Pendency of Medical Claims of CGHS Pensioner beneficiaries due to deficiency in documentation
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Z.15025/67/2019/DIR/CGHS/
Govt. of India
Min. of Health & Family Welfare
Directorate General Of CGHS
Govt. of India
Min. of Health & Family Welfare
Directorate General Of CGHS
545-A Nirman Bhawan, New Delhi
Dated the 18th September,2019
Dated the 18th September,2019
OFFICE ORDER
Subject: Pendency of Medical Claims of CGHS Pensioner beneficiaries due to deficiency in documentation (More Documents Required)
The
matter concerning pendency of Medical Claims of CGHS pensioner
beneficiaries has been reviewed in this Directorate and the undersigned
is directed to state that it is now decided that the following revised
guidelines shall be followed in respect of such medical claims:
1.
The medical claims, which are incomplete in documentation shall be
examined to see if, there are any minor deficiencies, which can be
resolved to process the claims by Addl. Directors. These include:
i) Photocopy of CGHS Card and validity– Addl. Director,CGHS , may try if, the matter can be verified from CGHS data base.
ii) Emergency Certificate
– is not sacrosanct and from the clinical findings in the discharge
summary the emergency factor can be ascertained. Even powers are vested
with ADs to consider ex-post fact approval at CGHS rates even under non
emergency conditions using the powers for condonation of procedural
lapses.
iii) Some cities ask for Bed-Ticket issued at Hospital – these are not mentioned in the CGHS Check list and the beneficiary shall not be asked to submit the same
iv) If empanelled hospital has not provided credit facility and the pensioner has made payment,
often the beneficiary is asked to explain as to why the hospital has
not provided credit facility. Such practice shall be avoided and
explanation if any, shall be called for from empanelled hospital.
v) In case of Chemotherapy, there
is option to collect chemotherapy medicines from CGHS before undergoing
Injection/Infusion from empanelled hospital. However, it is not
compulsory and as per the policy of hospitals, particularly JCM
accredited hospitals and some of the NABH Accredited hospitals , they
shall not accept medicines from outside hospital supplies. In such
cases, the processing of the claims shall not be delayed unnecessarily
on this ground.
2. Despite
the steps undertaken as mentioned above under Para (1), if some
deficiencies still persist in documentation, Addl. Director, CGHS shall
send a letter to the beneficiary by speed-post clearly indicating the
requisite documents within Five working days of receipt of claim papers
at the office of Addl.Director, CGHS. The beneficiary shall also be
informed by telephone / e-mail to submit the same to the Office of
Additional Director, CGHS.
3.
As per the existing guidelines the medical claims of beneficiaries aged
80 years and above shall be processed on priority out of turn.
4.
CMOs i/c or a person nominated by CMO i/c may be given training at the
office of Addl. Director regarding verification of documentation before
accepting the same at the CGHS Wellness Centre.
(Dr.Atul Prakash)
Director CGHS
Director CGHS
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