Guidelines to CGHS Empanelled hospitals on referal letters and settlement of claims

Department of Health and Family Welfare, Ministry of Health and family welfare has formulated certain guidelines for Private empaneled hospitals and UTI Infrastructure Technology and Services Limited (UTIITSL) which is entrusted with the processing of settlement of claims in case of reference made by CGHS to empaneled hospitals.

These guidelines are relating to various clarifications sought for on referral letters and settlement of bills of Empanelled Hospitals / Diagnostic Laboratories / Imaging Centres through UTI-ITSL

Government of India
Ministry of Health and Family Welfare
Department of Health & Family Welfare
Nirman Bhawan, New Delhi 110 108

No:S.110011/23/2009-CGHS D.II/Hospital Cell (Part IX)

Dated, the 20th December, 2011

CIRCULAR

Subject: Guidelines regarding referral letters and settlement of bills of Empanelled Hospitals / Diagnostic Laboratories / Imaging Centres through UTI-ITSL

With reference to the above mentioned subject the undersigned is directed to state that in response to several queries received by Ministry seeking clarifications regarding settlement of hospital bills through UTI-TSL, it has been decided to issue the following guidelines for the Empanelled Hospitals / Diagnostic Laboratories / Imaging Centres, CGHS and UTI-ITSL:

 

2(A) INSTRUCTIONS TO EMPANELLED HOSPITALS / DIAGNOSTIC LABORATORIES / IMAGING CENTRES

1. The empanelled Hospitals / Diagnostic labs / Imaging Centres will honour permission letters (Referral letters) duly signed and stamped with proper issue number. Wherever the permission letters have been issued through computers, any manual corrections should be duly countersigned and stamped.

2. The Hospital shall not undertake treatment of referred cases in specialties for which it is not empanelled, But it shall provide necessary treatment to stabilize the patient and transport the patient safely to nearest recognized hospital under intimation to CGHS authorities. However in such cases the Hospital shall charge as per the CGHS rates only for the treatment provided.

3. The Hospitals / Diagnostic labs / Imaging Centres should provide treatment only for the procedures / investigations for which they are empanelled. If any inadvertent permission letter has been issued for other procedures for which they are not empanelled, the Hospital / Diagnostic lab / Imaging Centre will inform the beneficiary accordingly and refer him / her back to the dispensary, except in emergency condition.

4. In case of procedures like Chemotherapy / Radiotherapy / Dialysis and follow—up treatment procedures where the permission is valid for 3-6 months and a copy of the permission letter is enclosed with the hospital bill for the second and

5. subsequent admissions, hospitals will indicate the ID No. of the Claim wherein original permission letter had been enclosed.

6. CGHS Cards / Plastic cards are valid in all CGHS cities, irrespective of the city where the CGHS card is registered. In case any verification regarding the photocopies of Plastic card / CGHS card is required the details of the individual may be ascertained by accessing the data online at http://cqhs.nic.in/welcome.jsp by entering relevant details. A print out of the same may be enclosed. The beneficiary will not be asked to submit a colour photo copy of CGHS / Plastic Card.

6.1 In case of implants and coronary stents the bills must be accompanied by a copy of the relevant invoices pertaining to the procurement of the stents / implants by the hospitals. In addition to this, the outer pouch of the Stent packet along with the sticker on it on which details of the stent are printed shall also be enclosed with the medical bill for claiming reimbursement. In case of medicines, a consolidated list with relevant batch numbers and cost must be enclosed.

6.2 The empanelled hospital shall also submit a self certified undertaking that the hospital has not charged the CGHS / CS(MA) beneficiary more than the rate at which stent / implant / medicine has been procured by the hospital and in case of any detection and establishment that the hospital has overcharged the hospital shall be removed from the list of hospitals empanelled under CGHS without any further notice.

7. In case of serving employees admitted under emergency, the hospitals shall ensure that the details pertaining to the office where the patient is employed are entered in records.

