Central Government Health Scheme (CGHS Mumbai)

Check List for reimbursement of claims

Claim submission

  • In case of treatment in emergency in non-empanelled hospital/expenditure incurred for treatment in empanelled hospital, Medical Reimbursement Claim (MRC) will have to be submitted by the beneficiary for reimbursement of expenses incurred.
  • The claim is to be submitted to the concerned department by serving employees and to the CMO I/C of the CGHS wellness Centre (where the CGHS card is registered) by the pensioner beneficiary within 6 months of discharge from the hospital.
  • In case of delay in submission of claim beyond 6 months, the reasons justifying the delay must be stated by the beneficiary in a forwarding letter
  • The claim is to be submitted in duplicate in the prescribed form.

Acknowledgement and following up of the claim submitted by pensioner beneficiaries and serving CGHS employees:

  • The claim is to be submitted at the CGHS wellness Centre where the beneficiary is registered. On verification as per check list if the claim is found to be complete with all documents, then an acknowledgement will be generated with a claim number in the computer module of the wellness Centre.
  • The status of the claim can be viewed in the CGHS computer module using the claim number. SMS will also be sent to beneficiaries at each stage of MRC processing.
  • Particulars of the claims which are more than one month old are now displayed on the CGHS website.

Please see detailed checklist given below for documents to be enclosed for reimbursement of medical claims:

CHECK LIST FOR MRC

Please enclose Self attested Documents in the sequence given below FOR EVERY CLAIM along with page number

  1. Computer generated MRC No.
  2. Self-explanatory letter - duly signed by main card holder
  • Forwarded by CMO I/C
  • With detailed sequence and justification of the claim and reason for going to a non -empanelled hospital
  • In case of delay in submission of more than 06 months from date of discharge/treatment, the reason for delay to be mentioned clearly with request for condonation of delay.
  • If claimant is not in a position to sign, then Right thumb impression in case of females and left thumb impression in case of males may be put in place of signature. If medically unfit to sign, then a certificate from physician regarding the disability is to be enclosed.
  1. Photocopy of Card of the claimant and the patient duly verified by CMO I/C
  2. Medical Reimbursement Claim Form (MRC (S) for serving and MRC (P) for pensioner) available on cghs.gov.in under the link: downloads) duly signed by main card holder/claimant in case of death of card holder (Please mention email id and mobile no.)
  3. Mandate Form - MANDATE FORM IS MANDATORY (Please see “Downloads” for Mandate Form). In addition to:
    1. Cancelled cheque/photocopy of cheque bearing name of the main card holder/claimant in case of death of main card holder OR
    2. Copy of passbook showing account number with name of main card holder /claimant in case of death of main card holder OR
    3. Mandate form verified from concerned bank, if name of main card holder/claimant is not present on cheque.
  4. Original permission letter/ original emergency certificate.
  5. Discharge summary in original/copy
  6. Copy of referral from the specialist / advice of the specialist wherever this applies.
  7. Final consolidated bill in original.
  8. Original or copy of break up of hospital bill (Interim bill is not valid.)
  9. Receipts in original of total amount paid to hospital/pharmacy. Please note:
  10. Invoice needed in case of implants/devices specifying batch number and specifications of the device/implant
  11. If 'duplicate' receipt is enclosed in place of original, then affidavit regarding lost receipts needs to be submitted with MRC.
  12. List of all receipts/bills enclosed in the medical claim with receipt number/bill number showing total claimed amount.
  13. Duplicate set of whole claim with page numbers.
  14. Whether taken any advance or no-please state Yes/NO.
  15. If advance taken, then utilization certificate from hospital that the advance amount has been utilized

 

BENEFICIARIES TO PLEASE NOTE:

  • KINDLY NUMBER ALL PAGES OF YOUR MRC IN THE SEQUENCE GIVEN ABOVE
  • THEN MAKE 2 PHOTOCOPIES OF THE CLAIM
  • RETAIN 1 SET WITH YOURSELF AS RECORD AND SUBMIT THE OTHER SET ALONG WITH THE ORIGINAL MRC TO THE WELLNESS CENTRE
  • IF THE CLAIM IS BEING RETURNED AFTER CLEARING ANY OBJECTION, THEN THE FRESH DOCUMENTS SUBMITTED SHOULD BE IN DUPLICATE

CHECK LIST FOR MRC FOR SPECIAL CASES

Please enclose Self attested Documents in the sequence given below along with page number

