Medical Reimbursement Claim Archives - CENTRAL GOVERNMENT EMPLOYEES NEWS

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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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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CPWD Orders on Reimbursement of Medical Claims under CGHS

admin — Fri, 07 Feb 2014 18:00:47 +0000

CPWD Orders on Reimbursement of Medical Claims under CGHS

No. 21/26/2013-EC-X
GOVERNMENT OF INDIA
DIRECTORTE GENERAL OF WORKS
CENTRAL PUBLIC WORKS DEPARTMENT

Nirman Bhawan, New Delhi
Dated the 24th January, 2014

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

Subject: Reimbursement of Medical Claims-Regarding

Sir,
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 (item wise-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.

15. As per Ministry of Health and Family Welfare’s Draft MOA F.No. D.12034/22/09/CGHS-Desk-I following has to be checked.

(i) DISCOUNT : Hospital shall also allow a discount of 10% on every cash payment.

(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.

(iii) TREATMENT IN EMERGENCY:
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)

sd/-
(Rahul Ranbir Singh)
Deputy Director (Administration)

Source: www.cpwd.gov.in
[http://cpwd.gov.in/WriteReadData/other_cir/9291.pdf]

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