ECHS : SOP FOR BILL PROCESSING

INTRODUCTION Overview 1. ECHS has been launched to provide comprehensive Medicare to all ESM in receipt of pension or disability pension, as also to his/her dependents, which include wife/husband, legitimate children and wholly dependent parents. The Scheme is also applicable to NOK’s of deceased pensioners who are drawing family/special family /liberalized family pension. 2. This document lays down guidelines for processing of bills pertaining to empanelled Hospitals/Nursing Homes/Diagnostic Centers wherein an ECHS beneficiary has been referred to for treatment, in case of non-availability of accommodation or required facility for treatment in the Service hospital.

Aim 3. The aim of the Ex- Servicemen Contributory Health Scheme (ECHS) is to provide comprehensive and quality medical care to Armed Forces Veterans (AFV). The following categories are eligible for availing the facilities on membership:-

(a) Ex-servicemen drawing Pension/ Disability Pension.

(b) Widows drawing Family Pension.

(c) Spouse of pensioner.

(d) Unemployed sons below 25 years of age.

(e) Unemployed and/or unmarried daughters.

(f) Dependent parents whose income is less than Rs. 3500/- per month.

(g) Mentally / Physically challenged children for life

(h) New born baby up to 03 months based on birth certificate. (Auth:- Central Organization ECHS letter B/49770/AG/ECHS/POLICY, Dt. 25 sep 2007 Copy enclosed)

Facilities

4. Medical facilities are to be provided through a network of 426 Polyclinics spread across the country, established over the years. Basic outdoor services will be provided at the Polyclinics. In case further management is required, referral will be made from ECHS Polyclinics to Armed Forces Medical Services Hospitals, Empanelled Private Hospitals/ Dental and Diagnostic Centers as applicable. These referrals can only be made by authorized staff of the Polyclinics.

5. Empanelment of Hospitals/Nursing homes and Diagnostic Centers is carried out after signing a Memorandum of Agreement (MOA). Expenditure incurred on services provided by an Empanelled Hospital /Dental / Diagnostic centre will be paid directly to them by ECHS as per approved rates.

- 2 - Definition of Wards 6. ECHS beneficiaries are entitled to facilities of private, semi-private or general ward

depending on their Rank at the time retirement. The entitlement is as follows:-

(a) Private Ward. Private ward is defined as a hospital room where single patient is accommodated and which has an attached toilet (lavatory and bath). The room should have furnishing like wardrobe, bed-side table, resting bed for attendant. (b) Semi Private Ward. Semi private ward is defined as a hospital room where two to three patients are accommodated and which has attached toilet facilities and necessary furnishings. (c) General Ward. General ward is defined as halls that accommodate four to ten

patients.

Serial Rank at the time or Retirement Entitlement No.

1 NCOs & below of Army & equivalent in General Ward Navy & Air Force

2 JCOs in Army & equivalent in Navy & Air Semi Private Force Ward

3 Officers of Army, Navy and Air Force Private Ward 7. Normally treatment in higher category of accommodation than the entitled category is not permissible. However, in case of an emergency when the entitled category accommodation is not available, admission in the immediate higher category may be allowed till the entitled category accommodation becomes available. However, if a particular hospital does not have the ward as per entitlement of beneficiary, then the hospital can only bill as per entitlement of the beneficiary even though the treatment was given in higher type of ward. Authorisation 8. The authorization for payments to empanelled Hospitals, Nursing Homes, Diagnostic Centers and reimbursement of medical expenses to Ex-Servicemen is as per para-2(j) Govt of India letter No 22(1)/01/US(WE)/D(Res) dated 30 Dec 2002. Implementation Instructions: Revised ECHS Rates 9. Reference :-

(a) Central Organisation ECHS letter No B/49771/AG/ECHS/Empanelment dated

05th

December 2003

(b) Central Organisation ECHS letter No B/49773/AG/ECHS/CGHS dated 24th

Aug

2010 (vide which MoD ID No 22A (48)/2007/US/WE/D(Res) dated 19th

Aug 2010 was forwarded to all).

10. Rates for various empanelled hospitals have been revised for Delhi and five other cities and differentiated for NABH Accredited Hospitals, Non NABH Hospitals and Super Specialty Hospitals by CGHS. Package Rates 11. Package rates envisage up to a maximum duration of indoor treatment is as follows :-

(a) 12 days for Specialized (Super Specialties) treatment.

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(b) Seven days for other Major Surgeries.

(c) Three days for Laparoscopic surgeries/normal deliveries.

(d) One day for day care/minor (OPD) surgeries. 12. However, if the beneficiary has to stay in the hospital for his/her recovery for a period more that the period covered in the package rate, in exceptional cases, supported by relevant medical records and certified as such by hospital, the additional reimbursement shall be limited to accommodation charges as per entitlement, investigations charges at approved rates and doctors visit charges (not more than two visit per day per visit by specialists/consultants and cost of medicines for additional stay). 13. No additional charge on account of extended period of stay shall be allowed if that extension is due to infection resulting as a consequence of surgical procedure or due to any improper procedure and is not justified. 14. The package rates are for semi-private ward. The ECHS beneficiaries taking treatment in the empanelled hospitals will be entitled for reimbursement / treatment on credit as per the package rates/rates as per MOA whichever is lower. The package rates are for semi-private ward. If the beneficiary is entitled for general ward there will be a decrease of 10% in the rates. For private ward entitlement there will be an increase of 15%. However, the rates shall be same for investigation irrespective of entitlement, whether the patient is admitted or not and the test per se does not require admission to hospital. 15. A hospital empanelled under ECHS whose normal rates for treatment procedure/test are lower than ECHS prescribed rates shall charge as per the rates charged by them for that procedure/treatment from a non ECHS beneficiary and will furnish a certificate to the effect that the rates charged from ECHS beneficiaries are not more than the rates charged by them from non ECHS beneficiaries. 16. During in patient treatment of the ECHS beneficiary, the hospital will not ask the beneficiary or his/her attendant to purchase separately the medicines/sundries/ equipment or accessories from outside and will provide the treatment within the package rate fixed by the ECHS which includes the cost of all the items. 17. In case of treatment taken in emergency in any non-empanelled private hospitals, reimbursement shall be considered by competent authority at CGHS prescribed packages/rates only. 18. If one or more minor procedures form part of a major treatment procedure, then package charges would be permissible for major procedure and only at 50% of charges for minor procedure as per details given below :-

(a) In case of B/L TKR- 100% for both.

(b) 50% for CAG with PTCA /CABG even if done under separate sittings/same sittings.

(c) .

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19. For all the procedures which are mentioned in the old rate list but not mentioned/revised in

the new rate list payment should be made as per SEMO remarks for the procedure. 20. Any legal liability arising out of such services, responsibility solely rests on the hospital

and shall be dealt with by the concerned empanelled hospital. 21. Package rate shall mean and include lump sum cost of inpatient treatment/ day care/diagnostic procedure for which a ECHS 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) the following :-

(a) Registration charges.

(b) Admission charges.

(c) Accommodation charges including patient’s diet.

(d) Operation charges.

(e) Injection charges.

(f) Dressing charges.

(g) Doctor/consultant visit charges.

