CGHS Pune
Disclaimer This presentations is intended for educational purposes only and do not replace the available Office Memorandums or Office Orders issued from time to time about the topics discussed. Statements of fact and opinions expressed are those of the presenter as is interpreted by him and, unless expressly stated to the contrary, are not the opinion or position of the Ministry of Health & Family Welfare / Directorate of CGHS. The presenter does not endorse or approve, and assumes no responsibility for completeness of the information presented.
Expectations For you? For Your organization ? For me? For my organization ? Scope
Stepping out of the comfort zone If it scares you – it might be a good thing to try
Welfare of Employees Employees who pay contribution for the healthcare services It is their right that the amounts spent be reimbursed – ASAP Are you doing this ? What is the turn around time for settlement of claims in your office?
MRC for Central Government Employees www.cghspune.gov.in
MRC Claims - Employees OPD claims Consultation only Investigations only Consultation and investigations IPD / Admission claims Surgical Management only Medical Management only Surgical management + Medical Management Medical Management + Surgical Management Link for MRC form: https://cghs.gov.in/showfile.php?lid=3984
MRC Claims - Employees OPD claims Consultation only Investigations only Consultation and investigations Prerequisites: Referral from CGHS wellness center/ Govt specialist No separate permission letter required https://cghs.gov.in/showfile.php?lid=4830 https://cghs.gov.in/showfile.php?lid=5079
Validity of referral – for OPD consultation/ investigation/ procedure Q1. Referral slip from CGHS has been issued for consultation. The employee has done four consultations at empanelled hospital over next ten days from date of issue of reference. Claimant has submitted all documents and has claimed for OPD consultations. The admissible amount would be: A. As admissible for one consultation B. As admissible for three consultation C. As admissible for four consultation
MRC Claims - Employees Amount claimed Amount admissible Consultation only XYZ 135 × No. of consultations – Maximum of three for one referral letter Investigation/s XYZ As per the CGHS Rate list/AIIMS rate list Consultation and XYZ 135 × No. of consultations – Investigation/s Maximum of three for one referral letter + Investigations as per CGHS rate list/ AIIMS rate list https://www.cghspune.go v.in/images/stories/cghsi https://www.cghspune.gov.in/im mages/pdfs/file924.pdf ages/stories/cghsimages/pdfs/pr opratelist.pdf
OPD Claims - documents CGHS / Govt Specialist referral letter Original Bills & receipt Original Reports for investigations All other relevant documents as per check list for MRC claims
Validity of referral – for OPD consultation/ investigation/ procedure Q2. Referral slip from CGHS has been issued on 4 th March 2019 for blood tests. The employee has done the tests in empanelled hospital on 25 th of March 2019. Claimant has submitted all documents about the tests and reports. A. The claim is not admissible as it is used beyond two weeks of date of issue. B. The claim is admissible C. The claim is admissible if permitted ex post facto by the HOD / HOO.
Validity of referral – for IPD procedure Q3. Admission memo - Referral slip from CGHS has been issued to the beneficiary. The employee has done the procedure after two months of issuing the advice at an empanelled hospital. Claimant has submitted all documents and has claimed XYZ amount. The claim and admission was for surgical management/ package. The claim is admissible as per CGHS package rates. A. Not admissible – the advised procedure should be done B. within seven days of date of issue. Needs delay condonation for delay in procedure – from C. HOD as the procedure has been done immediately or within seven days of issue of memo. The claim is then admissible .
