<il14fw~~ li~Ii'l~ I<ilH:(orr. ~ -n.el. ~.q-.), 1\i1(iCi~ ~ Iq:()m 1r<f'f, ~ 1r<f'f ~ q-rn-, '1C! (<II '3>(1,

31~li ~lill~ - 380009.

qftq;r ~ ~ {~.'l.)Ift)f.\1rtlll 04 ~ 19.08.2019

m <H$I~@CflI{ ~ ~T Q-q ti'J\JlJQ'tH!'ft ~ ~ ~ ~ w ~ ~w t, FvR=r.t'liJ_,{'jQijQ'ft (:IT3nf~brr~ Rlfih,'ftl ~ 3'1iIT{"/tfc ~ w=n:r qr(q01 ~ ~ ~ mma=<:T

fa1m:IT ij;- ~* fq~elCf1{UI ~ ~TT ~T W ~ ~ 6i

~: t;TfIT;f <Ji~I~&lifiF{09.08.2019 t" RDiif.\1(1~rCircular No Bills (Au)lMedicall 04 dated 19.08.2019

Please find attached herewith Circular which has been issued in accordance with theorders of the Principal Accountant General and CGHS rules, regarding general rules to befollowed by CGHS beneficiaries, while taking medical treatment / test.

The contents of the circulars are brought to the notice of all officials for information andcompliance.

Authority: Principal Accountant General (Admn) orders dated 09.08.2019

-lR'ffi-

cr.~ q-fun dlf!l,*,lfI(~)

~: ~~.tf.)Jfilr.t>rt111\)jffiffifq :1.~ Jj,&lIl(>1'll ~ ~ (~ ~) I2.~~{2 ~)3.31R'.'Q'.m.ltfr.Q'.m., ~ ~, 316'1""lt;liIllt; I4.31R'.'Q'.:3ir.r-;fT.'C!"ft'.3fR'.tr.tfi.,~ I5.31R'.'Q'.m.ltfr.Q'.m., ~ I

q;11I'1t'i1i tnn;r 1H~1t4&Iq;I\{(3JT. 'tfCi ~.at ~.q-.). dj\iHld~

t'l&lqf!arr 3fCJ;f. ~CR m ~trnr. crf(~<idlq\{l,~

31((fA&litl& - 380 009.

General Guidelines for CGHS Beneficiaries:-

A. In Case of OPD treatment - (Ref - As per OM Z 15025/117/2017/DIR/CGHS/EHSdtd 15.01.2018 & Z 15025/117/ 2017/DIR/CGHS/EHS dtd10.12.2018)

1) All CGHS beneficiaries (in all CGHS cities) shall be permitted forseeking OPD consultation from specialists at private Hospitalsempanelled under CGHS after being referred by any MedicalOfficer/CMO of CGHS wellness Center.

2) Referral from CGHS Medical Officer/CGHS Specialist for consultationwith specialists at Private Hospitals empanel led under CGHS shall be valid for30 days in the same hospital

* Referral shall be valid for consultations upto 3 times in the same hospitalwithin 30 days.

* Referral shall be valid for consultation with a maximum of 3 differentSpecialists, if required during a single visit.

3) After consultation at empanelled hospitals beneficiary shall reportback to concerned wellness centre, where MOICMO would endorse listedinvestigation and issue medicines as per guidelines.

4) Advice of the CGHS Medical Officer! CGHS Specialist for listedinvestigations shall be valid for a period of 30 days.

5) If any listed investigation advised by Specialist of empanelled hospital isrequired urgently as a medical emergency and certified as such, may beundertaken at the same hospital.

6) For unlisted investigation/treatment procedures serving employee shallseek permission from their department as per prevailing guidelines.

7) The medicines prescribed by specialists shall be supplied by CGHSas per the available generic name at the CGHS wellness centre.

8) It is clarified that the validity of the advice of Central Govt.! State Govt.Specialist / CGHS Medical officer for listed treatmentprocedures shall be treated as valid for three months unless mentionedotherwise and no other referral (permission) letter is required to undergothe treatment procedure at any of the empanelled hospitals.

9) In case of Haemo-Dialysis, the advice for treatment can be madeupto six months and in such cases the advice shall be valid for uptosix months.

10) In case of Radio-therapy/Chemotherapy advised by a Governmentspecialist the advice shall be valid for all the cycles of Radio­therapy/Chemotherapy. The specialist has to specify the specific Radio­therapy procedure. Self-attested (by beneficiary) photo­copies of the permission letter is required to be submitted.

11) Beneficiaries in all CGHS Cities can avail OPD consultation fromspecialists in any Government Hospital directly without the need forany referral except for purchase of Hearing AIDS.

B. In Case of IPD treatment -

1) After reference from any CGHS center, CGHS beneficiary can undergothe specific treatment/procedure in any empanelled hospital at CGHS rate.

2) For Cashless Indoor treatment at Shalby & Apollo Hospital, Prior or Post­facto permission from the department should be obtained by the employee.

3) Otherwise, Employee can submit the bill within 3 months from the dateof discharge for reimbursement.

4) When a treatment procedure is done at an empanelled hospital, it includesrelated pre-operative investigations, two pre op and two post opconsultation, room charges as per entitlement, medicines and all suchfacilities during admission period. The cost of implants/grafts/stents isreimbursable as per CGHS ceiling rates (or actual whichever is lower) inaddition to package rates.

