Guidelines for Medical Claim reimbursement claim and Permission cases – CGHS

CGHS Medical Claims Reimbursement

Guidelines for Medical Claim reimbursement claim and Permission cases – Controller of Defence Accounts Circular dated 01.09.2023

Office of the Controller of Defence Accounts
Rajendra Path, Patna- 800019

Circular

No -AN/Pay/Med/ Patna/Vol-III

Date: 01/09/2023

To
The Officer-In-Charge
All section of M.O CDA Patna
All sub offices

Subject: Guidelines for Medical Claim reimbursement claim and Permission cases.

Of late, it is observed/ noticed during course of audit of medical reimbursement claims, received in this Office that some of officials/ officers are not adhering to CGHS/ CS(MA) Rules resulting in return/rejection of bills at audit level. Some of the officials/officers are not even taking a little bit pain to go through audit Observation /advice given by this office and resubmitting the claim without or partial complying the requirements resulting in multiple return/ rejection of the claims. Accordingly, list of the documents are numerated below for information and strict compliance so that reimbursement of claim to the individual may be process within the stipulated timelines.

• Submission of Medical Claims with enclosing following documents:-
  • MED-97 form in respect of CSMA beneficiaries or, MRC(S) /MED-2004 form in respect of CGHS beneficiary are to be duly filled and signed with date by the beneficiary.
  • Referral Memo of the CGHS for CGHS beneficiary and CGHS Doctor may clearly mention on the prescription for what type of treatment/OPD consultation is to be taken at empanelled hospital (Auth: MH & F.W. OM No.Z.15025/117/2017/DIR/CGHS/EHS, dated- 15.01.2018)
  • Certificate ‘A’ is required in case of OPD treatment taken at AMA. (Auth: M.H & F.W. OM No. H.11022/01/2014-MS, dated-15.07.2014)
  • In OPD case, Prescription slip of treating doctor clearly indicating Medicines description and Pathology test is to be enclosed with the claim. (Auth: M.H & F.W. OM No. Z.15025/ 117/ 2017/DIR/ CGHS /EHS, dated- 15.01.2018)
  • Details/ Bifurcation of all medicines, lab tests, investigations, no. of consultation etc is to be included in IPD/OPD bills and submitted separately. (Auth: M.H & F.W. OM No. S.11011/9 /2012-CGHS(P), dated-05.06.2014)
  • Photocopy of CGHS card for CGHS beneficiary. (Auth: M.H & F.W. OM No. S.11011/9/2012-CGHS(P), dated-05.06.2014)
  • In IPD Case, Bed History Sheet/Bed Head Ticket ie prescription sheet during admission is to be enclosed with the claim.
  • Legal heir certificate in case of death of the Govt. servant. (Auth: M.H & F.W. OM No. S.11011/9/2012-CGHS(P), dated-05.06.2014)
  • Discharge Summary of the hospital in case of inpatient treatment. (Auth: M.H & F.W. OM No. S.11011 /9/2012-CGHS(P), dated-05.06.2014)
  • In case of treatment taken as per CSMA rule, all Medicine bills should be verified by the treating doctor with his stamp. (Auth: M.H OM No. F. 1-17/52-LSG(M), dated-18.12.1952)

• Incase of Emergency treatment obtained:
  • In addition to the above documents, the following documents should also be submitted:
• • Emergency certificate (Original) from the treating doctor.(Auth: M.H & F.W. OM No. S.11011/9/2012-CGHS(P), dated-05.06.2014)
  • Self-application of the beneficiary highlighting the emergency circumstances. (Auth: M.H & F.W. OM No. S.11012/1/91-CGHS(P) (Vol. I), dated-18.03.1992)

2. Submission of request for Permission from the Head of the Department involving TA with enclosing following documents:

• Referral letter from the CGHS dispensary/Govt. Hospital may clearly indicate about said treatment is not available at the same station or, referral letter from Govt. Hospital/CGHS dispensary for availing the said treatment in different city with the name of the hospital. (Auth: MH & F.W. OM No. S.14025/7/2000-MS, dated-28.03.2000)

3. The claims for advance should have the following documents:

• Reference letter from CGHS/AMA for taking treatment.
• Estimate of Medical Expenditure with break-up details from the hospital authorities of inpatient treatment. (Auth MH & F.W. OM No. Z.15025/8/ 2021/DIR/CGHS, dated- 22.09.2021)
• Incase of emergency, emergency certificate from the hospital.
• A copy of CGHS card/list of dependent family members.
• Application from the beneficiary/ dependent family members for requisition of advance.

4. Implants: Tax Invoices in Original along with outer pouch and stickers is required for reimbursement of the claims. This is mandatory requirements and cannot be substituted in any way. (Auth: MH & F.W. OM No. S.11011/9/2012-CGHS(P), dated-05.06.2014)

5. Time period of Submission: 6 month in case of non advance case and within 1 month in case of advance cases. {Auth: M.H & F.W. OM No. S-12015/3/93-CGHS(P), dated- 30.12.1993 (for Medical advance) & M.H & F.W. OM No. 1-60/2017-CGHS/C&P/EHS, dated- 01.06.2020 (for non advance case)}

6. All Medical Re-imbursement claims may be sent in duplicate and all enclosed documents may be self-attested.

7. Important: OPD medicines prescribed by empanelled hospital have to be taken from CGHS wellness center. (Auth: MH & F.W. OM No. Z.15025/117/2017/ DIR/CGHS/EHS, dated- 15.01.2018)

8. It is also noticed that some of the officers/staff are transferred to Non-CGHS covered area has not surrender his/her CGHS cards. Those officers/staff who is posted and residing in Non-CGHS covered area, CGHS cards of the self and his/her family members will be forwarded to this office for surrender. (Auth: M.H & F.W. OM No.4-36/99-C&P/CGHS/CGHS(P) , dated-01.07.2005)

CDA has seen.

Ranjan Kumar
Senior Accounts Officer