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Relaxations

Relaxation for above 70 years

Relaxation is to avail consultation only
Other tests and treatments shall compulsorily have advise of treating doctor
The unlisted tests and treatments shall have approval of additional director unless it is emergency.
Pl ensure to give Hospital the advise of doctor mentioning investigations or treatments along with duly filled undertaking
It should not be self investigation or treatment

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Relaxation for all after referral for consultation

if doctor advises follow up consultation / investigation , the same may be availed in the same hospital without referral from CGHS subject to following conditions

Up to five more consultations including cross consultations with other specialists. however, such visits should be justified based on doctors notes .
Since validity of a consultation is for 7 days , the hospital cannot charge for a follow up visit within 7 days in the same speciality.
Follow up tests costing less than Rs 3000 .(based on doctors notes ).
Even , minor OPD procedures not requiring admission and costing less than Rs 3000 based on doctors advise
However for CT MRI , OCT eye , Physiotherapy and Dental procedures require permission from CGHS
All above to be performed in the same hospital within 3 months from the date of initial referral.
During such follow up tests and consultations , fill up undertaking (don’t just sign ) with all tests being advised and being availed , enable Hospital to take geo tag photo and provide OTP while registering.

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Revision of CGHS rates

CGHS General Rates (for most treatments and procedures) – Now Revised
CGHS Cancer Rates (applicable specifically to cancer surgeries).

For cancer surgeries, the CGHS Cancer Rates shall apply;
for all other cancer treatments (including chemotherapy, radiotherapy, and stereotactic surgeries), CGHS General Rates apply.

For specialised high end procedures like liver transplant , Cochlear implantation, DBS implant, Heart transplant,Lung transplant etc Office memoranda issued by CGHS are applicable
In all cases, the chargeable rate to the beneficiary shall be the CGHS prescribed rate or the HCO’s rate for general public (Beneficiaries not covered under this scheme), whichever is lower.

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Salient features of Revised General rate list

Alpha-Numerical Coding System

Introduced a standardized set of five-character alpha-numerical codes.
Ensures system-specific use, preventing misuse across specialties.
Facilitates robust process flows, trend analysis, and anomaly detection.

Elimination of Duplication
Clear Inclusion and Exclusion Criteria
Prevention of Unbundling Practices
Over all 147% increase in rates
Differential rates are applicable based on Type of city, NABH status, super specialty status and ward entitlement of patient.
Rates lists notified separately for tier 1 ,Tier 2 and Tier 3 cities and has mention of NABH , NON NABH and Superspeciality rates
Prescribed rates are for Semiprivate ward

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Summary �

Retained: 1593 codes among 1859 codes

Obsolete/Duplicate/Cancer Surgery Codes: 266 removed

Newly Added: 405 investigations/procedures

Total Codes Revised: 1998 (Surgeries, Daycare, and Diagnostic Procedures)

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EMPANELMENT – RECENT CHANGES

EMPANELMENT is permitted in

CGHS cities (81 cities)
District Head Quarters- based on no of beneficiaries
The jurisdictional areas are defined in empanelment document

Powers delegated to ADs to empanel HCOs in their juridictional area
Shall constitute Hospital empanelment Committee

AD –Chairman
2 Senior most GDMO as Members
1 GDMO as convenor

This committee is also responsible for taking any disciplinary action against hospitals
AD shall also appoint Physical observers for inspection of HCO – GDMO or other doctors depending on type of Hospitals.
ADs shall constitute anti fraud cell in order to curb frauds
Shall appoint and train Nodal officers ( 1 or many depending on No of HCO recommended 1 nodal officer for every 50 HCO)

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Category HCO empaneled under CGHS

Multi-Specialty/Single Specialty /Exclusive Cancer Hospitals
Super specialty Hospitals
Exclusive Eye Hospitals
Exclusive Dental Clinics
Chemotherapy Centres/Dialysis Centres
Laboratory And Diagnostic Centre
Eligibility criteria, PBG vary based on tier of the city
Application fee same for HCO located in all tier cities.

