CGHS: Guidelines to Process for Settlement of Medical Claims

Guidelines to Process for Settlement of CGHS Medical Claims

The Guidelines to Process for Settlement of CGHS (Central Government Health Scheme) Medical Claims are a set of rules and regulations established to ensure that all medical claims submitted by beneficiaries are properly evaluated and processed in a timely manner. These guidelines outline the specific steps that must be taken by both the claimant and the CGHS authorities to ensure that the claims are settled fairly and efficiently. The guidelines cover topics such as the documentation required for claims, the time limit for submitting claims, the process for reviewing claims, and the appeals process in case of a dispute. By following these guidelines, the CGHS aims to provide high-quality healthcare services to its beneficiaries and ensure that they receive the medical care they need.

Here are some instructions to help you with processing your medical claim settlement requests.

1. New Timelines for settlement of the Medical Claims

The new timelines prescribed for settlement of normal medical claims are 30 days from the date of submission to the payment by Pay & Accounts Office. Every effort must be made to avoid delay at any stage. Proper calculation sheet must be prepared in the file, so that the same could be shared with the beneficiaries, if there are requests for reasons for the deductions.

2. Full reimbursement case /Cases for relaxation of Rules

As per the new guidelines they fall into two categories

(a) Full reimbursement – Non-HPC (Non- High Power Committee) cases
(b) Full reimbursement – HPC (High Power Committee) cases

a) Full reimbursement – Non-HPC cases
The following cases fall under this category;

i) Treatment was obtained in a private unrecognized hospital under emergency and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalized for a prolonged period.

ii) Treatment was obtained in a private unrecognized hospital under emergency and was admitted for prolonged period for treatment of Head Injury, Coma , Septicemia, Multi-organ failure , etc.

iii) Treatment was obtained in a private unrecognized hospital under emergency for treatment of advanced malignancy

iv) Treatment was taken under emergency in higher type of accommodation as rooms as per his/her entitlement are not available during that period.

v) Treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections

vi) Treatment was obtained in a private unrecognized hospital under emergency when there is a strike in Govt. hospitals.

vii) Treatment was obtained in a private unrecognized hospital under emergency while on official tour to non-CGHS covered area.

Although the new OM has not mentioned about STC recommendation, it is advisable to have expert Committee meetings under the Chairperson of Addl. DGHS (as in the case of earlier STC meetings) in respect of item Nos. i), ii),iii) and v) before arriving at a decision. The conditions mentioned at Nos. iv),vi) and vii) are administrative in nature and do not require meetings of expert committees and may be recommended by Addl. Director, if conditions are satisfied.

In Delhi the expert committee meetings shall be organized by respective CMO(R&H) and by AD(R&H) in case of claims of serving employees of Delhi. Such meetings in respect of other cities shall be organized by Sr. CMO in the office of Addl.DDG(HQ).

The requests for full reimbursement as examined by Additional Director (HQ)/ Addl. DDG(HQ), in consultation with expert committee meetings, wherever deemed necessary and recommended for full reimbursement shall be submitted to Director, CGHS and concurrence of IFD may be obtained after approval of AS&DG, CGHS before the seeking the approval of Secretary for reimbursement in excess of CGHS rates.

If the above criteria are not satisfied (including the regrets by expert committees) the requests may be regretted by Addl. Director of concerned City, with a covering letter explaining the reasons and referring to the concerned OM.

In case there is a representation to consider as a special case then only it may be placed before the High Power Committee.

Addl. Directors shall prepare a self-contained note giving details of case and submit the files with relevant documents to Director, CGHS though AD(HQ)/Addl. DDG(HQ)

If the proposal is approved by AS&DG,CGHS , concurrence of IFD and approval of Secretary , Health & Family Welfare are solicited for reimbursement in excess of approved rates.

b) Full reimbursement – HPC cases
The Composition of High Power Committee, shall be as under:

1. Special Director General — Chairperson
2. Directorate General, CGHS or his Nominee — Member
3. Additional Director, CGHS(HQ) / Addl. DDG(HQ),CGHS — Member
4. Addl. Director, CGHS(R&H) — Member Secretary
5. One Government Specialist (of concerned Speciality)—Member

The High Powered Committee shall consider the representations of only those CGHS beneficiaries having a valid CGHS Card.

The High Powered Committee shall consider representations received from CGHS beneficiaries holding valid CGHS cards only at the time treatment, in respect of the following conditions:

1. 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 / treatment facilities are available in city of residence

2. Representations from CGHS beneficiaries seeking full reimbursements under special Circumstances.

3. Relaxation of Rules

High Powered Committee shall meet once in a month and action on the decisions taken shall be completed within seven days of meeting, with the concurrence of the IFD , wherever , it is deemed necessary.

Addl Directors shall submit the files with relevant documents to the AD(HQ) / Addl. DDG(HQ) for placing the representations before High Power Committee.

AD(R&H) shall be Member Secretary , who shall with the help of Sr. CMO of the Office of Adl.DDG(HQ) shall issue meeting notices including notices to concerned Govt. Specialists and organize meting for the Meetings of High Power Committee.

The requests received upto the 15th of the month shall be placed before the Committee.

If the High Power Committee does not recommend the regret letters shall be issued explaining the reasons.

If the High Power Committee recommends full reimbursement / relaxation of rules, Concurrence of IFD and approval of Secretary (H&FW) shall be obtained within 7 days.

3. In addition there are expert committees to consider several cases

Expert Committee meetings for other purposes shall continue to be held as in the past in the following cases:

Expert Committee meetings for Consideration of Liver Transplant cases, Bariatric Surgery,

Bone-marrow / Stem Cell Transplant, Justification of treatment / Implants in selected cases shall continue as before.

Standing Committee meetings for Cochlear Implant shall continue as before.

Expert Committee meetings for approval of Drugs , etc., shall continue.