder viz TPA is not in a position to execute the full amount
              of work.


5.   Period of validity of Bids

     Bids shall be valid for acceptance for 100 days after the date of bid opening prescribed by the
     CGHS. Any bid valid for a shorter period shall be treated as unresponsive and rejected.

6.   Period of Contract

     The period of the contract shall be one year from the start of Contract. However, strictly on the
     basis of the satisfactory performance it is liable to be extended on an annual basis at the sole
     discretion of Director (CGHS) on the same terms & conditions for a maximum period of two
     more years.




                                                    4
7.   Performance Security Guarantee

     The successful bidder will have to furnish a Bank Guarantee for Performance Security for an
     amount of Rs.20 lakhs from a Scheduled/Nationalized Bank, valid for 12months after the date
     of completion of performance obligations, including warranty obligations, in the format
     specified in Performance Security Form (Annexure 7) provided in the tender document. If the
     period of contract will be extended the bank Guarantee shall have to renewed by successful
     bidder for further 12 months period.

8.   Penalties

     The tenderer shall maintain and manage the system mentioned in the Tender. In case violation
     of the provisions of the specifications and conditions of the Contract the sum of Rs.2,00,000/-
     (Rs. Two Lakhs) representing the Earnest Money will be forfeited.

     In addition, 10% to 15% of the bills submitted by the TPA shall be counter audited by CGHS
     randomly and in case of over payments to the Hospitals/Diagnostic Centers, five times the
     amount overpaid shall be recovered from the Performance Security Guarantee. In case of
     underpayments, two times amount underpaid shall be recovered. In case the amount to be
     recovered exceeds 50% of the Performance Guarantee at any point in time then necessary steps
     shall be initiated to terminate the contract and rest of the Performance Security Guarantee shall
     be forfeited and such TPA shall be debarred from any future work from Ministry of Health and
     Family Welfare. IRDA shall be requested to blacklist such TPA. The decision taken by the
     Ministry in this regard shall be binding on the TPA.

     The office of the Accountant General and office of CCA, Ministry of Health and Family
     Welfare also conduct Audit of Government Bills periodically and if they point out any
     irregularity in the bill already audited by the TPA then the concerned TPA will be answerable
     and that will be their liability.


9.   Bidders Declaration

     The Bidder will submit a declaration in the prescribed form duly signed by him or his
     authorized agent (Annexure-2)




                                              5
                                                        Annexure-A

NAME OF WORK: Medical Audit of Bills of CGHS Recognised Private Hospitals
              /Diagnostic Centers.

            List of CGHS Cities (Group-wise) Reference Annexure-5

          West Group

          (i)     Ahmedabad
          (ii)    Jaipur
          (iii)   Jabalpur
          (iv)    Nagpur

          East Group

          (i)     Bhubaneshwar
          (ii)    Ranchi
          (iii)   Patna
          (iv)    Guwahati
          (v)     Shilong

          South Group

          (i)     Pune
          (ii)    Trivendrum

          North Group

          (i)     Chandigarh
          (ii)    Dehradun
          (iii)   Meerut
          (iv)    Lucknow
          (v)     Kanpur
          (vi)    Allahabad
          (vii)   Bhopal

          Metro Group

          (i)     Delhi
          (ii)    Hyderabad
          (iii)   Mumbai
          (iv)    Kolkata
          (v)     Chennai
          (vi)    Bangalore
                                    6
                                    TENDER FORMAT

      NAME OF WORK: Medical audit of Bills of CGHS Recognised Private
      Hospitals/ Diagnostic Centers.
      (Technical and Infrastructure specification of the Third Party Administrators)

1.    Name of the Third Party Administrator.

2.     Address of the Third Party Administrator
      (Incl. Telephone No./Fax /E-mail /website /SMS No.

3.    Ownership (Specify)

4.    Ragistration number of licence issued by IRDA and the period of validity

5.    Details of staff on regular basis (with Qualification and Experience)
           a. Medical Consultant (s) (Post Graduates)
           b. Accounting Staff.
           c. Computer Professionals
           d. Data Entry Operator
           e. Clerk.
           f.    Group „D‟ Staff
6.    Details of the Staff on Provisional basis (with Qualification and Experience)
            a. Medical Consultant
            b. Accounting Staff.
            c. Computer Professionals
            d. Data Entry Operator
            e. Clerk
            f.    Group „D‟ Staff
7.    Office Equipment
            a. Computer with printer.
            b.    Photocopier
            c.    Internet
            d.    Fax.

