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Procedure to process of medical reimbursement claim – CHECK LIST FOR PROCESSING MEDICAL CLAIM

admin — Mon, 23 Nov 2020 03:18:34 +0000

Medical Reimbursement Claim – Central Government Employees

By SPEED POST

F.No.D-12015/06/ 2020-Ad.IX
Government of India
Ministry of Finance
Department of Revenue
Central Board of Direct Taxes

Room No.10, 5th Floor,
Jeevan Vihar Building,
Parliament Street, New Delhi – 110001

Dated : 28.10.2020

All Principal Chief Commissioner of Income Tax
All Director General of Income Tax (Inv.)

Sub : Streamlining of procedure to process of medical reimbursement claim.

Sir/Madam,

It has been observed that the medical reimbursement claims are being received in the Board, are incomplete and not subjected to any initial check. As a result a lot of time is spent on further communications resulting in delay in settlement of the claim.

2. It has therefore been decided that in future all medical claim are to be submitted to the Board on the basis of the attached Check List with proper referencing of the documents with page number and Annexure.

3. Offices of the Pr. CCIT and DGIT (lnv.) are requested for wide circulation of this advisory amongst the all subordinate offices under their control.

Yours Faithfully

Biswajit Guha
Under Secretary to the Govt. of India
Telefax: 011-23741823

Copy to : IFU/DT for information

Reimbursement of medical claims to pensioners residing in non-CGHS areas – DoT

CHECK LIST FOR PROCESSING MEDICAL CLAIM

Name & Designation of the Claimant: —————-

Office where working: —————-

Name of Patient & relationship with claimant: —————-

*S.No.*	*Detail about the claim*	*Remark*	*Page No.I Annexure*
1	Whether the patient is a CGHS beneficiary availing benefits under the Scheme. If, so whether a copy of the CGHS Card is enclosed.	Yes/No
2	In case of non-CGHS beneficiary, whether an AMA was appointed, and if so, whether the Appointment Order of AMA is enclosed.	Yes/No
3	Whether Medical Claim Form (duly filled in) has been submitted	Yes/No
4	Whether the claim was submitted within the stipulated period of three months from the date of discharge from the hospital.	Yes/No
5	If delayed, whether reasons for delay beyond 3 months was intimated.
6	Name of Hospital from where the treatment was taken/is being taken.
7	Whether the treatment was obtained from a Government Hospital or CGHS empanelled Private Hospital.	Government Hospital/ CGHS Empanelled Hospital/Non- empanelled hospital
8	In case of CGHS empanelled hospital, whether a copy of the Order/OM is enclosed.	Yes/No
9	Whether the case was referred by CGHS Doctor/AMA. If so, whether a copy of the ‘Referral slip’ is enclosed.	Yes/No
10	In case of treatment was obtained from a Private hospital under emergency, whether Emergency Certificate is enclosed in original.	Yes/No
11	Whether the permission was taken from the concerned office. If so, whether a copy of ‘Permission letter’ is enclosed.	Prior permission or Ex-facto permission
12	Disease(s) being treated
13	Whether the claim for reimbursement has been approved by the H.O.D.	Yes/No

14	Details of payments made by the employee.
15	Whether the treatment was obtained on credit basis. If so, whether a copy of the permission given by his/her office.	Yes/No
16	Whether ‘prescription slips’ of ‘day-to-day report’ of the treating doctor/hospital are enclosed.	Yes/No
17	Whether the Medical Bills of the Hospital are enclosed in original and certified.	Yes/No
18	Total amount of bills given by the Hospital
19	Whether the Discharged Summary has been enclosed in original.	Yes/No
20	Whether a table indicating each item of expenditure charged by the hospital vis-a-vis actual admissible amount as per CGHS rate/CS(MA) Rules, duly authenticated by the HoD concerned has been forwarded with the claim.	Yes/No
21	Amount admissible for reimbursement as per CGHS/CS(MA) Rates.	Rs.
22	A copy of CGHS rate list highlighting the treatment procedures done in the hospital.	Yes/No
23	Outer Pouch of the Stents used for the patients in the hospital is/are enclosed in original.	Yes/No/N.A.
24	A copy of Death Certificate was furnished (in case of death).	Yes/No/N.A.
25	Affidavit on Stamp paper was submitted by the Claimant (in case of death)	Yes/No/N.A.
26	Whether any medical advance was sanction. If so, the amount sanctioned and a copy of the Sanction Order to be enclosed.	Yes/No
27	Net amount to be sanctioned (after adjustment of Medical Advance, if sanctioned)	Rs.
28	Whether a self explanatory letter from the beneficiary if treatment taken in emergency has been enclosed.	Yes/No

medical reimbursement claim

CHECK LIST FOR PROCESSING MEDICAL ADVANCE

Name & Designation of the Claimant:

