On boarding of CGHS empanelled HCOs on NHA IT Platform for paperless Hospital Billing

On boarding of CGHS empanelled HCOs on NHA IT Platform for paperless Hospital Billing: CGHS OM dated 16.06.2021

44/60/MCTC/CGHS2021/DIR/CGHS
Govt. of India
Min. of Health & Family Welfare
Department of Health & Family Welfare
Directorate General of CGHS

545-A Nirman Bhawan, New Delhi.
Dated the 16th June, 2021

OFFICE MEMORANDUM

Subject: On boarding of CGHS empanelled HCOs on NHA IT Platform for paperless Hospital Billing

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CGHS has initiated the process of transitioning of Hospital Billing from UTI-ITSL to National Health Authority (NHA) IT platform to make the entire process smooth and paperless. The hospital bill submission and processing related to CGHS empanelled hospitals and diagnostic centres (also called Health Care Organizations or HCOs) is being implemented through National Health Authority (NHA) IT platform in a phased manner.

To achieve the above, all currently empanelled HCOs are required to register themselves with the NHA. The HCOs are required to provide their details on Hospital Empanelment Module (HEM) https://hospitals.pmjay.gov.in/empApplicationHome.htm?actionVal=loginPage]. On submission of the HCO details on HEM, it shall be forwarded online to the CGHS Additional Director of the city/HQ for approval. Post approval, HCOs shall receive the login for onboarding the Transaction Management System (TMS) [https://cghs.nha.gov. in/CGHS/loginnew.htm].
As an extension of the existing system for issue of permissions and referral from CGHS Wellness Centres for OPD consultations, listed investigations, listed procedures and follow-up, the system has now been made online and shall be accessed through the TMS, by the HCO where the beneficiary wishes to avail services. Each OPD consultation /investigation/procedure/follow -up or a set of consultations/investigations/procedures/follow -up issued to a beneficiary would be tagged to a system generated unique referral D. On entering the referral ID in the TMS, the HCO would be able to access the components of the referral ID and the accompanying remarks entered by the doctor in the CGHS Wellness Centre.
In case the doctor in the Wellness Centre issues online permission on his/her own, it would be termed as “referral” and in case the doctor issues online permission based on prescription issued by an empanelled hospital specialist, it would be termed as “endorsement”.
As per existing CGHS guidelines, when the beneficiary visits the empanelled HCO of his/her choice, he/she is expected to produce the following documents: i. the valid CGHS plastic card/Index card/print out of e-CGHS card : it is mandatory to produce any one of these ii. the CGHS issued printout of the referral having the online generated Referral D or valid prescription(s) from Specialists of Government hospitals or valid prescription issued through eSanjeevani portal (these documents are not required in case of emergencies or in case of beneficiaries of age 75 years and above). In the event of power failure/ net connectivity issues at the Wellness Centre, offline endorsement/referral issued by a Wellness Centre shall be accepted by the HCO.
In addition, as an initial step, the HCOs would be required to verify the beneficiaries on the NHA platform through the Beneficiary Identification System (BIS) [https://bis.pmjay.gov.in/BIS/mobileverify] as a one-time measure, using the CGHS beneficiary ID or Aadhar Card. Beneficiary would be given the option by the HCO to undergo the Aadhaar authentication, as that would ease the delivery of service. Subsequent visit of the beneficiary to any HCO would not require verification on the BIS.
The HCOs would be required to book treatment (OPD consultation/ investigations/procedures/follow-up/admission) of CGHS pensioner beneficiaries and submit claims on the TMS for reimbursement by CGHS.
In case of those empanelled laboratories that are providing Home Collection as a special service, they can submit their claims, along with the following (to be collected by the Home Collection Service personnel either digitally or physically) : i. valid CGHS plastic card/print out of e-Index card or paper Index Card/print out of e-CGHS card ii. Copy of online referral print-out issued from CGHS wellness center with Referral ID or valid manual prescription from a government specialist or valid prescription generated through esanjeevani portal Lab Home services need to complete the online BIS process and can proceed with further process of raising the claim.
In those cases where the pensioner beneficiary is referred by the CGHS Wellness Centre, he/she would be required to share the referral slip containing the referral ID with the HCO. Only a single print out needs to be generated by the CGHS Wellness Centre for Referral ID(s) generated on a single day by a doctor in the Wellness Centre, even if a beneficiary needs to visit multiple HCOs. The HCO, if required, shall retain a scanned copy of the print out and return the original print out to the beneficiary.