Rs 25000/- for Super speciality hospitals
Rs 10000/- for multi speciality/single speciality /Cancer hospitals
Rs 5000/-Exclusive Eye Hospitals, Exclusive Dental Clinics, Chemotherapy Centres/Dialysis Centres, Physical Medicine & Rehabilitation (PMR) Centres, Laboratory And Diagnostic Centre

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Accreditation criteria

All Hospitals and centres shall have full NABH or equivalent accreditation.
Other Hospitals and centres can also be considered if they have entry level NABH accreditation or QCI recommendation to stay on the panel of CGHS
Hospitals seeking empanelment as Superspeciality Hospitals shall compulsorily be NABH and NABL accredited
Stand alone laboratories shall compulsorily be NABL or equivalent accreditation

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RELAXATIONS …

In Tier II, Tier III and Northeastern States (Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, and Tripura), UT of J&K, UT of Ladakh HCOs (Except Stand alone Laboratory ) without any accreditation or QCI recommendation shall be provisionally empanelled subject to the condition that they must obtain QCI recommendation, entry-level NABH accreditation, or full NABH accreditation (or an equivalent certification) within 6 months from the date of empanelment
Tier III and Northeastern States, UT of J&K, UT of Ladakh Stand alone laboratories without accreditation shall be provisionally empanelled subject to the condition that they must obtain full NABL or equivalent accreditation within 6 months from the date of empanelment
Since there are no NABH or its equivalent standards for Chemo centres these centres shall also be empanelled subject to the condition that they will obtain QCI recommendation within 6 months
HCO failing to acquire required quality accreditation or certification within 6 months shall be removed from the list of empanelled HCOs under CGHS.

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The HCO shall compulsorily register itself with the Ayushman Bharat Digital Mission (ABDM) Health Facility Registry and obtain a unique Health Facility (HFR) ID prior to or at the time of empanelment. The HFR ID must be provided in the empanelment application and maintained active. If the HCO attains ABDM M3 compliance the HCO is entitled for 20 % discount in PBG . (The charitable HCO (as per income tax act )shall be given 50 % discount in PBG)
All consultants shall register on ABDM and provide HPR ID details in HEM portal
Shall compulsorily register on consumer helpline portal
Shall register for e visa / medical visa
Shall nominate two nodal officers , grievance redressal officer and also provide details of MOD in each shift

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Differential rates shall be applicable to the HCOs empanelled under CGHS depending on the NABH and NABL accreditation, Super speciality status of the HCO and geographic location of HCO i.e. Tier I, Tier II .and Tier III cities
The Healthcare Organization (HCO) will be empanelled for a period of three years, covering all available facilities (OPD and IPD). (extendable by 1 year by mutual consent)
There will be no empanelment for selected services. All services (OPD and IPD) must be provided at CGHS rates, regardless of whether the facility is outsourced or in-house.
If a hospital adds new facilities or services, it must inform CGHS and provide these services to beneficiaries at CGHS-approved rates and guidelines.

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Super-speciality hospitals

The Hospitals desirous of getting empanelled under this category shall meet the following conditions
Hospitals with 200 or more beds.(In tier 2 and tier 3 cities 100 or more beds)
Should be mandatorily accredited by NABH or its equivalent such as Joint Commission International (JCI) of USA, ACHS of Australia or by any other accreditation body approved by International Society for Quality in Health Care (ISQUA).
It should have inhouse lab and there should be separate NABL full accreditation
Should mandatorily have the following inhouse Super Specialties along with general specialities like General Medicine, Surgery , OBG, ENT , Opthal , Paediatrics etc

Nephrology and Urology (including Renal Transplantation).
Neurosurgery,
Cardiothoracic Surgery,
Medical Oncology,
Surgical Oncology
Radiation Oncology
Transplant facilities.
Endocrinology.
Specialized Orthopaedic Treatment facilities that include Joint Replacement Surgery
Gastroenterology and GI-Surgery Transplantation.

All facilities shall be inhouse and if there is any outsourced facililty they are not entitled for superspeciality category

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Why -Need Revised MOA

Increase in no of grievances from beneficiaries and also HCO-suggesting gap in CGHS policy and Hospital policy
Dependence on empanelled HCO increasing –now we refer for consultation also
Increase in frauds
From manual to Paper less billing since 2021
Cancer rates since 2015
To accommodate many policy changes and new inititives
Revised rates
Old MOA – toothless with respect to frauds- disciplinary proceeding against HCO was not clear penalties were not sever enough and were not accommodating various kinds of fraud . Many grey areas

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Key features

Clear definitions – Package , ward charges , admissible and Non admissibles
Clear billing guidelines , inclusions exclusions
Mandates HCO to have Policy for CGHS beneficiaries
Clearly defined empanelment, disciplinary proceedings and deempanelment procedure
Creation of HEC plus entrusts with clear responsibilites – ensures strengthening the problem solving at CGHS end
Nominating grievance redressal officer , Nodal officers at HCO – strengthens at HCO end
Mandates more interaction amongst stake holders – ZAC and more rigorous reporting.Feed back from beneficieries
Fraud definition stringent penalties, creation of anti fraud cell, OTP aunthentication, clearly defined penalties etc major step towards fraud prevention
It was circulated to all stake holder and based on inputs received some clauses have been revised
17 Major clauses - At some areas there could be reiteration of certain clauses

