CGHS For Central Government Employees And Pensioners – Handbook
Contents
All about CGHS for Central Government Employees and Pensioners – Compilation of all facilities available for medical treatment, guidelines and procedures
CENTRAL GOVERNMENT HEALTH SCHEME
For the last six decades
Central Government Health Scheme is providing comprehensive medical care to the
Central Government employees and pensioners enrolled under the scheme. In fact
CGHS caters to the healthcare needs of eligible beneficiaries covering all four
pillars of democratic set up in India namely Legislature, Judiciary, Executive
and Press. CGHS is the model Health care facility provider for Central
Government employees & Pensioners and is unique of its kind due to the
large volume of beneficiary base, and open ended generous approach of providing
health care. Presently approximately 35 lakh beneficiaries are covered by CGHS
in 71 cities all over India and the endeavor is to include more cities to
improve the accessibility of the services.
CGHS provides health care
through following systems of Medicine
· Allopathic
· Homoeopathic
· Indian system of medicine
o Ayurveda
o Unani
o Siddha and
o Yoga
Eligibility
for Joining CGHS
All the following persons
are eligible for CGHS facilities
1. All Central Government
employees paid from the Central Civil Estimates (except Railways and Delhi
Administration), including their dependent family members residing in CGHS
covered areas.
2. Pensioners of Central
Government (except pensioners belonging to Railways and the Armed Forces) and
their families.
3. Central Government
Pensioners retiring with Contributory Provident Fund benefits and their
families.
4. Widows of Central
Government pensioners, in receipt of family pension.
5. Delhi Police personnel
and their families, in Delhi only.
6. Railway Board
employees.
7. Civilian employees of
Defence paid from Defence Service Estimates.
8. Child drawing pension
on death of a Central Government employee including minor brothers and sisters
of such child.
9. Ex-Governors and Lt.
Governors and their families.
10. Ex-Vice Presidents
and their families.
11. Central Government
servants who are deputed to semi government and autonomous bodies receiving
substantial grant from, or financed by the Central Government.
12. Central Govt.
employees on deputation to statutory or autonomous during the period of
deputation.
13. Military Officers
while on deputation to civil departments and getting their emoluments from
Central Civil Estimates.
14. Families of
Governments servants transferred to a non-CGHS area, for a maximum period of
six months on deposit of CGHS contribution (for the period of 6 months) in
advance.
15. Families of IAS
Officers on North-Eastern Cadre, who continue to stay back in Delhi even after
repatriation of the IAS Officer to the North-Eastern Cadre, provided that they
continue to occupy Government accommodation in Delhi or New Delhi, on deposit
of CGHS contribution in advance (one to three years). The same also applies to
families of IAS Officers of J&K Cadre.
16. Parliamentary
Secretaries of the Central Government and their families.
17. Members of Parliament
and their families.
18. Ex-Members of
Parliament.
19. Sitting Judges of
Supreme Court and High Court of Delhi and former Judges of Supreme Court and
High Courts.
20. Work Charged and
Industrial Staff working in establishments run by various Ministries or
Departments of Central Government, immediately from the date of their joining
the service.
21. Employees of Kendriya
Vidyalays Sangathan stationed at Delhi and NCR, Kolkata, Chennai, Hyderabad,
Mumbai and Bengaluru.
22. Employees of Ordnance
Factory Board Headquarters, Kolkata and Ordnance Equipment Factories
Headquarters, Kanpur.
23. All India Service
pensioners who retire while serving under the State at their option.
24. Freedom Fighters and
members of their family receiving Central Pension under the Swatantrata Sainik
Samman Pension Scheme.
25. Family members of the
Deceased Ex-Members of Parliament.
26. Pensioners of
Ordnance factories.
27. Members of Staff Side
of the National Council of the Joint Consultative Machinery, even though not
serving as Central Government employees.
28. Persons employed in
semi-government and autonomous bodies who are permitted to join the CGH Scheme.
29. An Accredited
Journalist who produces a certificate from the Press Council of India stating
that he is a member of the Press Association, New Delhi (for OPD and at RML
Hospital).
