The government has completely clarified the position on the procedures related to medical claim reimbursement under the Central Government Health Scheme (CGHS) operated for central government employees and pensioners. Often, while processing reimbursement claims, beneficiaries had to face a lot of problems due to bill rejection or referral. To overcome these technical hurdles and discrepancies, the Ministry of Health and Family Welfare and CGHS have issued new clear guidelines, laying down rules for OPD consultation, test limits, eye examinations and special tests.
Rules for checks up to and above ₹3,000
There was often confusion among beneficiaries whether the limit of ₹3,000 was the maximum capping of reimbursement. CGHS has clarified that ₹3,000 is not a maximum reimbursement cap, but is a parameter related to the selection of referral and testing centre. If a specialist doctor in an empaneled hospital prescribes any routine test or minor procedure up to ₹3,000, the beneficiary will have to get that test done in the same hospital where he had taken the initial consultation. There is no need to take separate referral from the wellness center for this.
If the patient wishes to get tested from any other empaneled hospital or diagnostic center based on the same consultation, it will be mandatory for him to take prior referral or endorsement from the CGHS Wellness Centre. On the other hand, for major and specialized tests like MRI, CT Scan and PET Scan costing more than ₹3,000, prior official referral from CGHS Wellness Center is mandatory, otherwise the claim will not be accepted.
Validity period of OPD prescription is 7 days
As per the guidelines, OPD consultation slip issued by a specialist doctor in any empaneled hospital will be considered valid for only 7 days within the same specialty. This simply means that if a beneficiary has consulted a cardiologist on Monday, he can get follow-up consultation, related medicine or investigation done for the next 7 days on the basis of the same consultation. After the expiry of the 7 day period, fresh consultation or re-verification will be necessary for follow-up.
New standards of eye examination and consultation fees
A tough stance has also been taken on complaints of private hospitals charging extra fees in the name of different procedures for eye treatment and examination. Under the new rules, three primary tests will be compulsorily included in the consultation fee of the specialist. These include Refraction (examination of the number of glasses), Tonometry (examination of eye pressure) and Fundus Examination (examination of the retina). The empaneled hospitals cannot charge any separate fee from the patient for these three tests.
Procedure for follow-up treatment and unlisted tests
If a specialist doctor recommends a test or medical procedure which is not listed in the approved rate list of CGHS (Unlisted Investigation), the patient will have to obtain prior permission from the concerned department or administrative office instead of getting the test done directly. Additionally, it is advised to continue the follow-up treatment in the same hospital where the patient's primary treatment was initiated so that there is continuity in the treatment records and the claim settlement is completed expeditiously without any objection.