(h) ICU/ICCU charges.

(j) Monitoring charges.

(k) Transfusion charges.

(l) Anesthesia charges.

(m) Operation Theatre charges.

(n) Procedure charges/Surgeon’s fee.

(o) Cost of surgical disposables and all sundries used during hospitalization.

(p) Cost of medicines.

(q) Related routine and essential investigations.

(r) Physiotherapy charges etc.

(s) Nursing care charges for its services. 22. Cost of Implants/Stents/Grafts. These costs are reimbursable in addition to package rates as per ceiling rates of CGHS/ECHS for implants/stents/grafts or as per actual in case there is no CGHS prescribed ceiling rates. 23. Treatment Charges for New Born Baby. Treatment charges incurred on new born

babies are separately reimbursable in addition to delivery charges for mother. 24. Reimbursement of Room Rent (Accommodation Charges). Maximum room rent for

different room categories are as under :-

(a) General Ward. Rs.1,000/-.

(b) Semi-Private Ward. Rs.2,000/-.

(c) Private Ward. Rs.3,000/-. 25. The hospitals empanelled under ECHS shall not charge more than the package

rates/rates negotiated in MoA whichever is lower.

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Zonal Jurisdiction of CGHS Rates 26. Zonal jurisdiction of CGHS rates for ECHS was laid down vide Central Organization letter No B/49771/AG/ECHS/Empanelment dated 05 Dec 2003. (Central Organization letter No B/49771/AG/ECHS/Empanelment dated 05 Dec 2003 is hereby superseded). Classification of Hospitals as ‘Super-Speciality’ Hospitals 27. As per Ministry of Health and Family Welfare vide their Office Memo No. S.11011/23/2009-CGHS D.II/Hospital Cell (Part I) dated 13 Sep 2010 for Delhi, entitlement of hospitals to super-speciality rates will not be, because the hospitals perceive themselves to be super-speciality hospitals, but subject to their fulfilling the eligibility conditions for being classified as super-speciality hospitals. These are as under :-

(a) Hospitals with 300 or more beds.

(b) Should be accredited by NABH or an equivalent agency such as Joint Commission International (JCI) of USA, ACHS of Australia or by any other accreditation body approved by International Society for Quality in Health Care (IS Qua).

(c) Should have ECHS empanelled treatment facilities in at least three of following Super Specialities in addition to Cardiology, Cardiothoracic Surgery and Specialised Orthopaedic Treatment facilities that include Joint Replacement Surgery :-

(i) Nephrology and Urology (including Renal Transplantation).

(ii) Endocrinology.

(iii) Neuro Surgery.

(iv) Gastroenterology and GI-Surgery including Liver Transplantation.

(v) Oncology-(Surgery Chemotherapy and Radiotherapy)

Referral to Empanelled Facility 28. Referrals to Empanelled facilities can be made by Medical Officers, Specialists and Dental Officers of ECHS Polyclinics Referrals will only be made once all available facilities of the Polyclinic are fully utilized. In case the referral to Empanelled facility is recommended by Service Specialist/ Dentist, a referral form will be generated by the ECHS Polyclinic under the signature of a Polyclinic Medical/ Dental Officer. All referrals from ECHS Polyclinics will be authenticated by Officer- In - Charge (OIC) Polyclinic under his signature and stamp. 29. Referrals to Empanelled Facilities will be Generated from ECHS Polyclinics The

choice of empanelled facility will be with the ECHS member. Authority to initiate referrals will

be as follows:-

(a) Referral for General Service Specialties. A list at Appendix ‘A’ is attached for

General Service Specialties. Polyclinic Medical Officers, Specialists and Dental Officers

(for dental treatment) are authorized to initiate referrals.

(b) Referral for Specialized Services. Referral for specialized services covering broadly various super- specialties also is attached at Appendix ‘B’. For these, referral can only be made by a specialist at the polyclinic or on advice of concerned specialist of service hospital subject to load, or concerned specialist of local Government hospital or concerned specialist of empanelled hospital (in the absence of service hospital).

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148. Emergency Referrals In case of emergency / life threatening conditions a patient is permitted to take treatment in any hospital. However, if such an emergency occurs while at Polyclinic, a Medical Officer of Polyclinic may directly refer a patient for specialized treatment / tests so that emergent medical management and necessary care is not delayed. In such cases, a certificate to this effect will be endorsed by the referring Medical Officer of the polyclinic

149. Authentication and Endorsement All referrals from ECHS, Polyclinic will be authenticated by the OIC Polyclinic under his stamp. A rubber stamp may be used for the above purposes. He will also endorse non-availability of spare capacity in Service hospitals. The endorsement should state as under :-

Military Stations with Service Hospitals. “Verified that beds / specialty /

facility is not available (NA) in the local Service hospital at present”.

Non – Military Stations / Military Stations without Service Hospitals.

“There is no Service hospital located in the Station”. 30. Referral from Military Polyclinics (with Service Hospitals The stipulation of referral to Service hospital before referring a patient to empanelled hospital is primarily to economize on the meager resources of the State. Intention of initial referrals to Service hospitals to the ‘extent possible’ is to utilize the spare capacity without causing harassment to the veterans or overloading the Service hospital. 31. In order to avoid undue inconvenience to the patients, the following guidelines will be

adhered to:-

(a) Patients must be referred directly to civil empanelled facilities by Medical Officer / Medical Specialist (as applicable) at ECHS Polyclinics in case of ‘overloading’ or non-existence of medical facilities at the Service hospital. A certificate by the Commanding Officer of local Military Hospital or hospitals or SEMO in a Military Station as the case may be with regard to existing/likely/ anticipated overloading specialty wise or in case of non availability of concerned specialists may be obtained on a monthly basis for the ensuing month. This arrangement will facilitate quick disposal of cases reporting at ECHS polyclinic avoiding unnecessary to and fro movement of ailing AFV between the polyclinic and the Military Hospital concerned. Such information must be provided by SEMO to the OIC ECHS Polyclinics under their SEMO cover on a regular basis. (b) Patients will be referred to a Service hospitals only for those diseases for which facilities exist in the Service hospital. All OIC ECHS Polyclinics must possess a list of such facilities.

(c) A list of specialties with a check box against each is attached as Appendix ‘C’. The same is to be completed by SEMOs and forwarded to the ECHS Polyclinics under their SEMO cover. OIC ECHS Polyclinic should be in touch with the concerned Senior Registrar of Command / Zonal Hospitals and CO of smaller hospitals to regularly update the information. In this connection, also refer to DGMS (Army) letters No B/75068/DGMS-5B/ECHS dated 27 Dec 2006 and B/75086/DGMS-5B/ESM dated 31 Mar 08.

(d) To the extent possible, a Service hospital of the station should NOT refer the patient to the Service hospital of a different station, unless in the opinion of the concerned specialist, such a step is in the interest of the patient. Hence, once a patient is referred to a service hospital, the patient will either be treated in the service hospital or outsourced locally to a civil empanelled facility of patient’s choice in that station through the ECHS Polyclinic.

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32. Referral from Non - Military Polyclinics (Including Military Polyclinics without

Service Hospitals).

(a) For the purpose of referrals, Military Polyclinics without Service hospitals (list at

Appendix ‘D’) will follow the procedure applicable to Non Military Polyclinics.