30. Retired Divisional
Accountants of the Indian Audit and Accounts Department and those whose pay and
pension are entirely borne by the State governments.
31. PSU absorbees who had
commuted 100 percent of their pension and have been restored one third portion
of their pension after 15 years.
32. Absorbees of
Statutory Bodies or Autonomous Bodies of Central Govt. (including those who
proceeded on deputation initially or were on deemed deputation and then
absorbed), who are in receipt of Central Civil Pension.
33. Serving and retired
Railway Audit Staff.
34. Serving and retired
Divisional Accounts Officers and Divisional Accountants posted in the Office of
Accountant Generals in States.
35. CISF personnel (and
their families) and CAPF (Central Armed Police Forces) personnel posted in CGHS
cities.
36. Employees of Supreme
Court Legal Services Committee.
37. Employees of India
Pharmacopoeia Commission, and their families.
38. Family and dependent members of a Central Govt. employee (a CGHS
beneficiary) who stay back in CGHS covered area after posting of the employee
to N.E. region (including Sikkim), Andaman and Nicobar Lakshadweep or Ladakh
region and CAPF personnel posted in Left Wing Extremist areas, on payment of
annual CGHS contribution in advance.
39. Defence Industrial
Employees of Naval Dockyard Central Ordnance Depot and AFMSD, in Mumbai.
Eligibility
Criterion
Residence alone (and not
the Headquarters) is the criterion for determining eligibility of a Central
Government servant for availing medical facilities under the Central Government
Health Scheme. Thus, Central Government employees and their family members etc.
residing in any of the notified cities are covered under the Scheme.
Facilities
available under CGHS
- OPD Treatment
including issue of medicines.
- Specialist
Consultation at Polyclinic/Govt. Hospitals.
- Indoor Treatment
at Government and Empanelled Hospitals.
- Investigations
at Government and Empanelled Diagnostic centers.
- Cashless
facility available for treatment in empanelled hospitals and diagnostic
centers for Pensioners and other identified beneficiaries.
- Reimbursement of
expenses for treatment availed in Govt. /Private Hospitals under
emergency.
- Reimbursement of
expenses incurred for purchase of hearing aids, artificial limbs,
appliances etc. as specified.
- Family Welfare,
Maternity and Child Health Services.
- Medical
consultation and dispensing of medicines in Ayurveda, Homeopathy, Unani
and Siddha system of medicines (AYUSH)
CGHS
Covered Cities
CGHS, presently provides
Comprehensive Health Care to more than 35 Lakh Beneficiaries in following
Cities
1. Agartala
2. Agra
3. Ahmedabad
4. Aizwal
5. Ajmer
6. Aligarh
7. Allahabad (Prayagraj)
8. Ambala
9. Amritsar
10. Baghpat
11. Bengaluru
12. Bareilly
13. Berhampur
14. Bhopal
15. Bhubaneshwar
16. Chandigarh
17. Chennai
18. Chhapra
19. Cuttack
20. Darbhanga
21. Dhanbad
22. Dehradun
23. Delhi & NCR
Delhi, Faridabad, Ghaziabad, Greater Noida, Gurgaon, Indirapuram, Sahibabad
24. Dibrugarh
25. Gandhinagar
26. Gangtok
27. Gaya
28. Gorakhpur
29. Guwahati
30. Guntur
31. Gwalior
32. Hyderabad
33. Imphal
34. Indore
35. Jabalpur,
36. Jaipur
37. Jalandhar
38. Jalpaiguri
39. Jammu
40. Jodhpur
41. Kanpur
42. Kohima
43. Kolkata
44. Kota
45. Lucknow
46. Meerut
47. Moradabad
48. Mumbai
49. Muzzafarpur
50. Nagpur
51. Nellore
52. Panaji
53. Patna
54. Puducherry
55. Pune
56. Raipur
57. Ranchi
58. Rajahmundry
59. Saharanpur
60. Shillong
61. Shimla
62. Silchar
63. Sonepat
64. Srinagar
65. Varanasi
66. Vijayawada
67. Tiruchirapalli
68. Tirunelveli
69. Tirupati
70. Thiruvananthapuram
71. Vishakhapatnam
* Soon to be started
72. Kochi
73. Kannur
74. Kozikoda
Wellness
Centre Timings and Online Registration
CGHS Wellness Centres are
open from 7:30 AM to 2 PM on all working days from Monday to Saturday except
emergency services wherever applicable.