5). Where inpatient treatment is provided to serving CGHS beneficiaries onpayment basis, the empanelJed private hospital will supply medicines forupto 7 days period on payment basis, for which employee can claimreimbursement from the office. The above facility will however, be subjectto the following conditions-

(i) Only essential medicines in generic form for continuity oftreatment will be issued by the hospital.

(ii) No Nutritional supplements, tonic, cough syrup, vitamins,injections will be issued by the hospital. These are not allowed.

(iii) No non-drug items / equipments / appliances will be issued.(iv) Total cost of such medicines issued by the hospital must not

exceed Rs. 2000/- in any case.

C. In Case of Emergency treatment -

I) In emergency CGHS beneficiary may be admitted to any Govt/privatchospital, but the reimbursement will be as per CGHS rates.

2) In such cases, if reimbursement is required, the private hospital has toissue an emergency certificate stating in detail the condition of the patient atthe time of admission which justified emergency.

D. In Case of Follow-up treatment - (Ref - As per OM Z15025/35/2019/DIR/CGHS/CGHS(P) dtd 29.05.2019)

I) Permission for post-operative follow-up treatment in respect of thefollowing post - operative conditions requiring frequent Consultationsfrom Specialists at private hospitals empanelled under CGHS, need not be rcvalidated from time to time and follow-up treatment may be under taken atCGHS rates without time limit.

2) The consultation /investigations are permitted under these follow-upcases. The conditions covered are:

a. Post Cardiac Surgery Cases including Coronary Angioplastyb. Post Organ Transplant Cases (Liver, Kidney, Heart, etc.,)c. Post Neuro Surgery CaseslPost Brain Stroke cases requiringregular follow-up treatment.d. End Stage Renal Disease/follow up cases of Liver Failuree. Cancer treatmentf. Auto-immune disorders like Rheumatoid Arthritis requiring regularfollow-upg. Neurological disorders like Dementia, Alzheimer's disease,Parkinsonism, etc.,

..Medicines prescribed are to be procured from CGHS Wellness Ccntrc.

3) The beneficiaries shall have to submit a self-attested photo copy of thepermission letter to the hospital to enable the hospitals to provide creditfacility in respect of CGHS beneficiaries entitled for credit facility. Servingemployees (and their dependents) who may not be entitled for cashlessfacilities shall enclose a self-attested photo copy of permission letter toclaim reimbursement from the concerned Ministry !Department.

4) Permission for follow-up treatment in respect of serving beneficiariesmay be obtained from concerned Ministry /Department.

5) However, if any non-listed investigations / procedures are advisedpermission from competent Authority shall be required, except inemergency.

E. In Case of Medical Advance - (Ref - As per OM Z 14025/18/2015-MS/EHSSdtd 17.10.2016)

1) With the approval of the competent authority, Serving CS(MA) andCGHS beneficiaries may be granted 90% medical advance of the approvedCGHS package rates for all indoor treatments, irrespective of major andminor diseases, on receipt of a certificate from the treating physician of aGovernment/recognised hospital.

2) For outdoor treatment, it has also been decided that advance may belimited to 90% of the total estimated expenditure of the treatment, subject tothe condition that the advance for OPD treatment may only be granted whenthe total estimate of expenditure for OPD treatment includingtests/investigations is more than Rs.l 0,000/-

F. In Case of Elective treatment - (Ref - As per OM1967/2013/DEL/CGHS/SZ/D52/CGHS(P) dtd 30.12.2014) -

In case of serving beneficiaries request for permission / Ex-post factoapproval for elective treatment/ investigation to be considered by HODor HOO of individual Ministries/Department in respect of following

cases-

1 c 1 f treatment/investigation1) Permission/Ex-post facto approva lor. e ec I~e. 1 /d t tres subj cct totaken in Non-empanelled hospita s iagnos IC cen

reimbursement being restricted to CGHS package rates or actualexpenditure, whichever is less.

2) Ex-post facto approval of elective treatment/investigation in empanel ledhospitals/diagnostic centres without recommendation of Govt. Specialist orCMO i/c subject to reimbursement being restricted to CGHS rates or actualexpenditure, whichever is less. -

3) Ex-post facto approval of elective treatment at empanel led hospitals withrecommendation of Govt. Specialist/CMO i/c but without obtaining thepermission of competent authority, subject to reimbursement beingrestricted to CGHS rates or actual expenditure, whichever is less.

4) PermissionlEx-post facto approval for cancer treatment taken in Non­empanelled hospitals subject to reimbursement being restricted to CGHSrates or actual expenditure, whichever is less.

* Permission for treatment/investigation at Non-empanelled hospitalsIdiagnostic lab when facility for the same are not available in anyempanelled hospitals I lab or any Govt. Hospital- to be granted by AS &DC(CGHS) in consultation with experts, if required.

*Note:-

1. Medical bill should be submitted within 3 months from the date of OPDtreatment or from the date of discharge.

2. Prior or Post-facto permission is necessary for cashless indoor treatmentat Shalby & Apollo Hospital.

3. Cashless OPD treatment can be availed on prescription of CGHS. (Nopermission is required from Department)

4. Documents required for reimbursement of MRC-

a.Self-attested copy of prescription of CGHS Doctor / Governmentspecialist for consultation or specific investigation.

b.Copy of CGHS Card of the patient and main card holder.

O iginal Bills of consultation or specific investigation/treatment.c. nd.Emergency Certificate if treatment has been taken in emergency