Reimbursement of Medical Claim – Non Adhering to CGHS Rules for Endorsement & Permission for Tests & Investigation

The circular states that standard guidelines and instructions are not being followed by beneficiaries when availing of CGHS facilities, and that beneficiaries should follow due procedure when submitting claims for reimbursement to avoid claims being returned.

Submitting CGHS reimbursement claim

GOVERNMENT OF INDIA
MINISTRY OF DEFENCE
CONTROLLER OF DEFENCE ACCOUNTS, GUWAHATI
UDAYAN VIHAR, NARANGI GUWAHATI – 781171

IMPORTANT CIRCULAR

No. AN/III/MED/Orders/Misc/Vol -I

Date: 09/01/2023.

To,

All Sections of Main Office.
All Sub-offices (As per standard list).

Subject: Reimbursement of Medical Claim : Non Adhering to CGHS rules regarding endorsement of MO/CMO of CGHS and/or permission by the Department for test and investigation

Please find enclosed copies of the GOI MH&FW OM No Z.15025/117/2017/DIR/CGHS/ESH dated 15/01/2018 as amended by OM no Z 15025/64/2018/DIR/CGHS dated 31/07/2018 and Z.15025/117/2017/DIR/CGHS/EHS dated 10/12/2018 for information and strict compliance please.

In this connection, it is noted that while availing CGHS facilities by the beneficiaries, the standard guidelines and instruction on the subject are not being followed As per Para (i) of MH&FWO dated 15/014/2018which states that “ All CGHS beneficiaries (in all CGHS Cities) shall be permitted for seeking OPS consultation from Specialist at private hospitals empanelled under CGHS after being referred by any Medical Officer /CMO of CGHS wellness Centre the referral may be mentioned on computer generated Prescription Slip . After consultation at empanelled hospitals beneficiaries shall report back to concerned wellness centre, where MO/CMO would endorse listed investigation/listed treatment procedures and issue medicine as per guidelines mentioned below. For unlisted investigation/treatment procedure CMO in charge shall submit the prescription to competent authority for consideration in case of pension beneficiaries. Serving employees shall seek permission for unlisted investigation/treatment procedure from their department as per prevailing guidelines.

In view of the above it is stated that while submitting CGHS reimbursement claim due procedure shall be followed by the beneficiaries so that claim can be processed without returning to the beneficiaries.

GO (AN) has seen

(Ruby Bose)
Sr. Accounts Officer
(39T/T IL) /(AN-IID)

Source: cdaguwahati.gov.in