  1. If original bill lost (as per Medical Claim Form (S) or (P))
  • Affidavit on non-judicial stamp paper CLEARLY MENTIONING details of the lost document as per Annexure I of MRC Form.
  • Photocopies of all the above claim papers duly verified by treating specialist.
  1. For cases where partial credit is given: 
  • Complete final bill of hospital with break up
  • Break up bill from the hospital for items for which credit was not given
  1. In case of death of the card holder please note:
  • Death of main card holder (pensioner)-only living spouse is the eligible claimant irrespective of who has made the payment to the hospital for treatment. It is advisable to get a family pensioner card issued before the medical claim is put up for reimbursement.
  • Death of family pensioner (spouse)-Any of the living children can claim reimbursement provided he/she gives an affidavit that he is the legal heir and a separate NOC from other heirs that they have no objection if reimbursement is made to the legal heir (as per Annexure II of MRC Form).
  • Death of pensioner with no living spouse/ death of family pensioner and no surviving children, then a ‘succession certificate’ issued by the court has to be produced by whosoever is the claimant (proving that he is the legal heir) along with the proof that payment to the hospital has been made by him.
  • Kindly do not delete the CGHS card till final payment against the medical claim is received from CGHS in the following death cases:
        1. If card holder (claimant) was alive at the time of submission of Medical Claim to CGHS but died before the final settlement of the claim by CGHS
        2. If family pensioner has died and the legal heir/successor is the claimant
  • Documents to be enclosed in Death Cases :
        1. Affidavit on non judicial stamp paper by the claimant (as per Annexure II of MRC Form)
        2. NOC from all the legal heirs separately for each individual.
        3. Death certificate.
        4. Copy of death summary from the hospital.
        5. ID proof of claimant with name of father in cases where both main card holder and spouse have expired
        6. Succession certificate issued by court wherever required (see above)
  1. In cataract surgery with Intra Ocular Lens (IOL) claims (as per OM no. 536/202/R & H/CGHS dated 2/08/2014)
  • Original sticker of IOL with batch number of IOL, duly signed and stamped by the surgeon of private empanelled hospital
  • Bill of IOL showing type of IOL used and IOL batch no. in case of surgery in private empanelled hospital
  • Discharge summary/prescription to mention:
  • Type of IOL (Hydrophobic Foldable/Hydrophilic Acrylic/Scleral Fixated/PMMA (AC/PC)) used
  • Type of cataract surgery done
  1. For Cardiac/vascular stents (as per OM no. 002/2006/CGHS (R&H)/CGHS(P) dated 3/10/2011)
  •  Outer pouch of the stent with sticker on it with batch no. and other details.
  •  Invoice of the stent from the private empanelled hospital with batch number. and details of stent
  • Certificate from empanelled hospital that they have not charged the beneficiary more than the rate at which the stent has been procured by the hospital
  • Angiography report (for opinion of Government specialist)
  • CD of angiography & PTCA (for opinion of Governement specialist)
  1. For Pacemaker, Combo Device, Defibrillator,Rotablator (as per OM no. 2034/02/2014/Misc-CGHS-DIII dated 22/7/2014)
  • Sticker of device having batch number
  • Copy of terms of warranty
  • ECG and Holter report
  • ECHO cardiography report 
  • In case of replacement, copy of warranty of earlier device to be submitted
  1. Ambulance used (as per OM no. S-4924/200/CGHS(R&H)/CGHS(P) dated 7/1/2011)
  • Ambulance is allowed only for going to the hospital in emergency. It is not allowed after discharge.
  • Certificate from the treating doctor for justification stating the following – “The ambulance was essential as it was an emergency, and any other mode of transport would have aggravated the patients condition or endangered his life. Ambulance has been used within the city limits”
  1. Knee & Hip Implants (as per OM no. Z.1505/74/2017/DIR/CGHS/EHS dated 26/09/2017):
  • Ceiling rates applicable.
  • Cost of knee implant component-wise along with brand name, name of manufacturer/importer/batch number/specifications and other details, if any to be mentioned in the final bill/invoice
  1. For special Nurse/Aya/attendant-
  • Permitted only Govt. Hospital for in patients or private recognized hospital where treatment has been taken with prior permission.
  • No reimbursement of domiciliary nurse/aya/attendent (as per OM no. S-11011/7/88-CGHS (P) dated /8/1988)
  • Certificate from treating doctor that services of special nurse/aya/attendant were essential for recovery/prevention of serious deterioration in the patient
  1. For Domiciliary Physiotherapy (as per OM no. S-11011/2/2011/CGHS(P) dated 1/6/2011)
  • Prescription from PMT specialist/Ortho/Neuro/Neurosurgery/ENT specialist for home-based rehabilitation programme which should include the following descriptive specifics:
    1. The therapy to be used:
      1. Electrotherapy.
      2. Active Exercise Therapy.
      3. ADL Training.
      4. Speech Therapy.
      5. Gait Training; and
      6. Passive Exercises.
    2. The technical person required to institute the therapy
    3. The frequency of the therapy required by the patient.
    4. Duration of the therapy programme.
  • Receipt in original for payment made with stamp and designation of person who has given therapy
  • In case of locomotor disability, certificate showing >80% disability or 2 Govt specialists to certify that patient is totally dependent on care giver.
  1. For purchase of medicines for 7 days on day of discharge (OPD MEDICINES ARE NOT REIMBURSABLE unless permitted by CMO I/C in writing) as per OM no. S-11011/09/2014/CGHS(HEC)/CGHS(P) dated 20/6/2014 and OM no. S-11018/6/9-CGHS(P) dated 24/7/1999
  • Certificate from Private empanelled hospital that they have not issued the medicines on the day of discharge.
  1. For Insurance cases: beneficiary to first put up claim to insurance company (as per OM no.S- 11011/4/2003/CGHS(P) dated 19/2/2009
  • Certificate from insurance company indicating the amount for which beneficiary has received credit from them.
  • Photocopies of all bills and vouchers duly certified with stamp of insurance company
  1. For nebulizer (as per OM no. Misc.11006/2000-JD(R&H)/CGHS(P) dated 11/6/2001
  • Advise by Government specialist
  • Undertaking that nebulizer has not been procured at Govt. expense in the last 5 years and that cost of maintenance will be borne by beneficiary
  • Receipt of purchase
  1. Hearing Aid reimbursement (OM No. S.11011/37/2019-EHS dated 01/12/2020)
  • Original Permission Letter to purchase Hearing Aid
  • Empty carton/box with label showing details of Hearing Aid seller
  • Copy of CGHS card
  • Bill/Receipt in original for hearing aid bearing details of the hearing aid seller
  • Empty carton/box of Hearing Aid with label showing details of the hearing aids supplied

 

Checklist for MRC(206 KB) 

Checklist for reimbursement of OPD medicines purchased during COVID-19 lockdown(206 KB) 

 

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