The Wellness Centres
remain closed on all Central Govt. holidays. However in case of 3 consecutive
holidays occurring together, Wellness Centres will not be closed for more than
2 consecutive days.Limited Emergency services are available in following 4 WCs
only in Delhi.
- South Avenue
- North Avenue
- Zakir Hussain
Road and
- Kingsway Camp
Timings of WCs with
emergency services are as follows: WC timing 7:30 AM to 1:30 PM Limited
Emergency services 1:30 PM to 7:30 AM.
There are also First Aid
Posts (FAP) at following locations in Delhi
- Nirman Bhawan
- Central
Secretariat
- Vitthal Bhai
Patel House
- Shastri Bhawan
- Narmada House
opposite RML Hospital
- Supreme Court
and
- Moti Bagh
- PHA- for Honble
MPs and Ex. MPs only
- PH- for Honble
MPs and Ex. MPs only
The timings of these FAPs
is from 9:00 AM to 5 :00 PM
Registration
The registration of the
beneficiaries is done online. This registration is either self registration
(seeking prior appointment) or walk in registration (coming to the Wellness
center and getting registered at the Registration Counter).
The registration starts
on opening of the Centre and is stopped 15 minutes before scheduled closing
time of the Centre. However, no serious patient is returned back unattended.
Online Appointment (Self
Registration)
Online appointment with
Medical Officer of the Wellness Centre or with Specialist who visits a
particular Wellness Center can be booked by visiting CGHS portal cghs.nic.in
through the link Book Appointment.
The steps for booking
online appointment (Self Registration) are as follows:
1. Visit the website
cghs.nic.in
2. Click on the option
Book Appointment available on RHS of the screen
3. Enter beneficiary ID
and click on Generate OTP.
4. An OTP (One Time
Password) will be sent on registered mobile no. of the beneficiary or to the
main card holder mobile if that is the only registered number.
5. Enter OTP and click on
Proceed.
6. Beneficiary details
are displayed on screen. Click on Proceed button if the details displayed on
screen are correct otherwise click on NOT YOU. In that case login again and
proceed as above.
7. Select Specialty,
Dispensary, Doctor as per your choice and click on Proceed button. A
beneficiary can select a GDMO (General Duty Medical Officer) or a Specialist of
any of the CGHS wellness centre.
8. A calendar is
displayed to choose a date that has the availability of appointment for the
selected doctor. Select date for appointment.
9. On selecting date, top
of the screen shows the slot timings and the appointments available. A
beneficiary can choose the desired slot.
10. Click on Proceed to
Book Appointment. One can go back and make changes by using the Change the
Specialty button.
11. On clicking the
button Proceed to Book Appointment, beneficiary details and the appointment
details are displayed on the screen for confirmation.
12. Click on the option
Confirm to Book Appointment, Confirmation status page is displayed. One can
print the confirmation slip, or book another appointment. System would also
send an SMS to registered mobile number.
Appointment for the GDMO
can be taken within 72 hours of date of appointment whereas appointment for the
Specialist can be taken within 1 month of date of appointment. Online appointment
cannot be made for the same day or date. (This window period may change
depending upon the decisions taken from time to time)
Senior Citizens above the
age of 75 years can book the appointment by calling the CGHS Helpline no
18002088900 from their registered mobile number.
CGHS
Contribution and Ward Entitlement
For serving Central
Government employees residing in CGHS covered area, obtaining a CGHS card is
compulsory. The following deductions from salary of the employees are made by
the department, every month, depending upon their pay in the pay matrix of 7th
Pay commission (wef 1/1/2017) Corresponding levels in Pay Matrix as per 7th CPC
Contribution per month.
Level 1-5 Rs. 250
Level 6 Rs. 450
Level 7-11 Rs. 650
Level 12 and above Rs. 1000
Contribution to be made
by the Pensioners/Family Pensioners would be the amount that they were
subscribing at the time of their retirement or at the time of the death of
government servant. Pensioners who want to avail CGHS facilities can make
contribution either on yearly basis or one time (ten yrs) contribution for
whole life validity.
