Text of MH & FW. O.M No. S-11012/1/91-CGHS (P) (Vol-I) dt. 18/3/1992

Decentralization of Settlement of Medical Claims of CGHS beneficiaries.

The undersigned is directed to say that the question of decentralizing the work relating to examination of medical claims and payment thereof in respect of Central Government employees and their families covered by a Central Government Health Scheme has been engaging the attention of the Government for quite some time. On consideration of the difficulties being experienced by the beneficiaries and also the delay involved in settling the medical claims, it has been decided to delegate the power to examine and settle the medical claims of the Central Government employees covered by Central Government Health Scheme to the Ministries/Departments with effect from 1st April, 1992.

2. The medical claims of Central Government employees covered by Central Government Health Scheme can be broadly categorized into:

Claims preferred against treatment in Government hospitals/referral hospitals/recognized hospitals.

Claims preferred against treatment in unrecognized private hospitals.

 

Settlement of Claims of Government Hospitals/referral Hospitals/Recognized Hospitals

At present this category of claims of Central Government Health Scheme beneficiaries is being done by Central Government Health Scheme. It has now been decided that these claims will be processed by the Department of the individual and total payment made by the Department direct to the individual from ‘Service Head’. The procedure for processing the claim is as per the CS(MA) Rules of which the Departments are already familiar. For details the Department has to refer to CS (MA) Rules. The list of Government Hospitals/Referral Hospitals/Reognised Hospitals is given in Annexure – A. The rate list of some specialized tests for which rates are fixed in Delhi is given in Annexure – B. However, for reimbursement of tests done outside Delhi, the Head of the Department concerned may be empowered to allow for minor variations.

Settlement of Claims of Unrecognized Private Hospitals.

Central Government Health Scheme does not reimburse treatment taken from private unrecognized hospitals. However, in cases where treatment had to be taken in private unrecognized hospitals in an emergency, the claims preferred may be referred to CGHS concerned, who, after examining each case on merits, will recommend the admissible amount for payment to the beneficiaries. Such proposals should be recommended by the Heads of Departments. The payment will, however, be made by the Department concerned from ‘Service Head’.

Treatment taken at Private Nursing Home will not be reimbursed.

3. Processing of the claims is to be done as per CS(MA) Rules and the following guidelines for examination of medical claims are to be followed while processing the claim:

Prior permission of Additional Director, CGHS of respective city is required for taking treatment in government referral city is required for taking treatment in Government referral hospitals land private recognized hospitals under CGHS. No. Permission is required for treatment from Central/State Government hospitals and hospitals under other Government Bodies.

The Claims are to be preferred within 3 months period fro the date of discharge from the hospitals. If the claim becomes time barred, hen condonation of period is to be done by the Department concerned.

The claim should have the following documents completed :

Med’97 and Essentiality certificate ‘B’.

All original bills verified by the treating physician with his stamp.

Photocopy of CGHS Token card.

Discharge Slip of the hospital.

A detailed list of all medicines, laboratory tests, investigations, number of doctors visits etc. should be submitted for reimbursement with dates.

Self-explanatory letter from the beneficiary explaining the emergency circumstances.

Legal heir certificate in case of death of the cardholder.

The admissible amount should be worked out on his entitlement.

Costs of all medicines are reimbursable in full except preparations classified as food, tonics, vitamins, disinfectants, toilet preparations etc. The list of inadmissible items is given in CS (MA) Rules.

Surgical sundries, disposables like cotton, syringes, needles, catheters, tubes etc. are reimbursable in full.

Special nursing charges etc. are to be reimbursed as per CS (MA) Rules i.e. at rates prescribed by the local Nursing Association and further subject to restriction laid down therein.

Blood transfusion charges are reimbursed in full subject to certification by the treating physician that the specific blood group was not available in the Hospital and the charges of blood are comparable with the rates of Red Cross, State/Central Govt. hospitals.

 

Investigations and tests conducted in Government hospitals should be reimbursed in full. The same applies for referral and private recognized hospitals where permission has been granted by CGHS. In certain cases, investigations and tests have been done privately on the advise of Government hospitals/referral hospitals due to non-availability in these hospitals. In such cases, the admissible amount as mentioned in annexure ‘B’ may be given. The tests for which rates are not fixed by the Ministry of Health & Family Welfare be reimbursed in full.

Diet is not reimbursable. Where bed charges and diet are billed together, 20% of the amount should be deducted towards diet charges.

Medicines prescribed for outdoor treatment is not reimbursable under CGHS. However, expenditure on investigations and tests done in Government / referral / recognized hospitals may be reimbursed, if such tests / investigations have been done on the advice of the specialist of Government Hospitals.

In case where the claim pertains to treatment taken in a private recognized hospital but prior permission of CGHS has not been taken, then these claims should be sent to the concerned Additional Director, Central Government Health Scheme, for examining the case and taking decisions in the matter.

4. This circular is issued with the concurrence of Finance Division vide their Dy. No. 1240/92 JS & FA., dated 9/3/1992.