Office where working:

Name of Patient & relationship with claimant:

*S.No.*	*Detail about the claim*	*Remark*	*Page No.*
1	Whether the patient is a CGHS beneficiary availing benefits under the Scheme. If, so whether a copy of the CGHS Card is enclosed .	Yes/No
2	In case of non-CGHS beneficiary, whether an AMA was appointed, and if so, whether the Appointment Order of AMA is enclosed.	Yes/No
3	Name of Hospital from where the treatment is being taken/proposed to be taken.
4	Whether it is a Govt. Hospital or CGHS empanelled private hospital or Non-CGHS empanelled hospital
5	In case of CGHS empanelled hospital, whether a copy of the OM of its empanelment is enclosed .	Yes/No
6	Whether the case was referred by CGHS Doctor/AMA. If so, whether a copy of the ‘Referral Slip’ is enclosed.	Yes/No
7	Whether credit facility is extended to the patient.	Yes/No
8	Whether approval of H.O.D. was obtained.	Yes/No
9	Estimated cost for the treatment given by the hospital.	Rs.
10	Whether the admissible amount has been restricted as per CGHS rates I CS(MA) Rules I Govt. hospital rates.	Yes/No
11	Amount of Advance admissible for sanction	Rs.

Proforma for item-wise expenditure charged by the hospital vis-a-vis actual admissible amount as per CGHS rate/ CS(MA) Rules, duly authenticated by the HoD concerned

Name & Designation of the Claimant:

Office where working:

Name of Patient & relationship with claimant:

Name of the Hospital and address;

Duration of the Treatment:

SI. No.	Items	Amount Charged	Amount admissible as per CGHS rate/ CS(MA) Rules	Remarks
1)	Bed Charges			Annexure – 1
2)	ICU Charges			Annexure -2
3)	Doctors’ Visit			Annexure -3
4)	Medicines			Annexure -4
5)	Lab/ Test Charges			Annexure -5
6)
7)
8)
9)
10)

medical reimbursement claim

Checked and verified by:

Signature with stamp

Certified and authenticated by HoD

Signature with stamp

Annexure

Proforma for Item-wise details

Name of item : Medicines

SI. No.	Date	Name of medicines	CGHS Code	Amount Charged	Amount admissible as per CGHS rate / CS(MA) Rules	Remarks
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)

medical reimbursement claim central government employees

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Defence: RELAXATION OF RULES FOR CONSIDERATION OF REIMBURSEMENTS IN EXCESS OF THE APPROVED RATES PERTAINING TO MEDICINAL CLAIMS UNDER ECHS

admin — Tue, 12 Feb 2019 10:23:00 +0000

File No.22 A(37)/2018/WE/D(Res-l)

Government of India
Ministry of Defence
(Department of Ex-Servicemen welfare)
Sena Bhavan, New Delhi

Dated- 15 January, 2019

The Chief of Army Staff
The Chief of Naval Staff
The Chief of Air Staff

Subject: RELAXATION OF RULES FOR CONSIDERATION OF REIMBURSEMENTS IN EXCESS OF THE APPROVED RATES PERTAINING TO MEDICINAL CLAIMS UNDER ECHS.

Sir,

With reference to Gol, MoD letter No 22(1)/01/US(WE)/D(Res) dated 30 Dec 2002 and Gol, MoD letter No. 24(8)/03/US(WE)/D(Res) dated 19 Dec 2003 and in light of M/o Health and Family Welfare order No. Z.15025/ 38/ 2018/ DIR/ CGHS/ EHS dated 22nd May 2018 and No. Z15025/ 51/ 2018/ DIR/ CGHS/ EHS dated 6-6-2018, partial amendments are hereby made to the procedure for payment and reimbursement of medical expenses under ECHS with relaxation of rules for consideration of reimbursement in excess of the approved rates as per the details given under the succeeding paragraphs.