8.    Names of the Government departments/PSU‟s for which auditing work has
      been done / is being done for the last three years.

9.    Office Accommodation in various cities.

10. Whether TPA is having any Association /Affiliation with any Hospital/ chain of Hospital.


                                                                             Signature
                                    Head of Firm / Authorized Signatory / Agent
                                        7
                                                                             Annexure-1
NAME OF THE WORK:-Medical Audit of Bills of CGHS Recognised Private Hospitals/
                  Diagnostic Centers.

 The following are the minimum documents that are to be submitted along with the Tender
                          (Technical Bid):-


      1. Earnest Money of Rs. 2,00,000/- (Rupees Two lakhs) in the form of a demand draft in the
         name of “Pay and Accounts Officer, CGHS, Delhi” from any Scheduled Commercial/
         Nationalized Bank.

      2. Tender cost of Rs.1,000/- in the form of DD in the name of “Pay and Accounts Officer, CGHS,
         Delhi” form any Scheduled Commercial/ Nationalized Bank.

      3. Attested Copy of certificate of registration with IRDA.

      4. Attested Copy of qualifications and experience certificate of CEO/CPP/CAO/CFO.

      5. Certificate from a Chartered Accountant about the net worth of theTPA for the last three years
         in the format prescribed at Annexure-6.

      6. Certified copy of certificate of incorporation/ partnership deed/ any other legal document that
         would establish the legal status, place of registration and principal place of business of the
         firm, etc.

      7. Authorization letter of signatory signing the bid as per format prescribed at Annexure-3.

      8. Name and address of the bankers of the TPA.

      9. Declaration of the TPA in Annexure-2.

      10. Bid Letter as in Annexure-4.

      11. Declaration on the TPA‟s letter-head that, the Financial Bid covers all the items of the Bid
          Document.

      12. Certificate that the TPA and any of its employee does not have any association or affiliation
          with any hospital or chain of hospitals recognised by the CGHS.


         Note: Tenders not containing the above particulars are liable to be ignored.


                                                          8
                                                                           Annexure-2
                    DECLARATION OF THE BIDDER (SAMPLE)

NAME OF WORK: Medical Audit & Computerised Processing of Bills of CGHS Recognised
Private Hospitals / Diagnostic Centers.


I/We hereby declare that the particulars given in the Tender document are correct to the best of my
knowledge and belief.


I/We have fully studied the various relevant data/requirement covered under this tender.

I/We have also made my/ourselves conversant with the local conditions, place of various service
deliveries, statutory requirements.

Should this tender be accepted. I/We hereby agree to abide by and to fulfill all the terms and the
provisions of the specifications and conditions of contract annexed hereto so far as they may be
applicable, and in default thereof to forfeit and pay to the Government to India the sums of Earnest
Money mentioned in the said conditions.




Signature
Bidder




                                                    9
                                                                Annexure-3
                                    Letter of Authority

                            (To be signed by the Head of the firm)

NAME OF WORK: Medical Audit & Computerised Processing of Bills of CGHS
Recognised Private Hospitals / Diagnostic Centers.



Shri…………………….working                 as……………………….in                  (Name      of  the TPA)
………………........has been authorized to sign the Tender documents for the Medical Audit of
Bills of CGHS Recognised Private Hospitals / Diagnostic Centers on our behalf. He is also
authorized to take decisions whatever is necessary in connections with this tender.


The specimen signature of Shri………………………are given below duly attested by us.



Specimen Signature of Shri………..                  Attested by (Name of the TPA with Stamp)




______________________________                     __________________________________




                                          10
                                                                          Annexure-4
                                         BID LETTER

NAME OF WORK: Medical Audit & Computerised Processing of Bills of CGHS Recognised
Private Hospitals / Diagnostic Centers.

To,

The Director, CGHS
Room No. 545 „A‟ Wing,
Nirman Bhawan, New Delhi.

Sir,

         I/We hereby tender for the execution, for the President of India (hereinbefore and
hereinafter referred to as “Government”) of the work Specified in the under-written Memorandum
within the time specified in such memorandum at the rates entered in Annexure 5 and in
accordance with the specifications, and instructions, in writing referred in the description of the
item.

MEMORANDUM


(a)    General description: Medical Audit of Bills of CGHS Recognized Private / Hospitals /
       Diagnostic Centers.

