CGHS: Guidelines for submission of Medical Reimbursement Claims

CGHS: Guidelines for submission of Medical Reimbursement Claims
cghs-guidelines-for-submission-of-medical-reimbursement-claim

Reimbursement of Claims
Claim submission
  • In case of treatment in emergency in non-empanelled hospital/expenditure
    incurred for treatment in empanelled hospital, Medical Reimbursement Claim
    (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 Centre (where the CGHS
    card is registered) by the pensioner beneficiary within 3 months of
    discharge from the hospital.
  • In case of delay in submission of claim beyond 3 months, 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 Centre where the
    beneficiary is registered. On verification as per checklist 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
    Centre.
  •  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: CGHS
[https://cghs.gov.in/showfile.php?lid=5116]

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