Clarification regarding admissible / non-admissible items under CGHS

F.No. 2-1/2012/CGHS/VC/CGHS(P)
Government of India
Ministry of Health & Family Welfare
Department of Health & Family Welfare
Nirman Bhawan, New
Dated the 1st October,

Subject: Clarification regarding admissible / non-admissible
items under CGHS.
The undersigned is directed to refer to the directions given
by Hon’ble High Court of Delhi in the case of Sh. Kanhiya Singh Vs UOI and
others [W.P.(C) 9044/2011], regarding admissibility and non-admissibility of
certain items under CGHS, the following clarifications are issued:-

2.         “CGHS Package Rate” means and
includes lump sum cost of inpatient treatment I day care / diagnostic
procedures for which a CGHS beneficiary has been permitted by the competent
authority or for treatment under emergency from the time of admission to the
time of discharge including (but not limited to) –
(i) Registration
Admission charges,
Accommodation charges including patients diet,
Operation charges,
Injection charges,
Dressing charges,
Doctor I consultant visit charges,
ICU / ICCU charges,
Monitoring charges,
(x) Transfusion
Anesthesia charges,
Operation theatre charges,
Procedural charges / surgeon’s fee,
Cost of surgical disposables and all sundries used during hospitalization,
Cost of medicines,
Related routine and essential investigations,
Physiotherapy charges etc.
Nursing care and charges for its services.
3.         Cost of
Implants / stents / grafts is reimbursable in addition to package rates as per
CGHS ceiling rates for Implants / stents I grafts or as per actual, in case
there is no CGHS prescribed ceiling rate.
4.         During In-patient
treatment of the CGHS beneficiary, the hospital will not ask the beneficiary or
his / her attendant to purchase separately the medicines / sundries I equipments
or accessories from outside and will provide the treatment within the package
rate, fixed by the CGHS, which includes the cost of all the items.
5.         In cases of
conservative treatment, where there is no CGHS package rate, the above
mentioned items are admissible – items wise at CGHS rates or as per AIIMS rates
(if there is no CGHS rate) or as per actual Of there is no CGHS I AIIMS rate)
for any item.
6.         Package
rates envisage up to a maximum duration of indoor treatment as follows:
12 days for Specialized (Super Specialties) treatment;
7 days for other Major Surgeries;
3 days for Laparoscopic surgeries I normal deliveries; and
1 day for day care / Minor (OPD) surgeries.
7.         However, if
the beneficiary is required to stay in the hospital for his / her recovery for
a period more than the period covered in the prescribed package rate, in exceptional
cases, supported by relevant medical records and certified as such by the hospital,
the additional reimbursement shall be limited to accommodation charges as per
entitlement, investigations charges at approved rates, and doctors visit
charges (not more than 2 visits per day per visit by specialists / consultants)
and cost of medicines for additional stay).

No additional charge on account of
extended period of stay shall be allowed if that extension is due to infection
on the consequences of surgical procedure or due to any improper proceed.

8.         The above
list is however not exhaustive. Some patients may require additional facilities/
procedures, which are admissible depending upon the medical requirements as
advised by the treating doctors/specialists, with proper justification.
Therefore, it is not possible to indicate a comprehensive list of items, which
are not admissible.
However, the following items are not admissible for the
purpose of reimbursement under CGHS:
Telephone charges
Sanitary napkins
Talcum powder
Mouth fresheners
Deputy Secretary to the Government of India
Original Order/Source: http://msotransparent.nic.in

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