(b) ECHS patients will be referred to civil empanelled facility having valid MoA with

the Station Headquarters as per instructions contained in Para 5 above.

(c) In absence of local empanelled facilities, direct referrals by Non – Military Polyclinics to Service hospitals in nearby stations are permitted except to the Army Hospital (Research & Referral) Delhi Cantt.

(d) A patient can be referred directly to empanelled facility in a nearby city provided the Station Commander of originating Polyclinic has a valid MoA with the concerned hospital of that city. Such cross-empanelment is essential to widen the network of referral facilities. The Station Commanders must proactively liazise with empanelled facilities of nearby stations and sign MoA for commencement of direct referral to such facilities. Headquarters Commands must intervene and facilitate this process of cross empanelment of civil hospitals /facilities.

(e) Till the time instructions on cross-empanelment are implemented, all referrals to

outstation empanelled facilities will be routed through the local ECHS poly clinic. 33. Referral for ECHS Members in Remote/Hilly Area.

(a) Representations have been received from the environment that ECHS beneficiaries residing in remote/hill areas face great inconvenience for getting referrals even for minor ailments from their nearest polyclinics due to difficult terrain/distance involved.

(b) ECHS beneficiaries are permitted to avail the facilities/services of the nearest Govt. Health Care Centres/Primary Health Centre/Government Hospitals (deemed empanelled) without prior referral from the Polyclinic as elucidated in Central Organization ECHS (AG) HQ letter No B/49774-P/AG/ECHS/Referral dt 05 Apr 07 and letter No B/49774-P/AG/ECHS/Referral dt 25 Apr 07 (c) Regional Centre, ECHS and HQ Commands may as and when required review areas to be declared remote for the above purpose and forward their recommendations for addition/deletion to Central Organization for approval.

34. Referral to Reputed Hospitals for planned Treatment.

(a) Presently, ECHS beneficiaries are referred from ECHS Polyclinic to various empanelled hospitals/diagnostic centres/dental centres, to avail cashless medical treatment. In emergency, they can avail medical facilities at any hospital. In case of non-empanelled hospital, the individual has to make payment and claim re-imbursement at CGHS rates.

(b) Certain private reputed hospitals, viz. Sir Ganga Ram Hospital, Rajiv Gandhi Cancer Institute, Indraprastha Apollo Hospital and VIMHANS, had signed MoA with ECHS but later terminated the MoA. Patients had to pay to get treatment from such hospitals (deemed non-empanelled). Re-imbursement was not permitted to individual and piecemeal sanctions were issued to tide over such contingencies.

(c) ECHS members may be referred to such hospitals for planned procedures on merits of the case. Approval for such referrals would be granted on case to case basis by Central Organization, ECHS based on recommendations by Medical Officer/Specialist at the Polyclinic, OIC Polyclinic and concerned Regional Centre.

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(d) Ex-Post-Facto sanction is not permitted. There is no provision for waiver to such

a sanction.

(e) The cost of treatment would be borne by ECHS member. Reimbursement would

be limited to CGHS approved rates.

(f) TA/DA will NOT be entitled in such cases. 35. Treatment at Medical Institute of National Repute Admission/treatment in the Institutes of National repute listed below is permitted. In case ESM or their dependents are referred by ECHS Medical Officer/Specialist to any of the Institutes mentioned below, an advance in the form of a crossed cheque payable to the concerned hospital will be drawn by the patient from the concerned Station Headquarters after submitting the referral for by an ECHS Polyclinic and estimate from the concerned hospital. The hospitals where such an arrangement is permitted are as follows:-

(a) All India Institute of Medical Science, New Delhi.

(b) Post Graduate Institute, Chandigarh.

(c) Sanjay Gandhi Post Graduate Institute, Lucknow.

(d) National Institute of Mental Health and Neurosciences, Bangalore.

(e) Tata Memorial Hospital, Mumbai (for Oncology).

(f) JIPMER, Pondicherry.

(g) Christian Medical College, Vellore.

(h) Shankar Nethralaya, Chennai.

(j) Medical College and Hospitals under the Central or State Government. 36. Outsourcing of Investigations Outsourcing of Investigations is often resorted to by empanelled hospitals. In all these cases, the payment to the outsourced facility is to be made by the hospital referring the case. ECHS will not be dealing with any third party. Bills may be submitted by the empanelled facility and will be cleared by ECHS as per CGHS rates. Excess cost, if any, may be recovered from the patient directly, with his/ her prior consent. Use Of Referral Form 37. The referrals to empanelled facilities will be made by the authorized Medical

Officers/Specialists in the Polyclinics on “ECHS Referral Form” only. A format of the referral form

is enclosed. The referrals will be duly signed and stamped by the seal of the Polyclinic and will

clearly outline a brief history of the case, the provisional diagnosis / diagnosis as the case may be,

the Hospital/ Diagnostic Centre to which the ECHS beneficiary have been referred, and the

specific treatment procedure/investigation for which the referral has been done. 38. In emergencies and life threatening conditions, when patients may not be able to follow the normal referral procedure, they are permitted to be admitted to any / nearest hospital. In case of admission to an empanelled facility, the member would be required to produce his/ her ECHS card as proof of ECHS membership. In such circumstances the empanelled hospital/ facility is required to inform the Polyclinic of that station, or the nearest Service Hospital/ Station Headquarters (Station Head Quarter) in case the Polyclinic cannot be contacted, within a period of 48 hours, regarding the particulars of patient and the nature of admission. The OIC Polyclinic may make arrangements for verification of the facts and issue of a formal referral accordingly.

- 9 - 39. By and large the conditions of emergency are listed as under: -

(a) Acute Cardiac Conditions/ Syndromes including Myocardial Infarction, Unstable

Angina, Ventricular Arrhythmias, Paroxysmal Supra-ventricular Tachycardia, Cardiac

Tamponade, Acute Left Ventricular Failure/ Severe Congestive Cardiac Failure,

Accelerated hypertension and Complete dissection.

(b) Vascular catastrophies including Acute limb ischaemia, Rupture of aneurysms,

medical and surgical shock and peripheral circulatory failure.

(c) Cerebro-Vascular Accidents including Strokes, Neurological Emergencies including coma, cerebro- meningeal infections, convulsions, acute paralysis, acute visual loss.

(d) Acute Respiratory Emergencies including Respiratory failure and de-

compensated lung disease.

(e) Acute abdomen including acute obstetrical and gynaecological emergencies.

(f) Life threatening Injuries including Road traffic accidents, Head Injuries, Multiple

Injuries, Crush Injuries. and thermal injuries.

(g) Acute poisonings and snake bite.

(h) Acute endocrine emergencies including Diabetic Ketoacidosis.

(j) Heat stroke and cold injuries of life threatening nature.

(k) Acute Renal Failure.

(l) Severe infections leading to life threatening sequelae including Septicaemia,

disseminated/ miliary tuberculosis.

(m) Acute Manifestation of Psychiatric disorders. [Refer Central Organisation letter

No B/49778/AG/ECHS/POLICY dated 13 Nov 2007 copy att.]

(n) Dialysis treatment as an emergency.