The HCO would access the Transaction Management System (TMS) [https://cghs.nha.gov.in/CGHS/loginnew.htm] of the NHA and enter the referral ID, to view the components (OPD consultation/investigation/procedure/follow up) advised/endorsed by the CGHS doctor through the Referral Module. The HCO would select the components which the pensioner beneficiary wishes to get done at that HCO and are available in that HCO.
If the beneficiary is required to visit another HCO for remaining components of a referral ID, the subsequent HCO(s) would be able to view all the components in the referral ID including those that have been consumed by the previous HCO on TMS. However, the subsequent HCO(s) would be able to consume only those components of the referral ID, that have not been consumed by the previous HCO(s). The details of the status of the referral (consumed or not consumed) would be made available by NHA to the Wellness Centre also.
When a beneficiary visits an empanelled hospital for specialist consultation, the specialist would be required to advise the investigations/procedures/further OPD consultation in printed format/ clear legible handwriting, preferably mentioning the CGHS codes (serial number as per the CGHS rate list) to ensure that the doctor in the CGHS Wellness Centre is able to decipher the prescription issued by the empanelled hospital and generate an online “endorsement” through the Referral Module. Beneficiaries of age 75 years and above are not required to visit CGHS Wellness Centres for such “endorsements” for OPD consultations/listed procedures/ listed investigations.
For unlisted /unspecified investigations and procedures, advised in OPD, the pensioner beneficiaries (including those of age 75 years and above) would be issued permission by the Additional Director of the city/zone, as per extant CGHS guidelines. This permission issued by the Additional Director needs to be uploaded along with other documents by the HCO at the time of raising an intimation. In admitted beneficiaries, no permission is required to be issued by CGHS authorities.
In case of pensioner beneficiaries, ex-MPs, Freedom Fighters, serving beneficiaries of CGHS, DGHS and MoHFW, and such other categories of CGHS beneficiaries who are eligible for credit, the empanelled HCO would be required to extend cashless benefit, while the serving and pensioner beneficiaries belonging to autonomous bodies and serving beneficiaries would claim reimbursement from their Ministry/Department for treatment/investigation/procedure/consultation/follow up availed at the empanelled HCO, as per extant guidelines. Currently the hospital billing through NHA IT Platform is for pensioner beneficiaries only.
As per extant guideli9nes, the following three categories of beneficiaries are not required to visit the CGHS Wellness Centre for issue of permission for OPD consultation/listed investigations/ listed procedures/follow up: i. beneficiaries 75 years of age and above ii. beneficiaries carrying valid prescription(s) issued by specialists of any Government hospital/Centre iii. beneficiaries carrying valid prescription(s) issued through e-Sanjeevani teleconsultation The HCO would be required to upload such prescriptions in the TMS and capture online, the details of treatment/investigations/ procedures/further consultations advised in such prescriptions. This process shall also be followed by the HCO, in the event of offline endorsement/referral issued by a Wellness Centre due to power failure/net connectivity issues at the Wellness Centre. This information would also be made available in CGHS database by NHA.
For any deviation or addition of components by the HCO in the online referral/endorsement from the CGHS Wellness Centre or prescription issued by government hospital specialist (including tele-consultation through eSanjeevani ), the beneficiary would be required to visit the CGHS Wellness Centre for online endorsement.
Permission from CGHS Wellness Centres is not required for treatment in case of emergencies. Such cases would be auto approved by NHA at the empanelled hospital and treatment would be initiated.
The online intimation through TMS, regarding all beneficiaries registered/admitted by 11.59pm on a particular day, would need to be raised by the HCO by 11.59PM of the next day. A relaxation in this timeline would be given to HCOs till 30/06/2021.
HCOs shall submit the claim on the NHA TMS online system and same w ill be processed by a panel of claim processing doctors at NHA and approved for payment by CGHS sanctioning authority through TMS. PFMS system has been integrated with NHA’s TMS system for processing the payment directly into the bank account of the HCOs, upon sanction by competent authority. The provisions of this memorandum come into force on the date of issue.