Verification of Medical reimbursement claims in CGHS – Guidelines

Relaxation of procedures to be followed in considering requests for medical CGHS reimbursement.

CGHS medical reimbursement bills can be certified by the Doctor / Dean of the hospital who is giving the treatment. For special cases a team will be formed for approval.

No: 4-18/2005-C&P [Vol. l- Pt. (i)]

Ministry of Health & Family Welfare

Department of Health & Family Welfare

CGHS (P) Division

******

Nirman Bhawan, Maulana Azad Road

New Delhi, Dated the 20th February, 2009

OFFICE MEMORANDUM

Subject: Relaxation of procedures to be followed in considering requests for medical reimbursement.

The undersigned is directed to slate that under the extant instructions, a CGHS card holder who wishes to apply for reimbursement of the expenditure incurred by him / her on medical treatment of either self or his / her dependent family members, the present reimbursement procedure needs verification of bills and issue of essentiality certificate by the treating doctor, and the Medical Superintendent of the hospital. The process of verification of bills and issue of essentiality certificates are time consuming with the doctor at times being busy or being away from office for whatever reason. This necessitates repeated visits to the hospital for getting the verification done and essentiality certificate obtained. Representations have been received in the Ministry of Health & Family Welfare requesting for doing away with the two requirements and for the Ministries / authorities concerned to verify and check the authenticity of the claims on the basis of the prescription slip and the diagnostic report submitted by the Government servant / pensioner. in the event of any doubt, the concerned Ministry / Authority can always get verification done from the hospital concerned.

2. The undersigned is also directed to state that CGHS guidelines currently provide for relaxation of guidelines to cover full reimbursement in individual cases depending upon merits of each case. In the case of Hon’ble Members of Parliament, the powers to relax the guidelines have been delegated to the Lok Sabha Secretariat and Rajya Sabha Secretariat respectively and in the case of Hon’ble Chief Justice of Supreme Court and Judges of the Supreme Court to the Secretary General of the Supreme Court.

3. In order to reduce the burden on the Specialists in individual cases of medical reimbursement claim, it has been decided with the approval of heads of the hospitals to revise the guidelines for reimbursement by the competent authority as follows:

(1) It has now been decided to do away with the procedure for verification of bills and issue of essentiality certificate by the treating doctor and the Medical Superintendent of the hospital. Ministries / authorities concerned may verify and check the authenticity of the claims on the basis of the prescription slip and the diagnostic report submitted by the Government servant / pensioner. In the event of any doubt, the concerned Ministry / Authority can always get verification done from the hospital concerned. Modified reimbursement claim form. alongwith checklist is annexed.

(2) All cases involving requests for relaxation of rules for reimbursement of full expenditure will henceforth be referred to a Technical Standing Committee. to be chaired by the DGHS /Addl DGHS and consist of Director (CGHS) and subject matter specialists. if the Technical Standing Committee recommends the relaxation of rules for permitting full reimbursement of expenditure incurred by the beneficiary, the full reimbursement may be allowed by the Secretary (Health & Family Welfare) in consultation with IFD. A check list for consideration of requests for reimbursements in excess of approved rates may include:

(a) The treatment was obtained in a private non-empanelled hospital under emergency and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalised for a prolonged period;

(b) The treatment was obtained in a private non-empanelled hospital under emergency and was admitted for prolonged period for treatment of Head injury, Coma. Septicemia, Multi-organ failure, etc.;

(c) The treatment was obtained in a private non-empanelled hospital under emergency for treatment of advanced malignancy;

(d) The treatment was taken under emergency in higher type of accommodation as rooms as per his I her entitlement are not available during that period;

(e) The treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections;

(f) The treatment was obtained in a private non-empanelled hospital under emergency when there is a strike in Government hospitals:

(g) The treatment was obtained in a private non-empanelled hospital under emergency, while on official tour to non-CGHS covered area;

(h) Approval for air-fare with or without attendant on the advice of treating doctor for treatment in another city even though he is not eligible for air travel / treatment facilities are available in city of residence and

(i) Any other special circumstances.

4. The Office Memorandum is issued with the concurrence of IFD vide D.No: 908/AS FA12009 dated the 2oth February 2009.

(R Ravi)

Deputy Secretary to the Government of India

Download CGHS OM No: 4-18/2005-C&P [Vol. l- Pt. (i)] dated 20.02.2009