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Implementation

Awareness of clauses to all stake holders – CGHS officials (doctors, staff) , Hospital officials and even beneficieries
Training all above at regular intervals
Feed back from audits , complaints , feed back form compulsory for all IPD cases
Revision also involved studying NHA portal (TMS ,HEM) and also CDAC portal ,make necessary changes

To accommodate MOA clauses
Easy billing and payment processes
Implementation of anti-fraud triggers

Formation of HEC , Anti fraud cell ( at LOCAL and also department level)

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Clause 6: Rights of CGHS Beneficiaries and Grievance Redressal�

Non-Discrimination & Priority- CGHS patients have right to seek consultation from Any consultants (visiting or inhouse )
Access to All Facilities: The beneficiary has the right to access all facilities (including outsourced facilities).
Grievance Redressal Mechanism:

The HCO shall establish an internal Grievance Redressal Mechanism specifically for CGHS beneficiaries.
An officer of the rank of Medical Superintendent or equivalent of the HCO shall be designated as the Grievance Redressal Officer for CGHS patients.
Any complaint or grievance from a CGHS beneficiary must be addressed promptly by the HCO. The Grievance Officer shall ensure that all grievances are resolved within 2 (two) working days of being reported.
A monthly report of grievances received from CGHS beneficiaries, and the resolution provided shall be compiled by the Grievance Officer, and a copy of this report shall be sent to the Head/Administrator of the HCO and to the Additional Director, CGHS of the city for review. Repeated or serious complaints may invite scrutiny by CGHS.

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Procedure of availing treatment at empanelled HCO

Documents to be given while availing treatment at Empaneled HCO -In case of referral treatment

Card copy
Referral letter
Geotag photo
Any pre op x ray or investigation

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When treatment is availed without referral letter

Instances

Patients aged 70 years and above eligible to avail OTP consultation without any referral from CGHS.
In case if the consultant advises any investigations or procedures then that prescription will become the referral for those investigations and procedures.
Follow-up visits of tests /consultations or cross consultations advised by specialist during primary consultation of an already referred case including below 70 years
Emergency

The following documents to be given

Card, Doctors advise for performing tests /cross consultations/ follow up consultations from patient
Undertaking in specified proforma by filling details of what tests or follow up consultations doctor has advised and what is being availed and beneficiary details like name, Age, mobile number and signature
All them to take Geotag Photo (Geo tag to be taken on each day if tests are done on different days)
Give OTP register

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Important requirements

SIGN ON THE FINAL BILL verifying the claim amount that will be submitted to CGHS. Mention your name, Mobile number
Fill up feedback form fully – don’t just sign and give please fill all details
Collect bill toward amount paid along with details -don’t collect only receipt
Pl help them to take geotag photo and OTP as per laid down guidelines
Any issues pl speak to nodal officer at the hospital
You have provision to collect discharge medication up to 7 days from hospitals (cost shall not exceed 2000 rs no tonics syrups or vitamins allowed)
Collect all OPD medicines from CGHS wellness centers only. No OPD medicines shall be reimbursed

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Don’t take too many referrals without need specially consultations.

Limit consultations
Tests – lipid profile
HbA1c
LTF
KFT
Serology – HIV , HBsAg, HCV
Echo cardiogram
CT , MRI
PET CT

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Guidelines while submitting the MRC

We, at MRC section of the CGHS Bangalore are making every effort to timely reimburse the admissible amount as per the applicable CGHS rates. We seek your kind cooperation in this regard by adhering to guidelines issued time to time
It is requested that Pensioners adopt to the laid down CGHS system, where in, on the advice of Govt. / CGHS doctors, treatment can be taken in Govt. or Empanelled Hospitals after obtaining permission from CGHS. This will minimize the hurdles as well as prevent unnecessary economic burden. In case of emergency also pensioner beneficiary can avail cashless treatment at empaneled hospitals.
MRC should be submitted only in the Parent Wellness Centre. It will not be accepted in Head Office. The other city card holders are to submit the claims at the parent wellness center of their respective CGHS city or at CGHS city the treatment is obtained
The reimbursement shall be as per NON NABH rates as applicable to tier of the city
Kindly make use of nomination facility

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Please note that it is the responsibility of the claimant to provide all the required documents
Kindly enclose all required documents with a request letter explaining the circumstances for availing emergency treatment.
Arrange all the bills in Chronological order and prepare a summary of all bills.
In case of claim from dual sources ie where the beneficiary has received some amount from private medical insurance, The beneficiary has to

submit final claim settlement letter where there is mention of total claimed and amount settled
all claim documents (to be obtained from insurance company) which are signed and stamped on each page in ink by the insurance company
The claim shall be restricted to difference of actual expenditure minus the amount already received OR the admissible amount whichever lower.