(b)    Amount of Earnest-Money to be paid by Demand Draft of Rs.2,00,000/- (Rupees Two
       lakhs).

(c)    Time allowed for the work from the date of written order to commence 45 days from the
       date of issue of the work order.



Yours faithfully,
Signature & Seal
(Bidder‟s Address)

                                                    11
                                                                         Annexure-5
                                   Price Schedule

NAME OF WORK: Medical Audit of Bills of CGHS Recognised Private Hospitals /
              Diagnostic Centers.

(Rates to be quoted Group-wise as per the list of CGHS Cities Annexure-A)


      S. No.         Nature of Bill/Claim        Cost per bill/ claim both in figures and words




        1                 OPD Bill


        2               IPD Bill upto
                         Rs. 5 Lakhs

        3              IPD Bills above
                         Rs. 5 Lakhs

        4              Diagnostic Bill




Signature & Seal
Of the Bidder

                   Note: - Separate sheet should be used for each Group.


                                            12
                                                                        Annexure-6

NAME OF WORK: Medical Audit of Bills of CGHS Recognised Private Hospitals /
Diagnostic Centers.

              Financial Capability of the Bidder (to be submitted by the bidder)

Name of Bidder…………

 S. No.                                   2007- 2008     2006- 2007    2005- 2006
   1.     Paid up Enquity
   2.     Reserves
   3.     Revaluation Reserves &
          Special Reserves if any
   4.     Miscellaneous Expenditure
          not written off
   5.     Profit After Tax
   6.     Depreciation
   7.     Non Cash Expenditures (other
          than depreciation )
   8.     Net Worth = 9(Paid up equity
          + Reserves) - (Revaluation
          Reserves + Miscellaneous
          Expenditure not Written Off)
   9.     Net Cash Accruals = Profit
          After Tax + Depreciation +
          other non-cash expenditure

  10.     Average Net Worth
  11.     Average Net Cash Accruals


This information should be extracted from the Annual Financial Statement / Balance Sheet, which
should be enclosed, and this response sheet shall be certified by the Statutory Auditor of the
Bidder. “Other Non-Cash Expenditure” items (S.No.7) should be individually mentioned along
with corresponding amounts. The Bidder should provide the Financial Capability of its own.
Financial Capability of the Applicant‟s parent company or its subsidiary will not be considered.


                                                  13
                                                       Annexure-7
NAME OF THE WORK: - Medical Audit of Bills of CGHS Recognised Private
Hospital/Diagnostic Centers
             BANK GUARANTEE FOR PERFORMANCE SECURITY
To
      The President of India,
      Acting through
      (Name and Designation of Director, CGHS
      With complete address)

       WHEREAS_____________________________________________________________
(Name of successful Bidder) herein called “the Successful Bidder” has undertaken, purchase of
Contract No.________________________________________________________________dated
__________, 2008 to _______________________________________________________
(Description of Services) hereinafter called “the Contract”.

        AND WHEREAS it has been stipulated by you in the contract that the successful Bidder
shall furnish you with a Bank Guarantee by a scheduled commercial bank for the sum specified
therein as security for compliance with the Successful Bidder‟s performance obligations in
accordance with the Contract.

       AND WHEREAS we have agreed to give the Successful Bidder such a Bank guarantee.

        AND THEREFORE we hereby affirm that we are guarantors and responsible to you, on
behalf of the Successful Bidder, up to a total of ……………………(Amount of the guarantee in
words and figures), and we hereby irrevocably and absolutely undertake to pay you immediately,
upon your first written demand declaring the Successful Bidder to be in default under the contract
and without cavil or argument, any sum or sums within the limits of (amount of guarantee) as
aforesaid, without your needing to prove or to show grounds or reason for your demand or the sum
specified therein.

       We hereby waive the necessity of your demanding the said debt from the Successful Bidder
before presenting us with the demand.

       We further agree that no change or addition to or other modification of the terms of the
contract to be performed there under or of any of the contract documents which may be made
between you and the Successful Bidder shall in any way release us from any liability under this
guarantee and we hereby waive notice of any such change, addition or modification.

       This guarantee will not be discharged due to change in the constitution of the “Bank or the
Bidder”.
       This guarantee shall be valid upto and including the _________day of 200___.

Signature & SEAL
Of Guarantor                                       14

								
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