(o) Any other condition in which delay could result in loss of life or limb. In all cases

of emergency the onus of proof lies with the ECHS member. 40. OIC ECHS Polyclinic may suitably take actions in the interest of the patient accordingly under advice of Medical Officer / Senior Medical officer of the polyclinic as the case may be. All possible help will be provided to AFV in such cases. In case of misrepresentation regarding the facts of emergency, the admitting hospital /facility shall be solely responsible for financial consequences thereof with the decision of Station Commander being final in such cases keeping in view the interest of the ECHS Organization. Admission to a Non-Empanelled Hospital/Facility 41. Such admissions will be dealt as under:-

(a) The ECHS beneficiary or his/her representative should inform nearest Polyclinic / Parent Polyclinic / nearest ECHS Regional Centre / Central Organization (e-mail ID mdechs@bol.net.in ) within two working days of such admission. OIC of nearest Polyclinic will make arrangements for verification of facts and issue Emergency Information Report (EIR) as per format (attached) on receipt of information from representative of ECHS beneficiary/OIC Parent Polyclinic / Regional Centre / Central Organization as the case may be.

- 10 - (b) The responsibility for clearing of the bills in such cases will rest with the ECHS member. He/she may thereafter submit the bills along with summary of the case and other documents to the concerned Polyclinic. The sanction for reimbursement of such bills has been delegated to Competent Financial Authorities (CFA) by the Central Organization ECHS vide their letter No B/49778/AG/ECHS/Policy dt 19 Aug 2008 as amended vide letter No B/49773/AG/ECHS/Policy dt 01 Dec 2008 (copies enclosed as Encl 4 and Encl 5.Such bills will be submitted within a period of one month from the date of discharge from hospital. Bills will be processed as CGHS/ECHS/AIIMS RATES/ACTUAL if unlisted.

(c) In the case of delay in submission of such bills, sanction of Station Commander to waive off the delay may be obtained for delays up to six months. Regional Director may waive off the delay up to one year. Delays beyond one year will be dealt by the Central Organization ECHS suitably as per merit of the case. The decision of MD, Central Organization shall be final in such cases.

42. While being treated in emergency, if another test/procedure is to be carried out on account of new illness/complications, the treatment of which cannot be deferred, the same may be undertaken in the hospital and fresh referral is not required. Need for additional procedure undertaken in emergency is to be elaborated and justified in clinical summary submitted with the bills. If the clinical complications arose due to negligence of the hospital the financial costs for the same will be borne by the concerned hospital. The ECHS Organization may also initiate suitable compensation proceedings against the concerned hospital in such cases on a suo-moto basis or on application by the AFV or in his/ her behalf by the relatives /heir as the case may be as deemed fit. 43. Policy already exists for permitting Haemodialysis as an emergency procedure in a non-empanelled hospital (Central Org ECHS letter No B/49770/AG/ECHS dated 26 May 2009; enclosed as Encl 6). The requirement of obtaining Emergency Certificate from the Hospital and subsequent EIR from the ECHS Polyclinic is therefore dispensed for such cases. Further, if Haemo-dialysis is undertaken on an OPD/Day Care basis there will be no requirement of attaching discharge summary/certificate signed by the Medical Superintendent /Hospital Signatory with the claim for reimbursement. 44. Payment of bills for Emergency treatment will be made by ECHS as per approved rates

and the member is not required to pay. Follow-Up Treatment/ Reviews 45. In cases where regular follow-up/review is required, such follow-up treatment, (OPD/ Indoors) will be provided for a maximum period of 1 month at a time. First referral form in such cases should mention the same i.e. "Referred for follow-up treatment for a period of one month." Fresh referral has to be initiated on expiry of the one month period. 46. The same provisions will apply for cases where treatment procedures are to be repeated at regular intervals as an ongoing process, e.g., cases requiring dialysis or regular long term physiotherapy. An example of what the referral should read is illustrated below:

“Referred for Haemo-dialysis, 3 sessions per week for a period of one month.” 47. In case of Military-Polyclinics, referrals for follow up treatment for the same ailment, should not be routed through the Service hospitals, up to three months. A review of case will be undertaken through the polyclinic 15 days before the expiry of the three month period, to assess the requirement of further treatment, if any.

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(a) The Original referral form will be attached along with the first lot of bills in all such cases. A photocopy of the referral form will be attached with subsequent bills for the same referral, with an endorsement by the hospital linking the case to the original referrals.

(b) When another test/procedure is to be carried out on account of new illness/ complication (other than the one for which referred), treatment of which cannot be deferred, the same may be undertaken in the hospital and fresh referral is not required. However, as in the CGHS, the 'other' procedure will be charged at 50% of package rate. For non-package investigations / treatment, actuals as per authorized rates are admissible. Need for additional procedure undertaken is to be elaborated in clinical summary submitted with the bills.

Oncology Referrals 51. In order to rationalize Oncology (Onco) referrals, the following procedures will be

implemented:-

(a) All patients reporting initially to ECHS Polyclinic and suspected / confirmed to be suffering from cancer should first be referred to a Oncology Centre of a Service hospital (if available locally) or in the absence of service hospital with Oncology Dept, to an empanelled hospital recognized for oncology where registration, work-up and treatment planning can be carried out.

(b) Patients requiring surgery as part of their multi-modality treatment will be treated in the Service hospital (subject to availability to spare capacity) or the empanelled hospital (recognized for Onco surgery). If facility is not available locally, patient will be referred to the nearest Service hospital/empanelled facility where such a facility is available.

(c) Patient requiring Chemotherapy/Radiotherapy (RT) will be issued a referral to local Service hospital with Oncology Dept (subject to load) or ECHS empanelled Oncology(Onco) centers once only for the entire duration of treatment.

(d) The stipulation of one month validity for referral forms will not apply for Oncology cases prescribed Chemotherapy/Radiotherapy. The referral form on top should clearly mention “SPECIAL ONCOLOGY REFERRAL” to distinguish it from routine referrals.

End Stage Disease 52. In certain cases where the medical finality has been reached and active treatment is over, the patient would require rehabilitative care/terminal care. Such patients should be transferred to an appropriate empanelled institution like a Rehabilitation Centers or a Hospice. Hospitalization in non-empanelled hospices/ terminal care centers has been permitted vide Central Organization ECHS letter No. B/49771/AG/ECHS/POLICY dated 07 Aug 2009, with a view to reduce expenditures on prolonged hospitalization of such patients. Treatment in such cases in special institute / centre is permitted for a maximum period of six months. 53. Rehabilitation/Terminal care will be provided in empanelled rehabilitative homes and

hospices. Patients admitted to Service hospitals or empanelled hospitals/nursing homes where the

finality of treatment has been reached and definite medical treatment has run its course, will be

referred to rehabilitative care will admissible will be paraplegia , quadriplegia, Alzheimer’s disease,

cerebro-vascular accidents, other neurological and degenerative disorders ,

- 12 - amputations, cancer terminal care and other such medical conditions when duly referred by treating specialists. Approval of SEMO/SMO/PMO will be obtained for these referrals. The payments for such cases will be regulated as under:

(a) Rates of payment for rehabilitation / terminal care cases will be limited to maximum rates permissible under CGHS for special Nursing/Ayah/Attendant charges plus charges for medical treatment as per CGHS rules. Where the rates of CGHS are not laid down, AIIMS charges or actual which ever is less will be applicable. In case rates have not been defined by AIIMS, the actual will be reimbursed. Rehabilitative care/terminal care does not include old age homes.

