Timelines for settlement of Medical Claims in CGHS -Procedure

Prescription of Timelines under CGHS for settlement of Medical claims of Pensioner CGHS beneficiaries – Maximum of 45 days to 90 days prescribed

CGHS circular for prescribing Timelines for settlement of Medical Claims

Government of India

Ministry of Health and Family Welfare

Department of Health & Family Welfare

Directorate General of CGHS

Office of the Director, CGHS

No: Z.15025/79/1/DIR/CGHS

545-A Nirman Bhawan, New Delhi

Dated the 5th October, 2016

OFFICE MEMORANDUM

Subject :- Prescription of Timelines under CGHS for settlement of Medical claims of Pensioner CGHS beneficiaries.

With reference to the above subject the undersigned is directed to state that it has now been decided to define ‘Time Lines’ for processing and settlement of medical claims of pensioner CGHS beneficiaries as per the details given under:

Medical_Claims not requiring Special approvals

i. Issue of Serial No. for Medical Claim at CGHS WC – same day

ii. Submission of physical bill to Office of AD – within 7 days

iii. Processing of Claims by Dealing Asst. and submission to CMO(R&H) – within 10 days

iv. Processing of Medical claims by CMO(R&H) – within 7 days

v. Sanction of Addl. Director and return to CMO – within 3 days

vi. Preparation of Bill and submission to P&AO – within 7 days

(Total within 45 days)

Medical claims

requiring approval of higher authorities

Total time within 60 days in Delhi

Total time within 90 days in other cities

Medical claims

requiring opinion of specialists

Total time 60 days

Medical Claims requiring STC approval for full reimbursement

1st STC meeting may be conducted within 90 days

Chief Medical Officer in charge shall thoroughly check the papers initially for the completeness of the requisite documents before accepting the claim papers to ensure that the claim papers are not returned subsequently for want of some documents.

(D.C.Joshi)

Download CGHS Circular No: Z.15025/79/1/DIR/CGHS dated 05.10.2016