Pensioners who want to
avail CGHS facilities can make contribution either on yearly basis or one time
(ten yrs) contribution for whole life validity. Entitlement of wards in private
hospitals empanelled under CGHS (Based on basic pay in pay band) is as follows:
Corresponding Basic pay
drawn by the officer in 7th CPC per month
1 General Ward Upto Rs.
47,600/-
2 Semi Private Ward Rs. 47,601 to 63100/-
3 Private Ward Rs. 63101 and above.
Interactive
Online services
Following interactive
online services are available to the CGHS beneficiaries through CGHS portal
cghs.nic.in
1. Online application for
plastic card: At present a beneficiary can fill application for CGHS card
online. However online completed application has to be downloaded and the
printout is required to be submitted to CGHS Card Section with necessary
supportive documents. The facility of complete online application i.e.
uploading of necessary supportive documents and online payment of subscription
by pensioners is yet not available and is to be started soon.
2. Print your own CGHS
card: For self and dependent members a beneficiary can take a print out of CGHS
cards through Beneficiary log in.
3. Online appointment: A
beneficiary can book online appointment for Medical officer or Specialist.
4. Through Beneficiary
login on CGHS Portal cghs.nic.in following services can be availed:
- View Beneficiary
Details for self and dependent family members.
- Tracking of
medical reimbursement claim: Status of MRC submitted and the level of
processing of MRC can be tracked through this facility.
- Status of
processing of application for plastic card.
- Updation of his
and his dependents registered mobile number
- Updation of his
and his dependents email ids,
- Updation of his
and his dependents Aadhar number.
- History of
medicines issued to self and dependent
- History of
medicines issued to self and dependents.
- Medical
services: Apart from interactive online services mentioned above,
- Medical services
like prescription, issuing and indenting of medicines including life
saving medicines to CGHS beneficiaries through online Web. Application is
available.
24×7
National CGHS Helpline
A 24×7 National CGHS
Helpline service is available on a toll free number 18002088900. It is a
bilingual (Hindi and English) service which is universally accessible ( through
landline or mobile of any service provider).
The beneficiaries can
seek all CGHS service related information through this Helpline.
The Helpline provides information
on queries in the following areas
General information on
CGHS: Names and addresses of the Wellness Centers and their timings, addresses
of 24×7 Wellness Centers, contact details of the CMOs In charge of these
Centers, Contact Details of other officials etc.
Facilities: What all
facilities a CGHS beneficiary and his dependents are entitled to if living in a
CGHS covered area and a non CGHS area.
CGHS eligibility: Who all
are eligible for the CGHS services including the eligibility conditions of dependent
family members?
CGHS entitlement: What
contribution a beneficiary (serving and pensioner) has to pay according to the
pay scale/pension, what is the Ward entitlement of the beneficiary?
Related to Plastic card:
What is the procedure for getting a plastic card made for serving and pensioner
beneficiary, addition and deletion of names in the card, validity of the card
and transfer of the card, loss of the card etc.
Issue of medicines
including Life Saving medicines: Procedure of issuing of medicines from the
Wellness Center, Authorized Local Chemist, Medical store Depot. Documents
required for issuing of life saving medicines, issuing of medicines in
emergency, admissible and non admissible items, issuing of medicines for
longer durations, procedure for indenting and issuing the medicines not
available in the Wellness Center etc.
- Permissions for
investigations/procedures: Whether the permissions are required or not
required, who is the authority for granting the permission, what is the
procedure for getting permission, the documents required for permission
etc.
- Hospitalization:
Hospitalization in emergency, CGHS rates for investigations and
procedures, entitlement for cashless facility, procedure for referral,
permissions for hospitalization etc.
- Medical
Reimbursement Claims: Documents required to be submitted with the MRCs,
procedure for submission of MRC, filling of the MRC, information on
procedure to track status of a claim, clarifications on non reimbursement
of a particular item/claim etc.