(b) Reimbursement will be limited to maximum period of 6 months. Thereafter cost of

the treatment has to be borne by the patient. Guidelines For Domiciliary Rehabilitation Medicine Intervention 53. Guidelines have been issued on reimbursement entitled for domiciliary rehabilitation medical intervention to ECHS beneficiaries vide ECHS letter No B/49770/AG/ECHS/POLICY dated 31 Oct 2011 (Copy enclosed). The following allied health services need to be considered for domiciliary care:-

(a) Physiotherapy.

(b) Occupational therapy.

(c) Speech therapy (for stroke/head injury).

(d) Conditions requiring rehabilitation intervention and duration if domiciliary therapy:-

(i) Orthopaedic Disorders. post joint replacement surgery in acute phase,

physiotherapy after 2 weeks, post- discharge.

(ii) Neurological Disorders (for upto 6 weeks) :-

(aa) Post stroke. OT, PT, and ST

(ab) Brain injury OT, PT AND ST

(ac) G.B. Syndrome. OT AND PT

(ad) Spinal cord injury OT and PT

(ae) Motor neuron disease OT PT and ST

(iii) Locomotor Disability. With the disability of over 80% or those who are totally dependent on care-giver based on the opinion of two Govt. Specialists by certified care- giver[ MEANS Rehabilitation council of India certified personnel+ Physiotherapist and Occupational therapist]

(e) Admissible Rates. The following rates may be reimbursed:-

(i) Maximum of Rs 300/- per day per therapist.

(ii) Maximum of Rs 150/- per month for long- term requirement, whichever

is lesser to certified Caregiver

(iii) No reimbursement to be allowed for purchase/hiring of therapy

equipment/ devices. Period of Hospitalisation 54. Where a patient is admitted for specific treatment, he will be hospitalized for such period

as is necessary for completion of the treatment. For treatments, specialized procedures or

- 13 - diagnostic tests for which Package rates are specified, the periods of hospitalization should not exceed the following limits, under ordinary circumstances :-

(a) 12 days for specialized (super specialties) treatment.

(b) 7 days for other major surgeries.

(c) 3 days for laparoscopic surgeries/normal deliveries.

(d) 1 day for day care/minor (OPD) surgeries.

55. Restrictions /Limitations of Hospitalization Period and Related Charges:- There are Specific restrictions to hospitalization periods which all concerned must adhere to economize the costs on account of period of stay. These are elaborated as under:

(a) In case the beneficiary has to stay in the hospital for his/ her recovery for more than the period covered under Package rates, the additional payment beyond the package period will be limited to room rent as per entitlement, cost of the prescribed investigations, doctors visits (not more than 2 times a day in both ICU and wards) and cost of medicines (for additional stay). The requirement for additional stay beyond the package period will be justified by the hospital and approved by the SEMO considering the diagnosis and clinical condition of the case in Military Polyclinic or by the nearest Station Commander in case of Non Military polyclinic on advice of MO/ Senior MO of the polyclinic. A form is enclosed for such cases.(Ref. Central Org. letter No. B/49770/AG/ECHS/TREATMENT Dt. 15 Mar 2010 )

(b) No additional charges on account of extended period of stay shall be allowed if that extension is due to infection as a consequence of surgical procedure or due to any improper procedure and is not justified or due to professional negligence of any kind.

Conditions Requiring Prior Approval

56. Prior approval of Central Organization ECHS is required to be obtained by the Empanelled Hospitals/ Nursing Home/ Diagnostic Centers, when the anticipated expenditure for medical treatment/ investigation of an ECHS member for a single hospitalization period is beyond Rs 5 Lakhs. MD, ECHS, Central Organization is only empowered to permit for all approvals above Rs.5 Lakhs. The request must be routed through the Polyclinic. In case of an Emergency, the sanction will be obtained through Fax/ Signal/ Telegram/Verbally and will be supported by the following details:-

(a) ECHS Membership Number.

(b) Particulars and age of the patient.

(c) Preliminary Diagnosis of the Hospital.

(d) Summary of the case including brief past history.

(e) Tests/ Procedure/ Treatment recommended. 57. Unlisted Procedures. Medical care is a dynamic science with new technologies being introduced each day and on a regular basis. Before clinical implementation, these new methodologies of treatment have to undergo a process of rigorous cost effective trials. Many of these methodologies are not listed in the CGHS/ AIIMS procedures. Prior approval will be required only for those procedures, implants and tests (diagnostic) which are not listed in CGHS rate list of procedures/investigations/ceiling rates of implants. Where the implants/ methodologies of treatment not listed under the CGHS/ AIIMS are recommended for an ECHS

- 14 - member, prior approval will be obtained in writing as per table below. The request will be forwarded to the Polyclinic, for obtaining approval through the Senior Executive Medical

Officer (SEMO). Cost of Implant/ Procedure Approval

(a) Less than 02 lakh by SEMO/ SMO/ PMO

(b) 02 to 04 lakhs by Service specialist of concerned specialty

(c) Above four lakhs by concerned Senior Adviser/Consultant at Command / Zonal hospital [for NCR of Delhi , Base Hospital /Army Hospital(R&R) Delhi Cantt vide Central Organization letter No. B/49778/AG/ECHS/PA/RULING, Dated 28 Jun. 2011].

58. Cardiology

(a) Cardiac Procedures for which approval is required :-

Ser No Condition Requiring Approving Authority Approval

1. Angioplasty with

Coronary Stent

(a) Coronary Stents No approval required. (Upto two) Cardiologist of empanelled hospital

authorized to certify/ recommend

(b) Coronary Stents SEMO

( More than two)

2. Angioplasty with

Medicated Stents

(a) Drug eluting stents Classified Specialist (Cardiology) or

(Upto two ) Senior Adviser Medicine or Cardiology

(b) Drug eluting stents Senior Adviser Cardiology or (More than two) Consultant or Senior Consultant

(Medicine) 59. Procedure for Approval. Requests for approval are to be submitted by the Empanelled Hospital or Dental/ Diagnostic Centre to the Polyclinic by Fax/Courier. Polyclinic will fwd the request, as per proforma, to SEMO for obtaining the necessary approval and communicating the same to the concerned Empanelled facility. 60. Emergency Conditions. In certain emergency situations due to the urgency of the case or

to save life or limb of a patient, prior approval may not be possible. In all such cases the proposed

treatment should continue. Emergent/life saving treatment will not be denied on the plea that ‘Prior

Approval’ needs to be obtained. However, the concerned Empanelled Hospital will, in discharge

summary, give a detailed justification of the cause as to why the prior approval was not obtained for that particular procedure/test. There is no provision; however, of an ex post facto ‘Prior

Approval’ and the Proforma (Appendix A) will NOT be used in such cases.

- 15 -

.

