Text of Dept. of Health O.M. No. S-12020/4/97-CGHS (P), dated 7/4/1999.

Delegation of Powers under CGHS relating to refereal system, Permission cases and Ex Post Facto Approval.

The undersigned is directed to say that the matter regarding delegation of powers under CGHS has been under consideration of the Government for some time past so as to reduce the delay I obtaining facilities under CGHS including ex post facto approval of medical claims preferred by CGHS beneficiaries and tit has now been decided to delegate the powers for referral system, permission cases and ex post facto approval as indicated below:

(A) REFERRAL SYSTEM

1. Procedures/investigations for which there is no prescribed CGHS rate for CGHS recognized private hospitals/diagnostic center.

Permission for tests/procedures, the estimates of which re not more than Rs. 20,000 may be granted by Head of the Department (for Serving employees) and by Head of CGHS covered cities (for Pensioners) provided the tests/procedures have been recommended by Government Specialist.  Reimbursement my be limited to AIIMS rate in the case of Delhi and outside Delhi.  In case rates have not been fixed by AIIMS for any particular procedure / investigation / test, reimbursement may be made as per actuals.

2. In case of medical emergency, beneficiary may go directly to private recognized / Government referral hospital and submit a Medical Reimbursement Claim after discharge from the hospital.

Powers are delegated to the Heads of the CGHS organizations in various CGHS covered cities, in respect of both pensioners and serving employees, for deciding which cases fall under the “emergency” category.

3. In pregnancy Cases.

Once the pregnancy is diagnosed/confirmed by the Government/CGHS doctors including the Medical Officer working at the dispensary level, the Head of the Department of concerned Department/Ministry may permit admission for confinement purpose in the private hospitals recognized under CGHS.

4. In case of beneficiary, in spite of facility being available in the city still chooses to get treatment in CGHS recognized hospital in an other city.

The powers for grant of such permission are delegated to the Heads of CGHS organizations in various CGHS covered cities both in respect of pensioners and serving employees, but without grant of TA/DA.

5. In case of pensioners, if permission is granted for treatment in another city for such procedures/tests that are advised by the Government/CGHS specialists and are not available in the same city.

Permission may be granted to pensioner beneficiaries by Head of the CGHS Organization in the various CGSH covered cities on the basis of specific advice from treating Government specialist.

TA may be limited to the Referral Hospitals available in the nearest city by the shortest route.  In case of deviation, prior permission of Director, CGHS, may be obtained.

6. In case of emergency in respect of pensioners/serving employees.

Since it is not always possible to obtain prior permission in emergency, treatment taken by CGHS beneficiaries in emergency will be considered on merits even if the treatment is taken from a non-recognized private hospital.  For granting ex post facto approval in emergency cases, both for serving/pensioner beneficiaries, the power is delegated to the Head of the concerned CGHS covered city.

7. Treatment in private recognized hospital

Referral may be made on the recommendation of the treatment procedure by the Government specialist for indoor treatment in private hospitals, recognized under CGHS BY THE head of CGHS covered city in respect of pensioners and by the head of the Ministry/Department/Office in respect of working employees.

The permission for follow-up treatment may be given for a period of six months fro the date of discharge of the beneficiary from the hospital by the Head of CGHS covered city in respect of pensioners and by the Head of the Ministry/Department/Office in respect of serving employees.

 

(B) PERMISSION CASES

1. Cases where permission is to be given for items with ceiling rates.

When treatment is taken with prior permission and where the ceiling rates have been fixed for purchase of implants such as pacemakers, Rotablatar, total joint replacement, etc. the procedure of calling 3 quotations is not required and the Head of the CGHS organization of the concerned CGHS covered city may grant permission in such cases.

2. Permission for items for which standing committees exist and the Standing Committees exist and the Standing Committee has recommended the case.

Permission may be given by the Ministry of Health and Family Welfare for items which have been notified by the CGHS.

3. Supply of Oxygen Cylinder, Leucocyte, filter, Infusion pump, etc.

Permission may be given by the Ministry of Health and Family Welfare on the recommendations of the Standing Committee for items, which have been notified by the CGHS.

4. Air travel

Permission may be given by the Ministry of Health and Family Welfare on the basis of the recommendation of Director, CGHS.

