GUIDELINES FOR CGHS BENEFICIARIES:
CGHS beneficiaries require to take treatment in CGHS dispensary.
CGHS Doctor’s reference and office permission required for taking treatment / test in recognized hospital / Diagnostic Centers.
Emergency treatment can be taken from hospital in case of no government / recognized hospital located nearby.
Medicines purchased from open market, in case of OPD treatment taken from recognized private hospital is not reimbursable, and the same is to be obtained from CGHS dispensary.
If test / investigations are carried out privately by CGHS beneficiary on the advice of a government specialist, a non-availability certificate from the government hospital concerned should be attached
GENERAL PURPOSE TREATMENT AND DIAGNOSTIC PROCEDURE:
The entitlement for indoor treatment would be as under:
| i) | Basic Pay upto Rs.7500/- | General Ward |
| ii) | Basic Pay Rs.7501/- to 10500/- | Semi-pvt Ward |
| iii) | Basic Pay Rs. 10501/- and above | Private Ward |
The maximum room rent for different categories would be:
| i) | General Ward | Rs.500/- per day |
| ii) | Semi private Ward | Rs.1000/- per day |
| iii) | Private Ward | Rs. 1500/- per day |
| iv) | Day Care | Rs. 500/- per day |
Package deal rates include admission charges, accommodation charges, ICU / ICCU charges, monitoring charges, Operation charges, anaesthetic charges, Op. theatre charges, cost of drugs and disposable surgical sundries, Physiotherapy charges during the period of hospital stay.
If one or more treatment procedure form part of a major treatment procedure, the package charges would be made against the major procedures and only half of actual charges quoted for minor procedure would be added to the package charges of the first major procedure.
TREATMENT AT PLACES NOT COVERED BY THE CGHS:
If the Central govt servant or a member of his family covered under CGHS falls ill at a place not covered under CGHS, the treatment shall be admissible under CS(MA) Rules. The reimbursement in such cases shall be restricted to the amount which would have been incurred had the treatment been taken in a Govt / State government hospital in that city.
CGHS FACILITIES IN CASE GOVT. EMPLOYEES WHO ARE TRANSFERRED TO NON-CGHS AREAS AND THEIR FAMILIES CONTINUE TO STAY BACK AT THE OLD DUTY STATION:
Families of Government servant can avail CGHS facilities at old duty station for a maximum period of six months from the date of transfer of the government servant to non-CGHS area on advance payment of CGHS contributions to his old office.
Endorsement on CGHS card indicating the date up to which the CGHS card is valid to ensure that the CGHS card is not utilized beyond the specified date.
On expiry the CGHS card should be surrendered to the issued office
MEDICAL ADVANCE:
PURPOSE FOR WHICH ADVANCES AVAILABLE:
a) For indoor treatment in hospital.
b) For OPD treatment in case of TB / Cancer.
AMOUNT OF ADVANCE:
1) In case of (a) and (b) above Rs.10000/- or the amount recommended by the treating doctor whichever is less.
2) For major illness of By-pass surgery, Kidney transplant, Cancer etc., 90% of the package deal or amount demanded by the hospital whichever is less.
The duration of treatment and estimated cost of treatment has to be certified by the hospital concerned.
OTHER CONDITIONS:
1) The advance may be paid in one or more instalments for same disease, subject
to the prescribed limit.
THE CLAIMS FOR ADVANCE SHOULD HAVE THE FOLLOWING DOCUMENTS:
1) Reference letter from CGHS / AMA and permission letter from head of the office for taking treatment.
2) Estimate of medical expenditure with break-up details from the hospital authorities and date if admission probable period of inpatient treatment.
3) Sanction of Competent authority for grant of medical advance.
4) In Case of emergency, Emergency Certificate from the hospital.
5) Copy of CGHS card / list of dependent family members duly countersigned by head of the office.
GUIDELINES FOR AMA BENEFITIARIES:
1) AMA beneficiaries are required to take OPD treatment from AMA located near his residence.
2) AMA is not authorized for giving indoor treatment at his own clinic / nursing home in any case. If inpatient treatment considered necessary, patient to be referred to Govt / Pvt. Recognized / referral hospital for further treatment.
3) Emergency treatment can be taken from private hospital in case no government / recognized hospital located nearby.
4) AMA beneficiaries can take OPD / Indoor treatment from Government Hospital without permission from AMA.
5) When amount of medical expenses exceeds Rs.1000/- in a financial year, a certificate from controlling officer in terms of GOI, MOH & FW OM No: S-14025/15/94-MS Dt: 12/08/1994 has to be furnished.
6) Treatment from AMA is restricted to 10 days. If the treatment is expected to be prolonged beyond 10 days from the date of treatment a patient has to be referred to OPD of Govt / Recognised hospital by AMA.