- Health Care
Organization (HCO) empanelment: Names of Health Care organizations on the
panel of CGHS, facilities for which empanelled, contact details of the
Hospital authorities, the Accreditation status of the HCO etc.
- Guidance on
grievance redressal mechanism and RTI issues and
- Any other CGHS
related information.
Plastic
Cards
Importance of CGHS Card
1. All the CGHS
beneficiaries and their dependents are being provided with photo ID plastic
cards individually with unique beneficiary ID number which need to be produced
at each service point to avail the facilities.
2. Safe custody of the
CGHS Cards is the responsibility of the beneficiary and in case of loss of the
card beneficiary is required to inform the police and CGHS authorities.
3. Duplicate CGHS card
can be obtained against lost card by applying for the same to the concerned
Additional Director along with a copy of FIR and will be charged Rs. 50/-
Procedure
to get a CGHS Card
Eligible serving
employees/pensioners have to apply in the prescribed form (available on CGHS
web portal www.cghs.nic.in and website www.cghs.gov.in and also in the wellness
centres)
The form should be
completely filled up with individual photographs pasted as specified in the
form.
Following documents need
to be attached:
In case of serving
employee:-
1. Proof of residence.
2. Proof of stay of dependents.
3. Proof of age of son.
4. In case of differently abled dependent son above 25 years, disability
certificate from competent authority as specified.
In case of pensioners:-
In addition to 1 to 4
above:
1. Surrender certificate
of CGHS Card (only if CGHS Card was issued during Service Period).
2. Attested copies of
PPO/Provisional PPO/Last Pay Certificate (in case PPO is not readily available
immediately after retirement.)
3. Demand Draft in the
name of “PAO CGHS New Delhi”.
The amount of Demand
Draft will be for contribution due for one year if the card is to be made for
yearly renewal basis and for 10 years if whole life card is required.
Dependency criteria-
For availing the medical
facilities under the scheme, parents (or parents-in -law in case of female
employee), unmarried son till 25 years of age, dependent
unmarried/widowed/divorced/separated daughters and sisters, minor brothers are
deemed dependent on the Government employee if they are normally residing- with
him and their income from all sources including pension and pension equivalent
of DCRG benefit is less than Rs. 9000 +DA per month. This criteria does not
apply to spouse and disabled son irrespective of age (please see definition of
disability in instructions for filling CGHS card)
Channel of submission:-
In case of serving
employees the application is to be submitted through the department after due
endorsement. In case of Pensioners the application with enclosures are to be submitted
to Addl. Director (HQ) in Delhi and concerned Addl. Director of the city.
Provision for making
pensioner CGHS card while in Service:-
A serving employee can
apply for a pensioner CGHS Card along with his pension papers.
Application with
enclosures and bank draft is to be forwarded to the CGHS through the office of
the employee. The pensioner Card will be issued on the day of retirement
(provided it is applied for at least six weeks before retirement date) and will
get activated from next day.
Online Application for
CGHS Card
The card can be applied
online by visiting CGHS web portal www.cghs.nic.in or CGHS website
www.cghs.gov.in. However at present provision for uploading the supporting
documents is not available. After online submission of the application, the
applicant is required to take a print out of the application and submit it with
supporting documents (duly endorsed by the Head of the Department/Office in
case of serving employees) in the office of the Additional Director HQ in Delhi
or Additional Director in other cities.
Addition/Deletion of
names in CGHS Cards
On the death of the main
card holder, the card becomes invalid and fresh card has to be applied for by
the spouse after he/she starts drawing the family pension. Old CGHS card and a
Death Certificate need to be attached with the application.
A serving employee on
marriage or on the birth of his/ her child may get the names of spouse /child
added to the card after submitting the form for addition duly endorsed by his
department
After the death of spouse
and death/marriage/employment of a son/daughter/dependent it is the
responsibility of main card holder to inform CGHS for necessary deletion of the
card
Validity of the CGHS Card
The service card will be
valid till the date of retirement if otherwise the employee is eligible.
In case of yearly
contribution pensioner cards, in order to continue validity, contribution is to
be made prior to completion of the continuing year.
In case of transfer of
serving employee to a non CGHS covered area the service card will be valid for
the family members up to six months after transfer provided CGHS contribution
for 6 months is made before hand.