CGHS CEILING RATES FOR IMPLANTS

62. Cardiology Implantation Devices The reimbursement for implants will be as perceiling rates above or actual cost whichever is lesser. CGHS has revised the rates coronary/vascular stents recently. Revised rates and guidelines for stents to ECHS beneficiaries are given in succeeding paras :-

(a) DCGI approved stents will be reimbursed as per the ceiling rates as depicted in table as under :-

Ser No Name of the Stents Ceiling Rates

1. Drug Eluting Coronary Stents

(a) All DCGI and FDA approved Rs.65000/-

(b) All DCGI and CE approved Rs.50000/-

(c) All DCGI approved Rs.40000/-

2. Bare Metal Coronary Stents (a) Stainless steel stent

(b) Cobalt stents

(i) All DCGI and FDA approved

(ii) All DCGI and CE approved

(iii) All DCGI approved

(c) Coated / other stents

3. Bare Metal Vascular ( Non Coronary Stents)

(a) Stainless steel stent

(b) Cobalt stents

(c) Nitinol / other stents

Rs.12000/- Rs.20000/- Rs.18000/- Rs.15000/- Rs.25000/- Rs.20000/- Rs.22000/- Rs.25000/-

Auth: Central Organisation letter No B/49773/AG/ECHS/Rates/policy dated 25

Nov 2011 (copy enclosed) (b) Prior approval to be obtained as per Central Org letter No B/49773/AG/ECHS dated 25 Nov. 2011. The reimbursement for implants will be as per ceiling rates above

or actual cost whichever is lesser. (c) A maximum of three Coronary stents shall be permitted of which not more than

two shall be of Drug Eluting Stents (DES). (d) If a beneficiary under ECHS has been implanted by any other non- approved drug coated stent or a drug eluting stent is implanted in conditions other than those mentioned above, reimbursement shall be limited to the cost of Bare metal stent. (e) Other cardiac implants/ equipments and the ceiling costs are shown in table as under:

Ser Name of the Cardiac Implants/Equipments Ceiling Rates No

- 16 - 1. Rotablator Rs. 50,000/- 2. (a) Pacemakers (Single Chamber)

(i) Without rate Response Rs. 37,000/-(ii) With Rate Response Rs. 65,000/-

(b) Pacemaker(Dual Chamber) Rs. 1,15,500/-Auth : Central Organisation letter No B/49773/AG/ECHS/Rates/Policy

dated 10 Jan 2011)

(f) If a non-approved drug eluting stent (DES) is implanted or a drug eluting stent (DES) is implanted in conditions other than those mentioned above in an empanelled hospital and no written informed consent was obtained from the beneficiary, that he/she would bear the difference in cost between the DES and Bare Metal Stent and the hospital has charged this amount from the beneficiary. The additional amount shall be deducted from the pending bills of hospitals and shall be paid to the beneficiary.

(g) It is essential for the empanelled hospital to quote the Batch number when a coronary stent of any type (Ordinary metal/Drug Eluting stent) is implanted in the case of a beneficiary under ECHS. 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 along with invoice shall also be enclosed with the medical bills for claiming reimbursement from the Govt. In case the private empanelled hospital has not given the batch number and or outer pouch of the stent (s) in a particular case, the cost for stents will not be reimbursed (for reimbursement claims). In case of empanelled hospitals, the bills without supporting documents as above will NOT be accepted.

63. Neuro- Implants

(a) The ceiling rates for Neuro- Implants are shown in table as under:-

Ser No Name of the Neuro- Implants Ceiling Rates

1. DBS Implants(including MER) Rs. 3,60,000/-

Cost of Battery of DBS (or actual whichever is less)

Rs. 2,50,000/-

(or actual whichever is less)

2. Intra -Thecal Pumps:-

(a)Intra -Thecal Beclofen Pump Rs. 2,62,000/-

(b)Intra Thecal Morphine Pump Rs. 2,62,000/--

(c) Intra Thecal Infusion Pump Rs. 2,62,000/-

(d) Cost of battery Rs.2,25,000/- (or actual

whichever is less)

3. Spinal Cord Stimulator Rs. 2,62,000/-

Cost of battery Rs.2,00,000/- (or actual

whichever is less)

Auth: Central Organisation letter No B/49773/AG/ECHS/Rates/Policy dated

10 Jan 2011 (copy enclosed).

- 17 -

(b) Prior approval to be obtained as per Central Org letter No B/49778/AG/ECHS/PA/Ruling dated 28 June 2011. Original invoice along with the warranty/Implant stickers to be submitted along with claims. The reimbursement/payments for implants will be as per ceiling rates above or actual cost whichever is lesser.

(c) Guidelines for implants:

(i) DBS Implant: The patient should be a case of idiopathic Parkinsonism resistant to conservative treatment. ECHS/patient shall be informed in writing by

treating specialist of the cost of implant and the efficacy of the treatment.

(ii) Intra Thecal Pumps (Intra Thecal Beclofen Pump, Intra Thecal Morphine Pump)/Spinal Cord Stimulator: All conservative treatment procedures have failed and the diagnosis was confirmed. Treating specialist shall certify that there is reasonable chance of survival of terminally ill patient. Therapeutic trials shall be conducted and recommendation should be based on positive therapeutic trials. The treating specialist shall certify as such in writing. ECHS/patient shall be informed in writing by treating specialist of the cost of implant and the efficacy of the treatment.

(d) Warranty. The Company offers limited warranty for two yrs from date of Implantation to provide free replacement in the case of battery failure or if malfunctioning of the device is reported by the concerned Physician. The company shall also supply all the implants with not more than 1/6 of the life of battery exhausted.

(e) Life/Replacement of Batteries:

(i) Life of Battery is 3-5 years in case of DBS Implants and Spinal cord stimulator depending on parameters selected for stimulation and usage and up to 7 years in case of Intrathecal Infusion pump.

(ii) Replacement of Battery before 4 years may be permitted in exceptionalcases on the basis of justification by the treating specialist and shall be

considered on a case to case basis by Central Organization ECHS. 64. Hip and Knee Implants

(a) The ceiling rates for Hip/Knee Implants are as under in the table:-

Ser No Name of the Item Ceiling Rates

1. Knee Implant Rs. 60,000/- + the cost of bone cement Rs.5,000/-

2. Hip Implant Rs.35,000/- + the cost of Bone cement Rs.5,000/-

Auth: Central Organisation letter No B/49773/AG/ECHS/Rates/Policy

dated 10 Jan 2011 (Copy enclosed)

- 18

Invoice along with the Implant stickers will be submitted along with bills/claims. The reimbursement/payments for implants will be as per ceiling rates above or actual cost whichever is lesser.

65. IOL

(a) The ceiling rates for IOL are as under shown in the table:-

Ser No Name of the Item Ceiling Rates

1. Hydrophobic Foldable IOL Rs.5,000/-

2. Silicon Foldable IOL Rs.3,600/-

3. Hydrophilic Acrylic Lens Rs.5,800/-

4. PMMA IOL Rs. 490/-

Auth: Central Org letter No B/49773/AG/ECHS/Rates/Policy dated 10 Jan 11 (copy

enclosed)

(b) The ceiling rates mentioned above for different types of IOL implants to be used will be as per actual expenditure or the rates mentioned whichever is less and will be reimbursable in addition to the package rates for cataract surgery procedure.

