Text of MH & FW,  No. 25-Misc.1002/2006/R & H/CGHS         dt  :29/4/2014

  Revision of Ceiling Rates for Various Coronary Stents / Angioplasty & Angioplasty with Balloon for CGHS/CS (MA) Beneficiaries

            With reference to the above mentioned subject, the undersigned is directed to draw attention to the Office Memoranda of even No. dated 7/2/20412, 21/2/2013 and 7/2/2014 and to state that the ceiling rates for reimbursement of drug eluting coronary stents for CGHS beneficiaries / CS(MA) beneficiaries prescribed in the above referred to Office Memoranda are revised w.e.f the date of issue of this office memorandum as follows

Revised ceiling rates of Drug Eluting Stents : Rs.23, 625/- (Inclusive of all taxes)..

Bare Metal Coronary Stents : Rs. 12,000/-

Bare Metal Stainless Stell stents : Rs.10,000/- the rates were already notified vide OM of even number dated 7thFebruary 2013

2. This issues with the approval of the competent authority.     

 Terms and Condition :

1. Reimbursement to beneficiaries/empanelled hospitals shall be allowed subject to the ceiling rates or actuals, whichever are lower.

2. Coronary Stents shall be permitted on the advice of Govt. Specialist, of which not more than two shall be of Drug Eluting Stents (in any of the coronary stents as per the decision of treating specialist). Permission shall be granted as per the laid down procedure. If more than two drug eluting stents are implanted in an empanelled hospital and no written informed consent was obtained from the beneficiary that he/she would bear the difference in cost between the DES and Bare Metal Stent, and the hospital has charged this amount from the beneficiary, the additional amount shall be paid to the beneficiary and shall be deducted from the pending bills of hospitals.

3. It is essential for the empanelled hospitals to quote the Batch number when a coronary/vascular stent of any type is implanted in the case of a CGHS/CS (MA) beneficiary and also enclose a copy of the relevant invoices pertaining to the procurement of the stents 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 from the Govt. In case of treatment from a private non-empanelled hospital, where the treatment was taken in an emergency, it is the responsibility of the beneficiary to obtain the batch number, invoice and outer pouches of the stent(s) before the submission of the medical claim to CGHS/ concerned department, as the case may be.

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

5. UTI-ITSL, while processing the hospital bills of coronary / vascular stents shall ensure that the hospitals have enclosed copies of the relevant invoices pertaining to the procurement of the stents by the hospitals and the outer pouch of the Stent packet along with the sticker on it on which details of the stent are printed and that the prescribed rates and the guidelines have been followed, before making provisional payments to the hospitals.

6. The revised rates and guidelines shall come into force from the date of issue and shall be in force till they are revised.

7. This issues with the concurrence of Integrated Finance Division vide Note dated 20.12.2012 of AS&FA, Min. of H & FW.