CGHS card is valid in all
CGHS cities for treatment/investigation/ Hospitalization. There is no need for
transit permit to get treatment in another CGHS city except for receiving high
value medicines classified as “lifesaving”/restricted supply medicines for
which temporary attachment to a wellness center is required.
Transfer of CGHS Cards
In case of serving CGHS
beneficiary transferred from one department /ministry to another in the same
city, the same CGHS card will continue. The new department/ministry will duly
inform CGHS so that necessary changes can be made in the database of the
employee.
In case of transfer of a
serving CGHS beneficiary from one CGHS covered city to another, again the same
CGHS card will continue. The employee will submit an application along with the
transfer orders, to the AD of his present CGHS city for transfer of card to new
city of posting. The card will be transferred online to his new city of
posting. Thereafter on joining in new city, he will submit an application with
supporting documents to the AD of that CGHS city to validate his card.
CGHS Card for Pensioners
residing outside CGHS Cities
Pensioners residing
outside CGHS covered area can opt for a regular CGHS Card or an IPD (Indoor
treatment) CGHS Card with fixed medical Allowance (in lieu of OPD treatment)
from the nearby CGHS city. IPD card holders will not be eligible for OPD
treatment & issue of medicines from CGHS Wellness Centres.
Self Printing of CGHS
Card
As soon as the
Application for CGHS card is accepted at the CGHS Card Section, an
acknowledgment letter is issued to the applicant mentioning the card number and
the Ben ID of all family members. The plastic cards are available after one
month of the application at the parent wellness centre of the card holder. In
the meantime the acknowledgment letter can be used to avail the facilities from
the Wellness centre.
Print your own Card
online facility
A beneficiary can also
self print his and his dependents cards online through Beneficiary login. This
e-CGHS Card is equivalent to the Plastic Card. After downloading the card in
PDF format beneficiary can take a colour print out and get it laminated for
further use.
The beneficiary can print
his/her or family members card using following steps
- Visit CGHS
portal cghs.nic.in
- Click
Beneficiary Login
- Enter your Ben
ID, password and sign in
- Click Print card
for the beneficiary whose card needs to be printed
- Enter the
onetime password sent on your registered mobile
- Click Print CGHS
Card
- A message
appears on the screen requesting to take a colored print out and get the
card laminated. Click OK
- Download or open
the eCGHS card in PDF format
- Print the eCGHS
card using control P command
A beneficiary may user an
e CGHS card for availing health care facilities. The credentials of the
beneficiaries can be verified by the HCOs through the computer database using
the beneficiary ID number, if required.
Supply
of Medicines
- Supply of
Medicines from Wellness Centres
- Authorizing
Beneficiaries to Purchase Medicines
- Issuance of
Restricted Medicines
Supply of Medicines from
Wellness Centres
- Medicines
prescribed by CGHS doctors/specialists, which are available in Wellness
Center are supplied immediately.
- For the branded
medicines prescribed by the specialist, if the same composition (chemical
salt), same strength with same therapeutic value is available in the
Wellness Center in different brand name/generic name, the same will be
supplied against the prescription.
- Supply of
vitamins/minerals/antioxidants prescribed by the specialist will be
restricted to CGHS formulary medicines.
- Products
classified as Dietary Supplements/food items, cosmetics etc. are not
admissible for supply by CGHS.
- Medicines which
are otherwise admissible and not available in the store of the Wellness
Center will be indented from Authorized Local Chemist (ALC) and will be
normally distributed on the next working day after receipt of the same
from ALC. These indented medicines will have to be collected by the
beneficiary maximum within 15 days of date of indent.
- Medicines for
chronic diseases may be issued for 3 months at a time by any CGHS Doctor
against the valid prescription of a specialist.
- If the
beneficiary is planning to go abroad, medicines prescribed may be issued
upto 6 months at a time with permission of Addl. Director for which an
application with copy of valid prescription, CGHS Card and proof of travel
has to be produced.
- All the
medicines including ALC supplied medicines will be issued throughout the
duty hours of the Wellness center.