(c) The reimbursement at the above mentioned ceiling rates will be done as per the rates fixed for the various IOL mentioned above and the IOL actually used in the surgery. It is mandatory for the operating surgeon of all private empanelled hospital/ECHS beneficiaries to attach the empty IOL sticker, bearing the signature and stamp of the operating surgeon on it, along with the bill in support of the type of IOL used, containing its batch number. In the event of the private empanelled hospital not giving the batch number and/or empty IOL sticker in a particular case, the cost for IOL will not be reimbursed (for reimbursement claims). In case of empanelled hospitals, the bills without supporting documents as above will NOT be accepted.

66. Cochlear Implant Surgery

(a) The ceiling rate for Cochlear Implant Surgery is Rs.5,35,000/-(Rupees five lakhs

and thirty five thousands only).

(b) The best results are achieved if cochlear implants take place between the age of 1-5 years. It is therefore proposed to permit reimbursement in a graded manner as under:

(c) In the pre lingual deafness, total reimbursement of the ceiling rate or actuals, whichever is less, for cochlear implant will be allowed in respect of implants carried out on children aged between 1 and 5 years. (d) For children between the age of 5 and 10 yrs, 80% of the ceiling rate for implant will be reimbursed. For children above the age of 10 years, but below 16 years of age,

only 50% of the ceiling rate for the implant will be reimbursed.

(e) 50% of the cost of the wearable components, e.g. Speech Processor, Microphone, etc. (excluding cords, batteries) for the purpose of up-gradation and / or replacement due to wear and tear may be allowed, after a period of three years, to be considered on the basis of advice of Sr Adv (ENT).

- 19 - (f) Only unilateral implantation will be allowed. As cochlear implant surgery is a planned surgery, prior permission has to be obtained before the surgery is undertaken i.e prior approval procedure will be followed.

(g) Selection criteria for Cochlear Implant:

(i) Pre-lingually deaf children (severe to profound B/L S.N.H. Loss)

(aa) Age group between 1 to 16 yrs. However, children using hearing aids and getting auditory training from age 1 yr of less may be considered at higher age also on a case to case basis.

(ab) No appreciable benefit from hearing aids after 6 months of trial with hearing aids. No speech formation seen

(ac) No mental retardation.

(ad) No active middle ear cleft disease. Perforation of the TM should be closed at least three months prior to implantation.16

(ae) No cochlear aplasia and/ or agenesis of cochlear nerve.

(af) No retro cochl ear l esion or central deafness , and Good famil y

support for post op rehabilitation

(ii) Post- lingually deaf candidates (B/L profound S N H Loss)

(aa) There should be no appreciable benefit from hearing aids (both ears).

(ab) No active middle ear cleft disease.

(ac) Perforation of the TM should be repaired three months prior to the implantation.

(ad) Deafness should be due to cochlear lesions, and Post meningitis labyrinthitis osscificans of the cochlea is acontraindication. However cases like post inflammatory, ossification of cochlea, cochlear dystrophies and cochlear otosclerosis with visible perilymphatic shadows in MRI are relative indications and can be done on a case to case basis.

(h) Type of Cochlear Implants: Only multi channel cochlear implant duly approved by

appropriate authority should be recommended. (j) Basic pre-op Investigations for Cochlear Implant:

(i) Audiological

(aa) OAE

(ab) ERA/ASSR

(ac) Impedance (in children)

(ad) Audiogram/Aided audiogram

(ii) Radiological

(aa) HRCT temporal bone for bony cochlea and middle ear cleft

(ab) 3D MRI for membranous cochlea, Neural bundle and brain

(ac) IQ/Psychiatric evaluation in children with pre- lingual deafness.

- 20 - Bill Submission 67. General Instructions.

(a) Every page of the claim document needs to be serially numbered in hard copy.

(b) Referral Letter

(i) Seal and Signature of MO I/C and O I/C is mandatory on all printed

referral letters.

(ii) Computerized Referral letters needs to have the Name and Designation

of MO I/C along with seal and signature of O I/C.

(iii) Seal and Signature of MO I/C and O I/C is mandatory on the hard copy of

all the referral letters.

(c) MRP/Drug certificate for the Drugs/Medicines/Consumables is mandatory for items more than Rs.1000/- per unit price. (d) Drugs issued by the hospital post discharge are only payable for 7 days. Post

that, drugs needs to be issued from the ECHS dispensary.

(e) Detailed Discharge summary should be provided with complete details like - Presenting Complaints, line of treatment, events of sequential surgical interventions and advice on discharge etc. Discharge summary should have seal and signature of the treating doctor or resident doctor.

(f) Laboratory & Radiological reports

(i) All laboratory /radiological reports must be in printed form in Hospital/ DC

letter head and in original duly signed by the concerned specialist.

(ii) Computerized reports should be affix with digital signatures with name of

the specialist.

(iii) The CGHS code /Hospital code should be mentioned against all the billed

diagnostic tests.

(j) Reports should be arranged in chronological order.

(k) Final bill must have Bill No. along with seal and signature of the authorized person. Should have necessary details about amount claimed against accommodation, consultation, investigations, medicines & consumables and other Procedures.

(l) Final bill should be signed by the patient or the relative.

- 21 -

(m) Prior Approval for unlisted procedure/ implants, investigations and extended stay required as applicable.

(n) Approval of Cardiac Implants like AICD/ Bi Vent Pacemakers/ ICD/ ComboDevices CRT-D etc. need prior approval of Service cardiologist & ECHS competent authorities and will be paid as per CGHS/ ECHS guidelines.

(o) Invoices must contain the Nomenclature, Batch Number /Lot Number, Serial Number of the implant with date of manufacture & expiry and name of the patient should also be supported with matching outer pouch and sticker. Individual invoice should be provided with Name of Patient and Challan number. If the hospital is submitting a group invoice, then, the hospital should attach an individual invoice issued in the name of the patient for that implant. In such cases, the group invoice has to be supported by hospital’s invoice for a particular implant issued to the patient. All implants needs to be supported by pouch and sticker.

(p) Cardiac.

(i) PTCA cases - Pre & Post PTCA images with CD and CAG

images/sketches with CAG & PTCA report duly signed by the treating

Cardiologist. (ii) CABG cases – Graft Sketches/Images with CABG surgery notes mandatory duly signed by treating surgeon, along with LAD reports & CD of the

same.

(iii) In case of emergency PTCA/CAG, other supporting investigations leading

to PTCA/CAG like Echo and ECG have to be submitted.

(iv) Cardiac Implants – Data sheet is required to be submitted for implant

along with post- operative chest X-ray with image

(v) CD of procedure to be submitted

(q) Total Joint replacement Surgeries and other orthopedic surgeries need to be supported with Pre & Post Op radiological reports and images.

(r) Package rates to be considered as per CGHS guidelines as per No: OM. S.11011/23/2009- CGHS D.11/ Hospital Cell (Part IV), Government of India. Medical Management within package period 0-12 days to be considered as part of package and extra billing will not be allowed.

- 22 - (u) Blood Bank Expenses needs to be supported with voucher/ compatibility forms with

transfusion notes.

(v) Feedback Performa for Treatment duly signed by the beneficiary/ Relatives (with

relation specified) required to be submitted along with the claim documents.