8. In case of indoor treatment, routine investigations are included in the package.However, if any special investigations are performed, reports of such special investigations should be enclosed and reimbursement shall be considered on merits of each case.

9. ICU — package includes — accommodation charges in ICU, Monitoring and ECG.Other investigations cost of medicines and disposables and ‘2’ consultations charges per day are reimbursable as per applicable norms in addition to the package rate of ICU, Cost of ventilator and oxygen if, any are reimbursable as per applicable norms. In selected cases, where opinion of other specialists is necessary, only one consultation by a specialist per day may be considered necessary. Reports of Investigations should be enclosed along with the opinion of the other specialist.

10. In case of emergency treatment wherein a CGHS beneficiary has been admitted for more than 10 days detailed summary of reports of all the Investigations shall been closed.

11. In case of CAG / Angioplasty / CABG, the bills should be accompanied by the findings of Coronary angiography test of the beneficiary.

12. In case of pensioner CGHS beneficiaries on a visit to another city and treatments taken under medical emergency or with prior permissions, hospitals / diagnostic centres will send hospital bill through UTI- ITSL to CGHS of City, where the hospital / diagnostic centre is located, irrespective of the CGHS city, where the card is registered.

13.The rates and guidelines for Exclusive cancer hospitals are applicable only for Exclusive Cancer hospitals / units approved under Exclusive Cancer hospitals.

2(B). INSTRUCTIONS TO UTI-TSL

1. UTI-ITSL shall have to thoroughly scrutinize the physical bills submitted by hospitals before they are accepted. This is to ensure that the hospitals receive provisional payments within 10 days of submission of the physical bills.

2. UTI-ITSL shall seek clarifications, if any, within a maximum of ‘3’ days of receipt of the physical bill- all clarifications in one go.

3. UTI-ITSL shall submit physical bills to CGHS in small bundles and ensure that they are acknowledged by CGHS.

4. UTI-ITSL and CGHS shall ensure that reconciliations of the payment of bills with Pay & Accounts Officer is undertaken regularly.

5. UTI-ITSL shall inform the details of deductions made including TDS.

6. UTI-ITSL shall ensure that recoveries, if any are made from subsequent bills of hospitals.

2(C). INSTRUCTIONS TO ADs / JDs / CMOs I/C

1. Permissions shall be issued only for eligible persons and against approved hospitals and diagnostic centres It is the responsibility of the CMO i/c to ensure that permissions are issued only for approved centres and listed procedures.

2. Permission letter should be specific for the treatment / investigation to be undertaken.

3. In case of Chemotherapy / Radiotherapy and Haemodialysis, the permission letters shall clearly mention the number of cycles of Chemotherapy / Radiotherapy planned and how many dialyses are to be undertaken in a week.

4. CMOS i/c shall ensure that permission letters are issued on the same day, if a beneficiary applies for the same before 11 AM.

5. Addl Directors / Joint Directors shall not return the bills in original (RIO) to UTI-ITSL without specifying valid reasons or indicating the deficiencies or the amount to be adjusted in subsequent bills.

6. ADs / JDs shall indicate to UTI-ITSL, the details of deductions made in claimed amount — bill wise – online through an excel sheet.

7. ADs / JDs shall hold review meetings with representatives of UTI-ITSL and hospitals and diagnostic centres on a regular basis.

3.   These instructions will be applicable from 26/12/2011.

4.    Old settled cases shall not be reopened.

5.    These instructions shall supercede the earlier decisions taken during the meeting held on 5th , 6th and 7th of September 2011 in the office of Addl. Director, CGHS(HQ), New Delhi.

UTI-ITSL, ADs including AD (HO)  / JDs of CGHS / Empanelled Hospitals / Diagnostic Laboratories / Imaging Centres shall comply with these instructions & guidelines.

sd/-
(V.P.Singh)
Deputy Secretary to Government of India