2. The request for full reimbursement which fall under the defined criteria indicated in para 3 below and cases indicated in para 4 below shall be examined by a High Powered Committee whose constitution is indicated in para 5 below. After recommendation of HPC, the concurrence of MoD (Finance/Pension) and approval of Secretary, ESW will be required in all these cases.

3. The request for full reimbursement which fall under the following defined criteria would be considered by the High Powered Committee.

Treatment was obtained in non empanelled hospital under emergency condition and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalized for a prolonged period.
Treatment was obtained in non empanelled hospital under emergency and was admitted for prolonged period for treatment of head injury, coma, septicaemia, multiorgan failure etc.
Treatment was obtained in non empanelled hospital under emergency and was admitted for prolonged period for treatment of head injury, coma, septicaemia, multiorgan failure etc.
Treatment was obtained in a non empanelled hospital under emergency for treatment of advanced malignancy.
Treatment was taken under emergency in a higher type of accommodation as rooms as per his/her entitlement were not available during that period.
Treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections.
Treatment was obtained in a non-empanelled hospital under emergency when there was a strike in Govt. Hospitals.

4. Cases falling in the following categories would also be considered by the High Powered Committee.

Settlements of medical claims in relaxation of rules.
Approval of air fare with or without attendant on the advice of the treating doctor, for treatment in another city even though he/she is not eligible for air travel/treatment facilities are available in city of residences.
Representation from ECHS beneficiaries seeking full reimbursement under special circumstances, which are not covered under para 3 above

5. Composition of the High Powered Committee would be as follows :

JS, ESW – Chairman
Government Hospital Specialist Doctor (of concerned speciality) – Member
Director/DS/US, DoESW – Member
Director(Medical), CO, ECHS – Member-Secretary
Representative of MoD(Fin/Pen) – Member

6.. The other terms and conditions mentioned in the procedure for payment and reimbursement of medical expenses under ECHS vide Gol, MoD letter No.24(8)/03/US(WE)/D(Res) dated 19 Dec. 2003 shall remain unchanged.

7. This has the concurrence of Ministry of Defence(Finance/Pension) vide their U.O. No32(23)/2018/Fin/Pen dated 3-1-2019.

Yours faithfully
(A.K. Karn )
Under Secretary to the Govt. of India

Source: CGDA

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Relaxation of procedures to be followed in considering requests for medical reimbursement

admin — Mon, 26 Oct 2015 06:59:48 +0000

Doing Away With Need For Verification Of Medical Reimbursement Claims In CGHS and Guidelines for full reimbursement

No: 4-18/2005-C&P [Vol. l- Pt. (i)]

Ministry of Health & Family Welfare

Department of Health 8. Family Welfare

CGHS (P) Division

******

Nirman Bhawan, Maulana Azad Road

New Delhi, Dated the 20th February, 2009

OFFICE MEMORANDUM

Subject: Relaxation of procedures to be followed in considering requests for medical reimbursement.

The undersigned is directed to slate that under the extant instructions, a CGHS card holder. who wishes to apply for reimbursement of the expenditure incurred by him / her on medical treatment of either self or his I her dependent family members. the present reimbursement procedure needs verification of bills and issue of essentiality certificate by the treating doctor, and the Medical Superintendent of the hospital. The process of verification of bills and issue of essentiality certificates are time consuming with the doctor at times being busy or being away from office for whatever reason. This necessitates repeated visits to the hospital for getting the verification done and essentiality certificate obtained. Representations have been received in the Ministry of Health 8. Family Welfare requesting for doing away with the two requirements and for the Ministries i authorities concerned to verify and check the authenticity of the claims on the basis of the prescription slip and the diagnostic report submitted by the Government servant / pensioner. in the event of any doubt, the concerned Ministry / Authority can always get verification done from the hospital concerned.

2. The undersigned is also directed to state that CGHS guidelines currently provide for relaxation of guidelines to cover full reimbursement in individual cases depending upon merits of each case. In the case of Hon’ble Members of Parliament, the powers to relax the guidelines have been delegated to the Lok Sabha Secretariat and Rajya Sabha Secretariat respectively and in the case of Hon’ble Chief Justice of Supreme Court and Judges of the Supreme Court to the Secretary General of the Supreme Court.