No payment can be made against Provisional or Running or Intermediate or Interim bills.

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No payment can be made against photo copies of the bills.
No outpatient (OP) medicines can be reimbursed and they shall be collected from WC .
No costs towards Implants or Stents or Costly medicines and consumables (costing above Rs 5000) can be considered without invoice. The payments cannot be done based on letter issued by hospitals. If the item was purchased in bulk by the hospital, then copy of the bulk invoice to be obtained from hospital. The following documents to be submitted in cases of Implants or Stents or Costly medicines and consumables (costing above Rs 5000)

Copy of invoice / bulk invoice
Outer pouch /warranty card /sticker
Letter from treating surgeon mentioning detailed specifications
The treating surgeon shall also certify that implant is working satisfactorily

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Non-medical expenses are not covered under CGHS and hence expenditure incurred in this regard are not admissible as per CGHS Guidelines.
Kindly enclose the original paid proof for all the bills enclosed unless enclosed bill is bill cum receipt.
Amount claimed, actual amount paid to hospital (receipts) and the total bill amount should tally.
Reimbursement is subject to examination of the case by technical screening committee.
Beneficiaries are advised to keep one set of claims documents for reference.
Kindly enclose the NEFT details as the payment is settled by Electronic clearing system.

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Documents to be enclosed along with Medical Claim

Self-explanatory note (explaining the emergency circumstances)
Claim form duly signed by the claimant

Only the principal card holder can claim
If principal card holder is no more

The spouse can claim
Dependents can claim after enclosing affidavit/legal heir certificate along with NOC from other legal heirs.
Nominee may submit the claim along with nomination form.
Any of the other relatives (who claim to be legal heir) can claim but they have to enclose legal heir/succession certificates along with NOC from other legal heirs.

Emergency certificate.
Referral letters/Permission letters/Govt doctors advise wherever applicable.
Discharge Summary, (detailed OT notes are required in case of uncoded procedures/ complicated procedure / two or more procedures)

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Bills

Enclose consolidated bill
Enclose detailed break up bill
Ensure that all bills are signed and there is seal
Prepare a summary of bills if bills are too many
All bills to be arranged chronologically and numbered
If outpatient emergency treatment was obtained prior to being admitted, kindly enclose such bills before indoor bill.
Please ensure that total of all bills enclosed matches with the amount being claimed

Payment receipts matching with amount claimed (total paid = total claimed)
In case of implants/stents/valves/ costly medications and consumables costing above Rs 5000 etc enclose following documents

Copy of invoice / bulk invoice
Outer pouch /warranty card /sticker
Letter from treating surgeon mentioning detailed specifications
The treating surgeon shall also certify that implant is working satisfactorily

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Investigation reports
If original documents/bills are lost, then affidavit in prescribed format to be enclosed
Those beneficiaries having Private health insurance will first claim to the insurance company where he will be submitting the originals. Later pensioner shall submit the claim to CGHS with the following documents

Photocopies of all claim documents as required above should be obtained from Insurance company which will be duly certified in ink along with stamp of insurance company on reverse of each page.
Final Settlement letter - A letter addressed to CGHS shall also be obtained from Insurance company indicating the amount claimed and amount settled
Pl check the claimed amount and paid amount as per bill submitted and as per settlement letter match
Don’t submit pre authorizations. they are not same as final settlement letters
The insurance companies are obligated to issue such letters and documents as per the instructions of IRDA

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Non admissible items

Sl. No.	Item Description
1	Home visit/home consultation charges
2	Bed pan (utensils for patient use)
3	Urine container, Urine can, Urobag
4	Moisturizer (for skin care)
5	Underpad/Chux, Sanitary pad, Bath wipes
6	Room fresheners (air freshener sprays, etc.)
7	Hand Sanitizer solutions (Microshield, Sterillium), Mouthwash (Listerine), Depilatory creams (hair removal), hand wash liquids
8	Spectacles or Contact lenses (if given post eye surgery)
9	Food charges for attendant / extra meals, Mineral water bottles
10	Telephone, Email or Internet charges (patient communication)
11	Mortuary sheet or shroud

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