7) AMA beneficiaries may take treatment from any hospital recognized under CGHS / State government subject to condition that they will be reimbursed the medical expenses at the rates fixed by the government under the CGHS Rules / CS(MA) Rules or actual expenditure incurred whichever is less.
CONDITION FOR TREATMENT IN HOSPITALS OUTSIDE DISTRICT / STATE:
1) Non-availability certificate in respect of treatment / services from Govt / recognized hospitals.
2) Recommendation from AMA and countersigned by CMO of the district, if the treatment to be undertaken outside the district or by Chief Admin. Medical Officer of the state, if it is to be undertaken outside the state.
RME CLAIMS ARE TO BE SUBMITTED WITH FOLLWING DOCUMENTS:
1) Med – 97 in respect of CS(MA) beneficiaries and Med – 2004 in respect of CGHS beneficiaries and Essential Certificate A / B
2) Reference letter from CGHS / AMA and permission letter from head of the office for taking treatment.
3) All original bills verified by the treating physician with stamp containing his name, designation, registration number, qualification and hospital to which attached.
4) Photocopy of CGHS card / Dependency certificate in respect of CS(MA) beneficiary.
5) Discharge summary of the hospital in case of inpatient treatment.
6) Legal heir certificate in case of death of the govt. servant.
7) A detailed list of all medicines, lab tests, investigations, number of doctors visit, name of the procedure done at hospital etc., should be submitted for reimbursement with dates.
8, Break-up details for all the items billed by hospital and CGHS code for procedure done and for various lab-tests done should be furnished.
9) Reimbursement claim should be invariably preferred within one month in case of Medical advance availed cases and in other cases, three months from the date of completion of treatment. Time barred cases should require the sanction of Competent authority.
IN CASE OF EMERGENCY TREATMENT OBTAINED:
In addition to the above documents, following documents should also be submitted:
a) Emergency Certificate from the treating doctor.
b) Self explanatory letter from the beneficiary explaining the emergency circumstances.
c) Statement of case in triplicate from the Controlling officer duly justifying the treatment in emergency.
d) Letter addressed to the sanctioning authority for Ex-post facto sanction in duplicate forwarding the claim
OPD REGISTRATION SLIPS & PRESCRIPTIONS:
a) In printed OPD slips, the registration number and date with hospital seal should invariably affixed.
b) Prescriptions should be in regular printed letter-head of the doctor or hospital and not in small pieces of paper and bear the date, name and age of the patient with signature of the doctor with required seal affixed in all cases without fail.
RME CLAIMS IN RESPECT OF SERVICE PERSONNEL:
PBOR AND OFFICERS : ONLY INPATIENT BILLS COUNTERSIGNED BY MILITARY HOSPITAL , BELGAUM AND PANAJI ARE DEALT IN THIS OFFICE.
OUTPATIENT BILLS:
OUTPATIENT TREATMENT CASES ARE DEALT WITH BY CONCERNED PAOs IN RESPECT OF PBORs,
IN RESPECT OF OFFICERS : CDA(O) / CDA(AF) / CDA(NAVY)
ENTITLEMENT OF MEDICAL TREATMENT IN CIVIL / PRIVATE HOSPITALS:
Service personnel & their families are entitled treatment in a civil / private hospital vide Paras 293 and 295 of RMSAF.
CONDITIONS:
a) The AMA should consider it essential to admit the patient into local / private hospital.
b) No service hospital exists at that station or necessary specialist facility for treatment is not available at the service hospital.
c) The case is not in fit state for transfer to the nearest service hospital.
The facilities of treatment of families as out-patient from a local civil / private hospital / dispensary is allowed in stations if there is no service hospital irrespective of whether the head of the family is posted in that station or not and reimbursement of expenditure thereof will be allowed.
THE FOLLOWING DOCUMENTS SHOULD ACCOMPANY THE BILLS:
1) Admission in Government civil hospitals:
Non-available certificate from AMA that requisite specialist facility required for treatment of the patient is not available.
2) Admission to Private Hospital or Nursing Home:
Certificate from AMA that accommodation is not available in local govt. hospital or the patient is not in a fit state to be transferred to the nearest service hospital /civil govt. hospital.
Sanction from Are / Div. Commander that it was necessary to admit the patient in the private hospital. The sanction is the one under whose jurisdiction the OC Service hospital submitting the claim.
All the medical reimbursement claims are to be countersigned by the Commandant, Military Hospital situated in the station where treatment was taken or by the nearest Military hospital.
A certificate to the effect that the medicines prescribed are for reimbursement is to be endorsed by the Military Hospital
All cash vouchers and prescriptions are to be enclosed in original.
The hospital bill will be countersigned by the OC of Service hospital who will also make a contingent bill in respect of service personnel / his family member which the individual is required to bear if treated in the service hospital.
The inpatient bills in respect of PBOR and Officers to be submitted to the regional CDAs / CDA(AF) / CDA(NAVY), under whose audit jurisdiction, the service hospital countersigning the bill falls.