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CGHS for Central Government Employees and Pensioners – Handbook

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.

Click here to view/download the pdf

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