3. In order to reduce the burden on the Specialists in individual cases of medical reimbursement claim, it has been decided with the approval of heads of the hospitals to revise the guidelines for reimbursement by the competent authority. as follows:

(1) It has now been decided to do away with the procedure for verification of bills and issue of essentiality certificate by the treating doctor. and the Medical Superintendent of the hospital. Ministries i authorities concerned may verify and check the authenticity of the claims on the basis of the prescription slip and the diagnostic report submitted by the Government servant / pensioner. In the event of any doubt, the concerned Ministry / Authority can always get verification done from the hospital concerned. Modified reimbursement claim form. alongwith checklist is annexed.

(2) All cases involving requests for relaxation of rules for reimbursement of full expenditure will henceforth be referred to a Technical Standing Committee. to be chaired by the DGHS /AddIDGHS and consist of Director (CGHS) and subject matter specialists. if the Technical Standing Committee recommends the relaxation of rules for permitting full reimbursement of expenditure incurred by the beneficiary, the full reimbursement may be allowed by the Secretary (Health 8. Family Welfare) in consultation with IFD. A check list for consideration of requests for reimbursements in excess of approved rates may include:

(a) The treatment was obtained in a private non-empanelled hospital under emergency and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalised for a prolonged period;

(b) The treatment was obtained in a private non-empanelled hospital under emergency and was admitted for prolonged period for treatment of Head injury, Coma. Septicemia, Multi-organ failure, etc.;

(c) The treatment was obtained in a private non-empanelled hospital under emergency for treatment of advanced malignancy;

(d) The treatment was taken under emergency in higher type of accommodation as rooms as per his I her entitlement are not available during that period;

(e) The treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections;

(f) The treatment was obtained in a private non-empanelled hospital under emergency when there is a strike in Government hospitals:

(g) The treatment was obtained in a private non-empanelled hospital under emergency, while on official tour to non-CGHS covered area;

(h) Approval for air-fare with or without attendant on the advice of treating doctor for treatment in another city even though he is not eligible for air travel I treatment facilities are available in city of residence and

(i) Any other special circumstances.

4. The Office Memorandum is issued with the concurrence of IFD vide D . No: 908/AS FA12009 dated the 2oth February. 2009.

(R Ravi)

Deputy Secretary to the Government of India

Source: http://msotransparent.nic.in/writereaddata/cghsdata/mainlinkfile/File21.pdf

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New Medical Reimbursement Claim (MRC) Form for CGHS beneficiaries

admin — Tue, 10 Jun 2014 16:37:12 +0000

New Medical Reimbursement Claim (MRC) Form for CGHS beneficiaries. The Medical Reimbursement Claim Form has been reviewed and further simplified. Separate forms have been developed for serving beneficiaries and pensioner beneficiaries with requirement of minimum information required for processing of the claims. CGHS Order:-

No.S. 11011/9/2012-CGHS (P)

Government of India

Ministry of Health & Family Welfare

CGHS (Policy)

Nirman Bhawan, New Delhi

Dated the 5th June, 2014

OFFICE MEMORANDUM

Sub:- Revision of Medical Reimbursement Claim (MRC) Form for CGHS beneficiaries – reg.

The undersigned is directed to state that it has been the constant endeavour of the Ministry of Health & Family Welfare to improve the facilities under CGHS and simplify / liberalize the procedures to make the Scheme user friendly.

2. In furtherance of the above objective, the Medical Reimbursement Claim Form has been reviewed and further simplified. Separate forms have been developed for serving beneficiaries and pensioner beneficiaries with requirement of minimum information required for processing of the claims. The CGHS beneficiaries are required to submit their medical reimbursement claims in the prescribed forms with requisite documentary evidences to their Department / office or CGHS, as the case may be for further processing and settlement as per approved CGHS rates and guidelines.

3. The following forms have been prescribed:

Form MRC(S) – For Serving CGHS beneficiaries,
Form MRC(P) – For Pensioner CGHS beneficiaries.

Specimen Forms are enclosed
Encl: As Above

sd/-

[V.P. Singh]

Director

Click on following images to save or view:-

Medical Reimbursement Claim Form for Serving Employees Page 1

Medical Reimbursement Claim Form for Serving Employees Page 2

Medical Reimbursement Claim Form for Pensioner Page 1

Medical Reimbursement Claim Form for Pensioner Page 2

Medical Reimbursement Claim Form Annexure-I

Medical Reimbursement Claim Form Annexure-II

Source: http://msotransparent.nic.in/writereaddata/cghsdata/mainlinkfile/File692.pdf

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