- For collection
of indented medicines registration in the Wellness Centre is not required
Authorizing
Beneficiaries to Purchase Medicines
Beneficiary is to be
authorized by CMO I/C to purchase medicines prescribed to him and get
reimbursement when –
· Such medicine has been indented from ALC/ ALC authority slip
issued and the medicine has not been supplied by ALC
· In case the authorization to purchase is given the steps to be
followed are:-
·
- beneficiary has
to purchase the prescribed medicine from any chemist shop
- produce the
medicines with cash memo in the Wellness center
- fill up a
prescribed form with endorsement of CMO I/C
- Submit it with
the cash memo to ALC, who in turn will pay the cost of medicines incurred
by the beneficiary.
The empanelled hospital
will supply essential medicines for 7 days, on discharge of a CGHS beneficiary.
Issuance
of Restricted Medicines
Restricted medicines
include chemotherapy medicines for cancer and other medicines as enumerated in
the “restricted drugs” list of CGHS. This list is available in under
“circulars‟. When restricted medicines like those for cancer and other such
conditions are prescribed the following procedure is to be followed:-
1. An authority slip for
MSD/ AD of the city will be issued from the wellness center for the restricted
drugs on the specialist prescription.
2. This authority slip
along with following documents (all duly verified by CMO I/C) are to be
submitted at MSD/AD‟s office.
§ Application to AD forwarded by CMO I/C
§ Copy of specialist prescription/discharge summery(Emergency
cases) indicating restricted drugs
§ Copies of investigation reports
§ Permission letter for treatment in CGHS recognized hospital
§ Photocopy of CGHS card
§ Utilization certificate (This is required when the same
medicines have been issued earlier also. The certificate in case of orally
administered medicines can be given by the beneficiary himself and for those
administered parentally certificate from CMO I/C or treating specialist is
required.)
§ Person (If not beneficiary himself) who is to collect these
medicines must carry authorization letter, the original CGHS card and his photo
I/D
Procedure
for Referral
· Beneficiaries in all CGHS Cities can avail OPD consultation
from specialists in any Government Hospital directly without the need for
any referral.
· Beneficiaries in all CGHS Cities below the age of 75 years can
seek OPD consultation from Specialists in any of the CGHS empanelled hospitals
after being referred by the Medical Officer or CMO In-charge of the Wellness
Centre. The referral is valid for one month and for three OPD consultations.
The beneficiary is required to report back to the concerned Wellness Center and
the Medical Officer or CMO In-charge will endorse the investigations and issue
medicines as per guidelines.
· Beneficiaries aged above 75 years can directly avail the OPD
facilities at the empanelled hospitals without any referral from the Medical
Officer of CGHS. If any investigations or procedures are advised and required
in emergency, no additional permission or endorsement is required from the
Medical Officer of CGHS.
Investigations
and Treatment Procedures
Permission for
Investigations/Treatment Procedures:
· No Permission is required for getting listed Investigations/
Treatment Procedures done at the CGHS empanelled Diagnostic Centres /Hospitals,
if prescribed by CGHS Medical Officer/ CMO In charge or Government Hospital
specialist.
· Listed Investigations/Treatment Procedures prescribed by a
specialist of empanelled hospital need to be endorsed by the referring CGHS
Medical Officer/ CMO Incharge, however permission is not required in this case
also.
· For unlisted Investigations/Treatment Procedures permission is
required from the AD of the City/Zone in case of pensioners and Head of
Department/Office in case of serving employees. However for pensioners of
Autonomous bodies the permission is to be given by the concerned department only.
Procedure for getting the
investigations done by an empanelled Diagnostic centre / Hospital
The following documents
are required to be submitted:
1. Self attested copy of
prescription of CGHS Doctor / Government specialist
2. Copy of CGHS Card of
the patient and main card holder.
3. Original Prescription
and Original Cards are to be produced at the centre for verification.
Investigation can be done
within 30 days of the advice only. Procedure for getting for any treatment.
Procedure done at an
empanelled hospital
The following documents
are required:
1. Self attested copy of
prescription of CGHS Doctor / Government specialist
2. Copy of CGHS Card of
the patient and main card holder.
