Reimbursement of Medical Claims: CPWD’s Instructions

No. 21/26/2013-EC-X
Nirman Bhawan, New Delhi 
Dated the 24th January, 2014

1. All the CEs/SEs/SEs(Coord.)/EEs/DDG (Hort.)/DDOH.

Subject: Reimbursement of Medical Claims-Regarding


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 (itemwise-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.
(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.
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)
(Rahul Ranbir Singh) 
Deputy Director (Administration)
Source: http://cpwd.gov.in/WriteReadData/other_cir/9291.pdf

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