CGHS – Delegation of powers for settlement of reimbursement claims

CGHS – Delegation of powers for settlement of reimbursement claims / Permissions ex-post-facto approval in respect of Pensioner CGHS beneficiaries

Ministry of Health and Family Welfare OM on Delegation of powers for settlement of reimbursement claims

 Government of India

Ministry of Health and Family Welfare

Department of Health & Family Welfare

Nirman Bhawan, New Delhi 110108

No: Z.15025/79/2/DIR/CGHS

Dated the 5th October, 2016

OFFICE MEMORANDUM

Subject- Delegation of powers for settlement of reimbursement claims/Permissions ex-post-facto approval in respect of Pensioner CGHS beneficiaries, etc.

With reference to the above subject the undersigned is directed to state that that the matter has been reviewed by the Ministry in view of the difficulties faced by the CGHS pensioner beneficiaries Therefore, with a view to streamline and to simplify the procedures. it has now been decided to further delegate powers to the Addl. Directors of CGHS Cities / Zones in respect of CGHS pensioner beneficiaries. etc. as under:

i) Permission / ex-post facto approval in non-empanelled hospitals / Diagnostic Labs /Imaging Centre:

Requests for permission ex-post facto approval for elective treatment / investigations in non-empanelled hospitals / diagnostic centres in respect of Pensioners/ex-MF’s/freedom Fighters, etc. shall be considered by Addl. Director of concerned CGHS city / Zone subject to the reimbursement being restricted to CGHS package rates or actual expenditure, whichever is less

ii) Permission / ex-post facto approval in cases involving procedural lapse:

Requests for approval of elective treatment / investigations in empanelled hospitals / diagnostic centres without recommendation of Govt. Specialist or CMO and without prior permission in respect of Pensioners/ex-MPs/freedom Fighters, etc, shall be considered by Addl. Director of concerned CGHS city / Zone subject to the reimbursement being restricted to CGHS rates or actual expenditure whichever is less.

iii) Delegation of Powers for Settlement of Medical Reimbursement Claims (at approved rates) of Individual Pensioner Beneficiary. etc,

iv) Delegation of Powers for settlement of Hospital Bills (at approved rates) for the Treatment given to Pensioner Beneficiaries, etc,

v) Delegation of Powers for Permission / ex-post facto Approval / Settlement of Medical Reimbursement Claims of Individual Beneficiaries / Hospital Bills in respect of Unlisted procedures / Implants (no CGHS rates)

If there is no CGHS package rate for treatment I CGHS Ceiling rate for implant approval shall be granted as per AIIMS package rate (if only procedural charge. it shall not be considered as package rates)/ AIIMS rate for implant and if there is no CGHS/AIIMS rate approval shall be granted as per actual rate.

2. The revised delegations mentioned above will be subject to the conditions that it will not include any case involving relaxation of rules, irrespective of the amount involved. Further, cases where the amounts exceed the monetary limits prescribed above will have to be referred to the Ministry of Health & Family Welfare for obtaining the concurrence of Integrated Finance Division in the Ministry of Health & Family Welfare.

3. The above delegations are in supersession of all the earlier instructions in the matter in respect of the delegations now being conveyed.

This issues with the concurrence of Integrated Finance Division, Ministry of Health & Family Welfare, vide Dy. No C- 3373 dt. 20.09.2016

(Dr.D.C.Joshi)

Director, CGHS

Download CGHS OM No: Z.15025/79/2/DIR/CGHS dated 05.10.2016