Validity of referral – for OPD consultation/ investigation/ procedure https://www.cghspune.gov.in/images/stories/cghsimages/pd fs/clarinvestwoperm.pdf https://www.cghspune.gov.in/images/stories/cghsimages/pd fs/simplificationofprocedurefortreatment- guidelinestohco.pdf http://cgda.nic.in/adm/circular/AN-XIV-1905-200218.pdf https://cghs.gov.in/showfile.php?lid=5266
Delegation of power to HOD/ HOO http://cghsjaipur.nic.in/Pdf/delegation%20of%20powers%20to%20HOD%2030.1 2.2014.pdf -:Salient points:- Permission/ ex-post facto approval for elective treatment/ investigation taken in a non empanelled hospital/ diagnostic center Ex- post facto approval – for elective treatment-in empanelled hospitals – without referral from Govt specialist / CGHS wellness center. Ex post facto approval for elective treatment with recommendation of Govt specialist / CGHS wellness center but without prior permission from HOD/HOO. Ex post facto approval for cancer treatment in non empanelled hospitals. https://cghs.gov.in/showfile.php?lid=4830 No requirement of a permission letter.
Reference memo for consultation MRC claims for investigations / consultations done from a non empanelled private hospital / laboratory – must be supported by reference letter ( original) in printed format issued for the same from wellness center. Exception to this is – Beneficiaries over 80 years can take follow up treatment from same specialist in a non empanelled hospital from where he/ she was taking treatment earlier. The claim will be restricted to CGHS rates for follow up consultations/ investigations (relevant to illness for which they were admitted in the same private hospital ). Medicines purchased however are not reimbursable.
IPD Claims – Elective Treatment CGHS / Govt Specialist referral letter Discharge Card / Death summary Date wise break up of bills – room rent, investigations & medicines. Original Bills & receipt Original Reports for investigations Private Insurance related documents if any Implant related documents Blood and blood products details All other relevant documents as per check list for MRC claims
ICU/HDU/Step down ICU/ Positive or negative pressure room/Isolation Room Q4. What are the admissible Rates ??? Claim is for admission for suspected swine flu and patient was admitted in isolation room / Negative pressure room with justification from the hospital . The room rent for isolation room is charged at Rs. 4000/- per day. The admissible room rent is: As per entitlement A. As per actuals since the case is of swine flu and B. justification has been provided to isolate the patient As per entitlement + CCU rates subject to justification C.
Q5. What are the admissible Rates ??? Claim is for admission for stay in step down ICU or HDU after head injury, initially the patient was kept in ICU and now has been shifted to step down ICU / HDU before shifting to ward. The stay in ICU was for five days, In step down ICU / HDU for three days and then in ward for seven days. The charges have been at following rates – For ICU stay – Rs 4500/- per day, For step down ICU / HDU at Rs 4000/- per day and for ward at Rs 800/- per day. The patient is entitled for private ward. The admissible room rent is: 3750 ×5 + 3000×3 + 800×7 A. 4500 ×5 + 4000×3 + 800×7 B. 3750 × 5 + 3750×3 + 800×7 C.
Packages and stay duration to be allowed: Type of Treatment Number of Days admissible Specialized ( Super-specialty treatment) 12 Days Other Major Surgeries 7 Days Laparoscopic surgery & Normal Delivery 3 Days Day Care / Minor OPD surgeries 1 Day
Surgical Management with prolonged stay Q6a. Beneficiary admitted for CABG surgery – allowing twelve days stay as per the package under Super specialty – On 11 th day develops complication not related to the operation and requires further stay of seven days for recovery. A. Claimant would reimbursed as per package rate only B. If HOD allows would be reimbursed as per package rates + all other admissible charges as per medical management from date of complication. C. Claimant would be reimbursed as per package rates and case referred to CGHS for guidance about other charges
Surgical Management with prolonged stay Q6b. Beneficiary admitted for CABG surgery – allowing twelve days stay as per the package under Super specialty – develops infection of the wound or a complication related to the operation on 11 th day and requires further stay of seven days for recovery. Claimant would reimbursed as per package rate only A. If HOD allows would be reimbursed as per package B. rates + all other admissible charges as per medical management from date of complication. C. Claimant would be reimbursed as per package rates and case referred to CGHS for guidance about other charges
Surgical Management with prolonged stay Claimant would be reimbursed as per package rates + all other admissible charges as per medical management from date of complication. ( Room rent, investigations and medicines for the period of complication) Allowed if not related to surgical complication Allowed only if supplemented by justification from the treating specialist
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