3. Original Prescription
and Original Cards are to be produced at the centre for verification.
Treatment procedures can
be done within 3 months of the advice only
Hospitalization
Hospitalization in
emergency
· In emergency CGHS beneficiary may be admitted to any
Govt/private hospital, but the reimbursement will be as per CGHS rates. However
full reimbursement may be allowed in specific cases on the recommendations of
Technical Standing Committee (vide OM No. 4-18/2005- C&P-[Vol1 (Pt 1)]
dated 20/2/2009).
· In such cases, if reimbursement is required, the private
hospital has to issue an emergency certificate stating in detail the condition
of the patient at the time of admission which justified emergency
· CGHS empanelled hospitals cannot refuse admission in emergency
to CGHS beneficiary and have to provide treatment on credit to pensioner
beneficiaries and other entitled categories(even if the beneficiary is from
outside CGHS city/other CGHS city)
Important points
regarding indoor treatment in CGHS empanelled hospital
· When a treatment procedure is done at an empanelled hospital, it
includes related pre-operative investigations, two pre op and two post op
consultation, room charges as per entitlement, medicines and all such
facilities during admission period. The cost of implants /grafts/stents is
reimbursable as per CGHS ceiling rates (or actual whichever is lower) in
addition to package rates.
· In case of indoor treatment, the pensioner (and other entitled
category of beneficiary) will be provided credit facility by the hospital and
in case of serving employee he is to be charged as per the CGHS rates only.
· No extra amount will be charged from the beneficiary by the
hospital over and above the package rate/rate approved, except when the
beneficiary opts for costlier implant/device other than the CGHS approved one,
in which case a written consent from the beneficiary is to be obtained by the
hospital. This extra amount will not be reimbursed to the beneficiary.
Reimbursement
of Medical 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 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.
Acknowledgement and
following up of the claim submitted by pensioner beneficiaries and serving CGHS
employees:
· The claim is to be submitted at the CGHS wellness Centre 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 Centre.
· The status of the claim can be viewed in the CGHS computer
module using the claim number. SMS will also be sent to beneficiaries at each
stage of MRC processing.
· Particulars of the claims which are more than one month old are
now displayed on the CGHS website.
Please see detailed
checklist given below for documents to be enclosed for reimbursement of medical
claims:
CHECK LIST FOR MRC
Please enclose Self
attested Documents in the sequence given below for every claim along with page
numbering
1 Computer generated MRC
No.
2 Self explanatory letter
-duly signed by main card holder
-forwarded by CMO I/C
-with detailed sequence
and justification of the claim and reason for going to a non – empanelled
hospital
-In case of delay in
submission of more than 90 days from date of
discharge/treatment, the reason for delay to be mentioned clearly with request
for condonation of delay.
-If claimant is not in a
position to sign then Right thumb impression in case of females and left thumb
impression in case of males may be put in place of signature. If medically
unfit to sign, then a certificate from physician regarding the disability is to
be enclosed.
Grievance
: Complaint/Grievance Redressal
The complaints/
grievances can be sent
At Wellness center level
– to the CMO I/C
At city/zone level –to
the Additional Director of the city/zone
Higher administrative
level – For Delhi- Addl.Director (HQ)
The addresses and contact
numbers may be found in the contact list.
Beneficiaries are advised
to approach the authorities normally in the order they are mentioned above,
personally, or through phone calls, letters or emails at the contact details on
the CGHS website.
Written Complains/
suggestions may also be dropped in the complain /suggestion box displayed in
the Wellness centers. The grievances at Wellness Centre level can be sorted out
in the “Advisory Committee” meetings held on every 2nd Saturday of the month.
On all Wednesdays, from 11.00 AM to 1.00 PM complainants can meet the
Additional Directors for grievance redressal Grievances related to medical
reimbursement claims can be sorted out on Claims Day held in the O/O Additional
Directors Zone/city on every 3rd Thursday of the month, with prior intimation
and Claims Adalat held (after due advertisement) every six months.
Beneficiaries may also lodge their complains/grievances in the “ Public Grievance Redress And Monitoring System(CPGRAMS)” in the Government portal- “pgportal.gov.in” or through email.
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