No.
21/26/2013-EC-X
GOVERNMENT
OF INDIA
DIRECTORTE
GENERAL OF WORKS
CENTRAL
PUBLIC WORKS DEPARTMENT
Nirman Bhawan, New
Delhi
Dated the 24th January,
2014
To
1. All the
CEs/SEs/SEs(Coord.)/EEs/DDG (Hort.)/DDOH.
Subject: Reimbursement of Medical Claims-Regarding
Sir,
After repeated requests and
making available of the required formalities for processing of reimbursement of
medical claims, it has been observed that the medical reimbursement claims are
still being received in this Directorate are forwarded/processed in a very
casual manner resulting in delay in final settlement of claims of individuals
and settling medical claims of different C.G.H.S. approved Hospitals.
To minimize the delay and
to streamline the process of scrutinizing and submission of reimbursement of
medical claims the stage wise steps required are appended below for action on
the part of field units of this Directorate:-
1. The duly filled up
Modified Check list for Reimbursement of Medical Claims and Medical Claims Form
as per prescribed Performa.
2. The Copy of new CGHS
card.
3. The Copy of Permission
Letter from concerned office.
4. The Original Bills along
with discharge/ Death summary from the Hospital.
5. Emergency Certificate in
original from Hospital.
6. In case of death of CGHS
Card Holder following documents as prescribed in modified checklist:
i. Affidavit on stamp paper
by claimant.
ii. No objection from other
Legal Heirs on stamp paper.
iii. Copy of Death
Certificate.
7. Whether any advance was
granted in the medical Reimbursement Claim? If so, provide the details of the
same and under which rules the facility was allowed to applicant.
8. Whether credit facility
was granted for the treatment? If so provide the details of the same. Under
which rule the credit facility was allowed to serving Govt. official?
9. Medical Reimbursement
Claim has to be submitted in duplicate.
10. It has to be mentioned
by the forwarding /concern office (Chief Engineer) as to whether the amount
claimed for reimbursement is as per the CGHS prescribed rate or not and it has
also need to be certified that there is no need of any relaxation of rules in
the instant case.
11. Original pouch of Stent
packets along with requisite documents prescribed by MOHFW from time to time
needs to be enclosed in the MRC file in order.
12. The amount mentioned
for stents and other consumables may please be checked as per ceiling rates
fixed by MOHFW and the same may be indicated in the forwarding letter.
13. As per the observations
of IFD and Works Division in the precedent cases the case requires to be
submitted in line with the guidelines of precedent cases providing the details
of amount charged by the hospital indicating the S.I. No. of the CGHS items with
relevant instructions and thus arriving at the amount admissible.
The case may be submitted
with the details of amount charged by the hospital indicating the S.I. No. of
the CGHS items with relevant instructions and thus arriving at the amount
admissible as per the below format:-
(i) Name of the Hospital
……………………………… Period of treatment from ……….. to …………
(extracts of hospital
recognition be placed in the file or instructions relating of treatment from
non-empanelled hospital be placed in the file and it may be averred all
stipulations have been complied with
|
S.No.
|
Particulars/Name Item/(SI.
No. of the CGHS items list
with extracts.
|
Amount Claimed
|
(Quantity X CGHS Rates)
|
Extracts of Relevant Instruction s of CGHS Placed at F/….
|
Amount Admissible as per CGHS rates
|
(ii) All relevant OMs pertaining to the case (item wise-reimbursement) may be placed in the file alongwith the Mb o Health & Family Welfare OM No. S-11011/23/2009/CGHS D-11 dated 17th August, 2010 and subsequent clarificatory OMs issued thereafter.
(iii) It may be indicated whether 10% discount has been availed and case may be put up as per prescribed format as mentioned above.
14. Clarification regarding
admissible and non-admissible items under CGHS provided in Mb o Health &
Family Welfare’s O.M. No.F.No.2-1/2012/CGHSNC/CGHS(P) dated 01st August, 2013
has to be complied with.
15. As per Ministry of Health and Family Welfare's Draft MOA F.No. D.12034/22/09/CGHS-Desk-I following has to be checked.
(i) DISCOUNT : Hospital shall also allow a discount of 10% on every cash payment.
(ii) CREDIT: On
production of a valid permission by the CGHS beneficiary- the hospital shall
provide credit facilities to the Members of Parliament, Pensioners, Ex-Members
of Parliament, Freedom Fighters, Serving CGHS employees, serving employees of
Ministry of Health & Family Welfare, serving employees of Directorate
General of Health Services and such other categories of CGHS cardholders as
notified by the Government. In case of emergency the hospital shall provide
credit to all CGHS beneficiaries.
(iii) TREATMENT IN EMERGENCY:
In emergency the hospital
shall not refuse admission or demand an advance payment from the beneficiary or
his family member and shall provide credit facilities to the patient whether
the patient is a serving employee or a pensioner availing CGHS facilities, on
production of a valid CGHS card and the hospital shall submit the bill for
reimbursement to the concerned Deptt./Ministry/CGHS. The refusal to provide the
treatment to bonafide CGHS beneficiaries in emergency cases without valid
ground, would attract disqualification for continuation of empanelment.
The list of ailments which
may be treated as emergency has been mentioned in the MOA for the Hospitals,
which is illustrative only and not exhaustive, depending on the condition of
the patient.
(iv) For serving employees
(other than CGHS/ DGHS /Ministry of H&FW), the payment shall be made by the
patient and he shall claim reimbursement from his office subject to the
approved ceiling rates. The Private Hospital shall allow a discount of 10% on
all payments made in cash.
(v) The treatment procedure
shall be performed on the basis of the authorization letter issued by the Chief
Medical Officer of the concerned CGHS dispensary in case of pensioners and by
the administrative department / ministry in case of serving employees.
(vi) The Hospital agrees
that during the In-patient treatment of the CGHS beneficiary, the Hospital
shall not ask the beneficiary or his attendant to purchase separately the
medicines / sundries / equipment or accessories from outside and shall provide
the treatment within the package deal rate, fixed by the CGHS which includes
the cost of all the items. Appropriate action, including removing from CGHS
empanelment and / or termination of this Agreement, may be initiated on the
basis of a complaint, medical audit or inspections carried out by CGHS teams /
appointed TPA.
(vii) The hospital shall
not refer the patient to other specialist / other hospital without prior
permission of CGHS authorities. Prior intimation shall be given to CGHS
whenever patient needs further referral.
(viii) Entitlement for
various types of wards to CGHS beneficiaries has also been provided in the
aforesaid MOA.
This issues with the
approval of DDG (HQ)
Sd/-
(Rahul Ranbir Singh)
Deputy Director
(Administration)
Source:http://cpwd.gov.in/WriteReadData/other_cir/9291.pdf