5. Permission for highly expensive procedures like BMT, cardiac Defibrillator, Carotid Stents, etc. as per Government ceiling rates as the cost involved are very high or where there is no policy decision.

For highly expensive procedures like BMT, cardiac, Defibrillator, Carotid stenting, etc. Ministry of Health and Family Welfare notifies the equipments/instruments/implants for domiciliary use with specific ceiling rates. Hence, permission for any instrument / equipment / implant outside the notified list will be dealt by the Ministry of Health and Family Welfare on a case basis in consultation with CGHS/Finance Division.

 

(C) EX POST FACTO APPROVAL

1. Treatment taken without recommendation of CGHS/Government specialist, but with permission of CMO Incharge of CGHS dispensary in a recognized private hospital within approved ceiling rates.

Powers are delegated to the Heads of CGHS organizations in the CGHS covered cities both in respect of pensioners and serving employees to decide such type of cases.

2. Treatment taken in private hospitals recognized under CGHS without prior permission.

Powers are delegated to the Heads of CGHS organization in the CGHS covered cities both in respect of pensioners and serving employees to decide such type of cases.

3. Emergency cases within approved ceiling rates in respect of treatment taken in private hospitals recognized under CGHS.

Powers are delegated to the Heads of CGHS organization in the CGHS covered cities both in respect of pensioners and serving employees to decide such type of cases.

4. Emergency cases within ceiling approved rate in respect of treatment taken in private unrecognized hospital.

Powers are delegated to the Heads of CGHS organization in the CGHS covered cities both in respect of pensioners and serving employees to decide such type of cases.

5. Cases where prior permission for treatment in CGHS recognized Government referral hospital was granted for a particular procedure and at the time of actual operation, some device/artificial appliance/additional treatment/procedure/diagnostic procedure has been used/undertaken for which no prior permission was taken.

Powers are delegated to the Heads of CGHS organization in the CGHS covered cities both in respect of pensioners and serving employees to decide such type of cases.

6. Ex Post Facto permission for treatment in Government referral hospitals like AIIMS PGI Chandigarh, etc.

For serving employees:

Head of the department of the concerned Ministry/Department/Office may decide such type of cases.

For pensioners:

Head of the CGHS organization of the concerned CGHS covered city may decide such type of cases.

7. Treatment under emergency in private hospitals recognized under CGHS and approval to be given as per approved rates for approved procedures/appliances/devises.

Powers are delegated to the Heads of CGHS organizations in the CGHS covered cities both in respect of pensioners and serving employees to decide such type of cases.

8. Treatment taken under emergency but approval to be given above the approved rates.

Ministry of Health and Family Welfare may decide such type of cases in special circumstances. Depending upon the merits of each case.

9. Relaxation of CGHS Rules.

Ministry of Health and Family Welfare will decide such type of cases.

10. Air travel permission/Ex post facto approval for air travel undertaken for medical treatment.

Ministry of Health and Family Welfare will decide such type of cases.

11. Reimbursement of treatment/test for which there is no prescribed rates under CGHS.

Powers are delegated to the Heads of CGHS organizations in the CGHS covered cities both in respect of pensioners and serving employees and reimbursement may be made as per AIIMS rate/actual. Whichever may be less, or as per actual in case there is not AIIMS rate, both in the case pertaining to CGHS, Delhi and CGHS outside Delhi.

12. Monetary limit to issue sanction for settlement of individual Medical Reimbursement claims/ to accord permission / grant of medical advance.

Head of the CGHS organization of the concerned CGHS covered city in respect of pensioners and Head of the Ministry/Department/Office in respect of serving employees, where prescribed in the preceding paras, the monetary limit for issuing sanction will be as under : -

 (a) Rs. 2 Lakhs: 
In case of  serving
employees/Beneficiaries

By the Head of 
Ministry/Department/Office.

(b) Rs. 2 Lakhs:
( In case of 
 Pensioner/CGHS
 Beneficiaries)

By the Head of  the  CGHS covered city.

 

 

  1. These orders will come into effect fro the date is issue.

  2. The above orders are issued with the approval of Secretary (Health) and concurrence of JS & FA vide Dy. No. 1766/99-JS & FA, dated 23/3/1999.