Office of the Additional Director ,CGHS Bangalore
E Wing , 3rd Floor , Kendriya sadana
Koramnagala Bangalore -34
F. No.19-3/1/2014-Admn/6641 Date: 22/12/2017
OFFICE
MEMORANDUM
The
undersigned has been receiving complaints regarding problems faced by CGHS and
other Central Government beneficiaries while availing health care facilities
from empanelled Health Care Organisations (HCO’s). The Central Government Employees Welfare Co-ordination
Committee has also raised serious concerns over issues like refusal of admission/beds,
refusal of credit, not charging as per CGHS rates, non application of CGHS
rates to Central Government beneficiaries covered under other schemes like
CSMA, BSNL MRC and other schemes run by central autonomous bodies.
Hence,
the provisions as per the terms of agreement with HCO’s, are being reiterated
in order to streamline availing care from empanelled HCO’s
1. The
empanelled hospitals shall not refuse beds/admission to any of the central govt
beneficiaries and it is agreed that CGHS beneficiaries shall be attended to on
priority.
2. The
hospitals shall provide cashless/ credit facilities to pensioners and other
categories of CGHS beneficiaries on referral and in emergency. The cashless
facility is also available for serving central govt CGHS beneficiaries during
emergency.
3. The hospitals shall admit the beneficiary in the ward as
per his or her entitlement.
4. The
hospital shall not collect any money towards any essential treatments which
includes medicines investigations, consumables, consultations, equipments etc
from the credit entitled beneficiaries.
5. During emergencies hospitals shall not refuse
treatment. If a required facility is not
available then hospital shall stabilise the beneficiary before transferring to
another CGHS empanelled hospital.
6. The hospital has to charge as per the approved CGHS rates
for all central government beneficiaries including CGHS, CSMA and other
autonomous body beneficiaries. The
approved rate for a procedure is the “CGHS rate or the actual hospital rate
whichever is lower.”
7. The
hospital/diagnostic centres shall charge CGHS rates to Central Government
Employees/ Pensioners on production of valid I-Card/ Documentary proof, even
though treatment is not sought as CGHS beneficiary.
8. Hospitals shall perform annual health examination of the
beneficiaries as per the MOA at approved rates.
9. All
the coded investigations and procedures shall be performed based on prescription slip/ OPD notes issued by CGHS or any
other govt specialist. Coded investigations
and procedures are those which find a mention in the CGHS rate list and for
which CGHS rates are mentioned in the rate list.
10. The “CGHS “Package Rate” shall mean all inclusive –
including lump sum cost of inpatient treatment / day care / diagnostic
procedure for which a CGHS beneficiary has been permitted by the competent
authority or for treatment under emergency from the time of admission to the
time of discharge including (but not limited to) – (i) Registration charges,
(ii) Admission charges, (iii) Accommodation charges including patients diet,
(iv) Operation charges, (v) Injection charges, (vi) Dressing charges,
(vii)Doctor / consultant visit charges, (viii) ICU / ICCU charges, (ix)
Monitoring charges, (x) Transfusion charges and Blood processing charges (xi) Pre
Aesthetic checkup and Anaesthesia charges, (xii) Operation theatre charges,
(xiii) Procedural charges / surgeon’s fee, (xiv) Cost of surgical disposables
and all sundries used during hospitalization, (xv) Cost of medicines and
consumables (xvi) Related routine and essential investigations (xvii)
Physiotherapy charges etc. (xviii) Nursing care charges etc. . The cost of
Implants / stents / grafts is reimbursable in addition to package as per the CGHS
ceiling rate or the actual rate (as per invoice) whichever is lower.
11. All investigations regarding fitness for the surgery will
be done prior to the admission for any
elective procedure and are part of package
12. The HCO’s shall administer the medications/injections
issued by CGHS (if any).
13. The items like toiletries, sanitary napkins, talcum
powders and mouth fresheners are inadmissible for reimbursement.
14.
The heads of various central government
offices /departments are authorised to seek clarification from HCO’s on
problems being faced by beneficiaries / inspect the hospital premises.
15.
It shall be the
duty and responsibility of the empanelled HCO, at all times, to obtain, maintain and sustain
the valid registration, recognition and high quality and standard of its
services and healthcare and to have all statutory / mandatory licenses, permits
or approvals of the concerned authorities under or as per the existing laws”.
16.
The hospitals are required to display
the CGHS rates of following common procedures at prominent places within the
hospital premises
·
Balloon coronary Angioplasty/PTCA
·
CABG
·
Total Knee Joint Replacement
·
Total Hip Joint Replacement
·
Normal delivery with or without
episiotomy & perineal repair
·
Caesarean section
·
Laparoscopic Cholecystectomy
·
Laparoscopic appendectomy
·
Transurethral Resection of Prostate
(TURP)
·
Phaco with foldable IOL
17. Hospital shall display at the reception and at
other prominent places within the hospital ,
regarding
a.
availability
of cashless facility to CGHS pensioners, Ex-Members of Parliament, Sitting
Members of Parliament, Freedom Fighters, Serving CGHS/DGHS / Ministry of
H&FW employees and such other categories of CGHS cardholders as notified by
the Government etc., on referral and in emergency.
b.
Availability
of cashless facility to even the CGHS serving beneficiaries during emergency
(where obtaining prior permission/referral is not possible).
18. The hospitals shall not collect any advance amount
from any of the central govt. beneficiaries.
19. Hospital
shall display the names of 2 Nodal Officers along with their telephone contact
numbers at the reception counters and at other prominent places within
hospitals. Hospitals shall ensure that the nodal officers are always trained in
CGHS procedures to ensure smooth delivery of care to CGHS beneficiaries. Any
change in nodal officers shall be immediately informed to CGHS.
20. HCO’s shall provide electronic platforms for
accepting payments through electronic modes and accept digital payments
21. The empanelled HCOs are CGHS are to sign up as convergence partners by registering
themselves on the “consumerhelpline.gov.in” portal. So that the consumer
complaints shall also be directly dealt by Consumer help line.
22. Violations of the provisions of the MOA by the empanelled
HCO’s under CGHS like refusal of
service, undertaking unnecessary procedures, prescribing unnecessary
drugs/tests, over billing, reduction in staff/ infrastructure/ equipment etc.
after the hospital/ has been empanelled, refusal of credit to eligible
beneficiaries and direct charging from them, if not recommended by
NABH/NABL/QCI at any stage, discrimination against CGHS beneficiaries vis-à-vis
general patients etc shall be viewed very seriously . The amount of Performance
Bank Guarantee will be forfeited and the CGHS shall have the right to
de-recognize the health Care Organization as the case may be. Such action could
be initiated on the basis of a complaint, medical audit or inspections carried
out by CGHS teams at random. The decision of the CGHS will be final.
Additional Director
CGHS Bengaluru
