CPWD Orders on Reimbursement of Medical Claims under CGHS
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-RegardingSir,
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: www.cpwd.gov.in
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