Reimbursement CGHS Claims

Reimbursement CGHS Claims

Claim submission:-

In case of treatment in emergency in non-empanelled hospital/ treatment without permission in empanelled hospital, MRC will have to be submitted by the beneficiary for reimbursement of expenses incurred. The claim is to be submitted to the concerned department by serving employees and to the CMO I/C of the CGHS wellness center(where the CGHS card is registered) by the pensioner beneficiary within 90 of discharge from the hospital.
In case of delay in submission of claim beyond 90 days, the reasons justifying the delay must be stated by the beneficiary in a forwarding letter.

The claim is to be submitted in duplicate in the prescribed form.
The following enclosures must be attached with the claim forms(duplicate):-

Copy of CGHS card of patient (along with copy of CGHS card of principal cardholder if patient is other than the principal cardholder)
Copy of permission letter, if any
Emergency certificate(in original), in case of emergency admission
Copy of discharge summery
Ambulance use certificate(original), if any
Original bills/vouchers/cash memo etc. for the amount claimed
Other information/documents to be provided wherever applicable-

Break up of investigations /tests (details of individual tests, number of tests with rates) from hospital
In case of lost papers, photo copies/ duplicate copies of bills attested by treating doctor along with affidavit in prescribed format to be submitted. In case of death of principal cardholder affidavit as per prescribed format to be enclosed. In case partial settlement of claim by any insurance agency, copies of bills duly endorsed by insurance agency, mentioning that original bills have been retained by them and amount of claim settled by the agency, to be submitted

The documents to be attached in case-

(I) if implant used- invoice number, sticker with serial number of implant.

(II)if coronary stent/s used-outer pouch of stent/s with sticker

(III)when pacemaker/ICD replaced-copy of warranty certificate of earlier pacemaker/ICD. The bank details in the mandate form needs to be enclosed.

The telephone number and email ID of the beneficiary should invariably be mentioned correctly.
Cancelled cheque/Photocopy of a cheque needs to be enclosed
Acknowledgement and following up of the claim submitted:

The claim is to be submitted at the CGHS wellness center where the beneficiary is registered. On verification as per check list if the claim is found to be complete with all documents then an acknowledgement will be generated with a claim number in the computer module of the wellness center.
The status of the claim can be viewed in the CGHS computer module using the claim number.
Particulars of the claims which are more than one month old are now displayed on the CGHS website.
MRC claimed from dual source (CGHS and Medical Insurance Company)

In case the beneficiary is also covered under Insurance and the claim has been settled by the Insurance Agency, the liability of CGHS will be reimbursement to the extent of balance of total claim after payment by insurance company subject to the maximum amount of CGHS rate.

Source : http://cghs.gov.in/