Procedures to streamline Medical Reimbursement claims under CGHS

In the normal circumstances, the pensioner who is CGHS beneficiary and his/her dependent family members are entitled to get cashless medical treatment In CGHS empanelled private hospitals on a referral by a Government medical specialist / CMO in-charge, after obtaining prior permission from the CMO in-charge of the CGHS Wellness Centre/Dispensary they are attached to.

In certain situations, the pensioner and his/her dependents are also entitled for reimbursement of medical expenses incurred by themselves or any of their dependent family members.  In such cases, the pensioner has to file Medical Reimbursement Claims (MRCs) with the respective CGHS Wellness Centres they are attached to.

The CMO in charge of the concerned wellness centres, will examine the said claims with reference to the checklist perscribed to them and forward the claims to the Office of the AD/JD in charge of the Zone/City.  Thereafter, the concerned office of AD/JD will process the claim and do the needful to reimburse the admissible amount to the pensioner.

Based on the complaints received in this regard, the department of Health and family welfare has issued the following circular (F. No. S.11024/8/2011/CGHS(P) dated 14.11.2011).

F. No. S.11024/8/2011/CGHS(P)

Government of India

Ministry of Health and Family Welfare

Department of Health and Family Welfare

Directorate General of C,G.H.S.

Nirman Bhawan, New Delhi

Dated the 14th November, 2011

CIRCULAR

SUBJECT : Streamlining of Procedure for disposal of Medical Reimbursement Claims (MRCs) in CGHS

The pensioner CGHS beneficiaries and their dependent family members are entitled to get cashless medical treatment In CGHS empanelled private hospitals on a referral by a Government medical specialist / CMO in-charge, after obtaining prior permission from the CMO in-charge of the CGHS Wellness Centre/Dispensary they are attached to.

They are however, also entitled to obtain the medical services from any un-empanelled hospital in emergency condition and get reimbursement of medical expenses incurred by themselves or any of their dependent family members.

They can file Medical Reimbursement Claims (MRCs) with the respective CGHS Wellness Centres they are attached to- The CMO In charge is expected to scrutinize the claim papers with reference to the prescribed Checklist and forward the same to the Office of AD/ JD in charge of the zone/city. The Office of AD/JD processes the claim and arranges reimbursement of the admissible amount to the pensioner beneficiary at the earliest.

2. A number of complaints are being received from the pensioner beneficiaries about the slow and tardy pace of disposal of MRC claims by CGHS, Complaints have also been received about the unnecessary harassment of pensioner beneficiaries who are also senior citizens, affecting them mentally and financially, and thereby creating a bad image for CGHS. CGHS is responsible for taking care of healthcare needs and well being of the central government employees and pensioners. It has therefore been decided to lay down a comprehensive procedure to be followed by all concerned in CGHS to ensure timely and hassle free disposal of the MRC claims by CGHS in order to facilitate prompt reimbursement of medical expenses to the pensioner beneficiaries.

3. The procedure to be followed by CGHS for dealing with MRC cases shall be as
follows;
i. The beneficiary will submit the MRC in the prescribed format with all relevant supporting vouchers/documents in original, to the CMO-I/C of the relevant CGHS Wellness Centre. The CGHS Wellness Centre shall verify and ensure, before accepting the claim papers, that all relevant documents are enclosed as per the prescribed checklist and issue a dated acknowledgement to the claimant in token of receipt of the MRC by CGHS.

ii. The CGHS Wellness Centre shall forward the MRC papers online to the Office of Zonal AD/JD, CGHS for further processing for reimbursement of claims. The physical papers shall be sent to the office of the AD/JD within one / two days of receipt of claim papers.

iii. If there are still any deficiencies / gaps found in MRC documents/papers, the Office of AD/JD, shall retain the papers and communicate the list of deficiencies / observations, preferably online, to the CMO-I/C for removing the shortcomings. The MRC may also be returned in original to the CMO- I/C, if it is absolutely necessary for doing the needful to remove the deficiencies inconsultation wïth the beneficiary.

iv. The CMO-I/C shall contact the beneficiary concerned and inform him about the shortcomings in the MRC papers and request him to submit the requisite information / documents. The CMO I/C shall not return the MRC in original unless it is rejected in total.

v. The MRCs should be scrutinized and processed by the Office of AD/JD as far as possible through computerized software as per the extant policy and instructions issued from time to time about the CGHS rates and admissibility of claims under CGHS.

vi. The amount found admissible as per the CGHS guidelines may be passed for payment and forwarded online / manually to the PAO for making payment. The original documents should also be forwarded simultaneously to the PAO for making payment of the admissible amount to the claimant.

vii. When a bill is sent to the PAO, the details pertaining to the claimant will be entered through computer and the claimant shall be informed of the same along with bill number, amount admissible and details of disallowances clearly indicating the specific reasons / grounds for deductions.

viii. The Office of AD/ID of the zone / city shall submit a weekly report in Form —‘MRC-I’ and Monthly Return in Form — ‘MRC — II’ indicating the details of disposal of MRC cases, to the Office of AD(HQ), CGHS for Delhi & NCR and to the Office of Additional DDG (HQ), CGHS for other than Delhi and NCR CGHS cities.

ix. A separate analytical statement shall be attached with the Monthly Return in Form-’MRC- II’ giving therein, the details of the MRCs pending for 2 months and above, clearly indicating the reasons there for and steps taken to dispose of such cases.

x. The Office of AD (HQ), CGHS, New Delhi and Office of Addi. DDG (HQ), CGHS shall compile the Monthly returns received from the respective zones andc ities and submit a consolidated Monthly Return on MRC cases (Zone-wise/City wise) to the Director, CGHS for monitoring of MRC cases on a monthly basis. A copy of this Monthly Return shall also be endorsed by AD (HQ), CGHS and Addi. DDG (HQ), CGHS to Additional Secretary and Director General, CGHS for his information.

4. All the CMO — I/C of the CGHS Wellness Centres and the ADs and JDs of the zone /city are herby directed to follow the above procedure religiously in both letter and spirit to ensure speedy and timely disposal of the Medical Reimbursement Claims (MRCs) filed by the pensioner CGHS beneficiaries.

End: Forms – MRC-I & II