CGHS – Some Frequently Asked Questions & Answers…..

CGHS – Some Frequently Asked Questions & Answers…..

(Ministry of Defence – Fin) Principal Controller of Defence Accounts : Central Government Health Scheme – Some Frequently Asked Questions & Answers….. 1. What are the guidelines for obtaining treatment for CGHS / AMA beneficiaries? GUIDELINES FOR CGHS BENEFICIARIES: 1) CGHS beneficiaries require to take treatment in CGHS dispensary. 2) CGHS Doctor’s reference and office permission required for taking treatment / test in recognized hospital / Diagnostic Centers. 3) Emergency treatment can be taken from hospital in case of no government / recognized hospital located nearby. 4) Medicines purchased from open market, in case of OPD treatment taken from recognized private hospital is not reimbursable, and the same is to be obtained from CGHS dispensary. 5) If test / investigations are carried out privately by CGHS beneficiary on the advice of a government specialist, a non availability certificate from the government hospital concerned should be attached. GUIDELINES FOR AMA BENEFICIARIES: a. AMA beneficiaries are required to take OPD treatment from AMA located near his residence. b. AMA is not authorized for giving indoor treatment at his own clinic / nursing home in any case. If inpatient treatment considered necessary, patient to be referred to Govt / Pvt. Recognized / referral hospital for further treatment. c. Emergency treatment can be taken from private hospital in case no government / recognized hospital located nearby. d. AMA beneficiaries can take OPD / Indoor treatment from Government Hospital without permission from AMA. e. When amount of medical expenses exceeds Rs.1000/- in a financial year, a certificate from controlling officer in terms of GOI, MOH & FW OM No: S-14025/15/94-MS Dt: 12/08/1994 has to be furnished. f. Treatment from AMA is restricted to 10 days. If the treatment is expected to be prolonged beyond 10 days from the date of treatment a patient has to be referred to OPD of Govt / Recognized hospital by AMA. g. AMA beneficiaries may take treatment from any hospital recognized under CGHS / State government subject to condition that they will be reimbursed the medical expenses at the rates fixed by the government under the CGHS Rules / CS(MA) Rules or actual expenditure incurred whichever is less. 2.CGHS beneficiary gets admitted into a CGHS recognized hospital without getting reference from CGHS. What are the audit requirements to be complied with ? RME CLAIMS ARE TO BE SUBMITTED WITH FOLLWING DOCUMENTS: a) Med – 97 in respect of CS(MA) beneficiaries and Med – 2004 in respect of CGHS beneficiaries and Essential Certificate A / B All original bills certified by the treating physician with stamp containing his name, designation, registration number, qualification and hospital to which attached. Photocopy of CGHS card / Dependency certificate in respect of CS(MA) beneficiary. Discharge summary of the hospital in case of inpatient treatment. Legal heir certificate in case of death of the govt. servant. A detailed list of all medicines, lab tests, investigations, number of doctors visit, name of the procedure done at hospital etc., should be submitted for reimbursement with dates. Break-up details for all the items billed by hospital and CGHS code for procedure done and for various lab-tests done should be furnished. Reimbursement claim should be invariably preferred within one month in case of Medical advance availed cases and in other cases, three months from the date of completion of treatment. Time barred cases should require the sanction of Competent authority. Check list a.Emergency Certificate from the treating doctor. b.Self explanatory letter from the beneficiary explaining the emergency circumstances. c.Statement of case in triplicate from the Controlling officer duly justifying the treatment in emergency. d.Letter addressed to the sanctioning authority for Ex-post facto sanction in duplicate forwarding the claim 3. For indoor treatment in CGHS recognized hospital on a reference letter from CGHS, what supporting documents are required to be enclosed for preferring the medical reimbursement claim ? Med – 97 in respect of CS(MA) beneficiaries and Med – 2004 in respect of CGHS beneficiaries and Essential Certificate A / B Reference letter from CGHS / AMA and permission letter from head of the office for taking treatment. All original bills certified by the treating physician with stamp containing his name, designation, registration number, qualification and hospital to which attached. Photocopy of CGHS card / Dependency certificate in respect of CS(MA) beneficiary. Discharge summary of the hospital in case of inpatient treatment. Legal heir certificate in case of death of the govt. servant. A detailed list of all medicines, lab tests, investigations, number of doctors visit, name of the procedure done at hospital etc., should be submitted for reimbursement with dates. Break-up details for all the items billed by hospital and CGHS code for procedure done and for various lab-tests done should be furnished. Reimbursement claim should be invariably preferred within one month in case of Medical advance availed cases and in other cases, three months from the date of completion of treatment. Time barred cases should require the sanction of Competent authority. Check list 4.What might be the reasons for rejection of a medical bill in audit? MED–97/2004 not countersigned by the controlling officer concerned. Cash bill for purchase of medicines not counter signed by the Doctor. Essentiality Certificate not signed by the Doctor Office permission and CGHS / AMA reference not enclosed Break-up details for various lab tests not enclosed. 5. Whether the cost of Medicine on OPD treatment in a private hospital is reimbursable? No.For OPD treatment CGHS beneficiaries should get the Medicines from CGHS dispensary concerned.