CGHS Orders : Guidelines regarding referral letters and settlement of bills of Empanelled Hospitals / Diagnostic Laboratories / Imaging Centres through UTI-ITSL
Government of India
Ministry of Health and Family Welfare
Department of Health & Family Welfare
Nirman Bhawan, New Delhi 110 108
No:S.110011/23/2009-CGHS D.II/Hospital Cell (Part IX)
Dated, the 20th December, 2011
CIRCULAR
Subject: Guidelines regarding referral letters and settlement of bills of Empanelled Hospitals / Diagnostic Laboratories / Imaging Centres through UTI-ITSL
With reference to the above mentioned subject the undersigned is directed to state that in response to several queries received by Ministry seeking clarifications regarding settlement of hospital bills through UTI-TSL, it has been decided to issue the following guidelines for the Empanelled Hospitals / Diagnostic Laboratories / Imaging Centres, CGHS and UTI-ITSL:
2(A) INSTRUCTIONS TO EMPANELLED HOSPITALS / DIAGNOSTIC LABORATORIES / IMAGING CENTRES
1. The empanelled Hospitals / Diagnostic labs / Imaging Centres will honour permission letters (Referral letters) duly signed and stamped with proper issue number. Wherever the permission letters have been issued through computers, any manual corrections should be duly countersigned and stamped.
2. The Hospital shall not undertake treatment of referred cases in specialties for which it is not empanelled, But it shall provide necessary treatment to stabilize the patient and transport the patient safely to nearest recognized hospital under intimation to CGHS authorities. However in such cases the Hospital shall charge as per the CGHS rates only for the treatment provided.
3. The Hospitals / Diagnostic labs / Imaging Centres should provide treatment only for the procedures / investigations for which they are empanelled. If any inadvertent permission letter has been issued for other procedures for which they are not empanelled, the Hospital / Diagnostic lab / Imaging Centre will inform the beneficiary accordingly and refer him / her back to the dispensary, except in emergency condition.
4. In case of procedures like Chemotherapy / Radiotherapy / Dialysis and follow—up treatment procedures where the permission is valid for 3-6 months and a copy of the permission letter is enclosed with the hospital bill for the second and
5. subsequent admissions, hospitals will indicate the ID No. of the Claim wherein original permission letter had been enclosed.
6. CGHS Cards / Plastic cards are valid in all CGHS cities, irrespective of the city where the CGHS card is registered. In case any verification regarding the photocopies of Plastic card / CGHS card is required the details of the individual may be ascertained by accessing the data online at http://cqhs.nic.in/welcome.jsp by entering relevant details. A print out of the same may be enclosed. The beneficiary will not be asked to submit a colour photo copy of CGHS / Plastic Card.
6.1 In case of implants and coronary stents the bills must be accompanied by a copy of the relevant invoices pertaining to the procurement of the stents / implants by the hospitals. In addition to this, the outer pouch of the Stent packet along with the sticker on it on which details of the stent are printed shall also be enclosed with the medical bill for claiming reimbursement. In case of medicines, a consolidated list with relevant batch numbers and cost must be enclosed.
6.2 The empanelled hospital shall also submit a self certified undertaking that the hospital has not charged the CGHS / CS(MA) beneficiary more than the rate atwhich stent / implant / medicine has been procured by the hospital and in case of any detection and establishment that the hospital has overcharged the hospital shall be removed from the list of hospitals empanelled under CGHS without any further notice.
7. In case of serving employees admitted under emergency, the hospitals shall ensure that the details pertaining to the office where the patient is employed are entered in records.
8. In case of indoor treatment, routine investigations are included in the package.However, if any special investigations are performed, reports of such special investigations should be enclosed and reimbursement shall be considered on merits of each case.
9. ICU — package includes — accommodation charges in ICU, Monitoring and ECG.Other investigations cost of medicines and disposables and ‘2’ consuftations charges per day are reimbursable as per applicable norms in addition to the package rate of ICU, Cost of ventilator and oxygen if, any are reimbursable as perapplicable norms. In selected cases, where opinion of other specialists is necessary, only one consultation by a specialist per day may be considered necessary. Reports of Investigations should be enclosed along with the opinion of the other specialist.