(w) Hospitals must provide the Indoor case papers (ICP) as and when required.

(x) Ambulance charges are not admissible.

(y) Admission case notes/ Clinical assessment notes are required to be submitted for all emergency admissions with brief clinical details, proposed investigations and proposed line of treatment at the time of admission and hard copy at the time of claim submission.

Out Patient Department Bills 68. Copy of ECHS card, referral letter and OPD consultation slip in hospital letter head,

with signature of treating doctor should be attached with OPD consultation bill. 69. In case of investigation only, copy of ECHS card, referral letter with note of service

specialist/MO polyclinic along with reports should be submitted. In Patient Department Bills 70. Referral/Admission/Intimation

(a) The following procedure will be followed by all empanelled hospitals and

polyclinics:-

POLYCLINIC

a) PC AFV

i. Document: Referral Form ( Manual ) signed by MO AND OI/C Polyclinic with

stamp. ii. Case Note: Signed by MO/Specialist. and putting stamp of MO/Specialist

Countersigned by OIC PC with stamp iii. RF (Online): Name of MO/Specialist printed with designation. Signed by OIC PC

with stamp.

iv. Referral form should contain the details of case including clinical details along with

investigation reports (if any) and provisional diagnosis

b) Proof of membership ( Photocopy of ECHS membership card /Receipt): ECHS

membership card will be endorsed by OIC PC

AFV UTIITSL

Copy of ECHS membership card

Physical Referral form Empanelled Hospital

Copy of ECHS membership card Physical Referral form Admission Case Note

- 23 -

EMERGENCY

Copy of ECHS membership card

AFV ( Rep) Empanelled Hospital Intimation Uploaded

Empanelled Hospital

Acknowledge online bill submission UTIITSL

Emergency referral based on

emergency admission report

Emergency and admission note

admission

note

Upload hospital bills

Regional

Physical copy of the bills and Center

Polyclinic query reply submitted

(b) All claims should be uploaded on UTIITSL website in PDF format and submitted

in physical to the Regional Center.

(c) The documents need to be submitted as per the checklist mentioned below: Ser Required Documents

No

1. (a) Proof of membership/Photocopy of ECHS membership Card

(b) Referral Form

(c) Emergency Certificate by treating Hospital

(d) Admission Case Note

2. Bill Submission

(a) Original bill

(i) Summary of Bill

(ii) Itemized bill

(b) Prior Approval/Justification for not obtaining Prior Approval

(c) MOA ( Covering the period of Hospitalizations) along with Annexure-II

- 24 -

(d) Page numbering of case file

(e) MRP Certificate from empanelled hospital/ Polyclinic/Regional Center

(f) Discharge/Case Summary/Patient record by treating hospital and

Death summary if applicable

(g) Investigation reports

(h) Original Invoice +Sticker of Implantable devices along with outer pouch

(j) PTCA- Pre and Post PTCA Images with CD Details

(k) Cardiac Implant- Dealer’s Invoice with post procedure Chest X-Ray

(l) Joint Replacement- Pre and Post X-ray image & report.

(m) Patient Feedback Form

(n) MRP Wrapper of the high cost drugs

3. Miscellaneous- other Documents 4.

71. 10% deduction will be done on the cost of the chemo drugs. 72. All investigations reports are mandatory even for package procedure 73. Medical management prior to packages is admissible subject to supportive investigations and treatment. But if the medical management done falls under the preview of number of days for which a particular surgical / procedural package has been designed, it would be considered as a part of the package only. Anything exceeding the package duration may be considered to be paid extra if found relevant. 74. Myocardial perfusion studies (MPS), stress thallium done with CAG on same day- then

same not pay 75. MOA, NABL Certificate & NABH Certificate:- Hospital needs to submit MOA, NABH certificate and NABL certificate once and needs to update the same as and when reviewed (Auth Paras 3a, b and c of Central Org. letter No. B/49773/AG/ECHS/RATES/POLICY Dt. 10 Jan. 2011)

- 25 -

80. Package Deals negotiated with Empanelled Facilities as per MOU Zonal jurisdiction of Package deal rates of CGHS, will be applicable. For diseases and treatment procedures not covered in the list of package deals, the payment would be at the rates of AIIMS, New Delhi. Where the AIIMS rates are not available, the cost of drugs, room rent, laboratory investigations etc., will be paid as per authorized rates/ actual whichever is less. Billing in these cases will be for a lump-sum package. In case of two procedures, as mentioned in Para 26 above, the bill should mention them separately as under as per procedure under taken. Package Deal Rates (as per Zonal rates concluded in MOU):

(a) Major Procedure

(b) Minor Procedure (if applicable) 81. Action in Cases where Package Deal Rates Not Available When the Package deal

charges are not specified for a particular procedure, either in the CGHS or AIIMS list, the bills

from the Hospitals/Diagnostic Center should reflect the following details :-

(a) Hospital Charges. (Where Package deal rates are not applicable)

(b) Accommodation (List type of Ward- private/semi-private/general)

(c) Surgical Operation or Medical treatment charges.

(d) Pathological Tests (Specify tests and Number)

(e) Radiological tests (Specify investigations and number)

(f) Specialized investigations (Specify investigations and number)

(g) Medicine (Specify drugs and costs)

(h) Ordinary Nursing

(j) Special Nursing

(k) Consultation charges (Number and date)

(l) Other miscellaneous charges (to be clearly specified). 82. Cancer Treatment In the case of treatment undertaken for Oncology, billing will be as for

a Non-Package disease . The referral is valid for entire course of chemotherapy. The

following check list specifically will be utilized accordingly in addition to routine documents:

(a) Doctor notes specifying chemotherapy/radiotherapy cycle details, dosage and

periodicity

(b) Room rents/daycare charges as per CGHS rates

(c) Investigations/other procedures as per CGHS

- 26 - (d) Drugs as per actual

(e) Consultation as per CGHS.

(i) Radiotherapy/chemotherapy as per CGHS SUPER SPECIALITY rates.

(ii) Surgical procedures as per TATA MEMORIAL HOSP. RATES.

(iii) Photo copy of the referral is permitted for chemotherapy and radiotherapy.

(iv) Recommendation of concerned service specialist is mandatory

(v) Photo copy of the previous discharge summary and link up with

original referral is mandatory.

(vi) Approval of M.D Central ORG. for expenditure exceeding Rs.

5lakhs.(As applicable)

(vii) Approval of SEMO/ CONCERNED SPECIALIST for unlisted procedure/

all chemo drugs.(as applicable)

(viii) MRP wrapper of the chemo drugs.

(f) The summary of the case and the bills should specify the following:-

(i) Protocol for management of the case.

(ii) Radiotherapy – Type of course and charges for complete course.

(iii) Chemotherapy - Number of cycles of chemotherapy.

(g) The bill processing agency while medically processing the claim should clearly

mention in the remark chemotherapy/radiotherapy cycle details, dosage and periodicity. 83. Chemo-drugs Dealer’s invoice should not be asked. Instead, pharmacy invoice should

be submitted. MRP wrapper or sticker should be submitted. Guidelines On Oncology Treatment Rates 84. Refer to Central Organization ECHS following letter No’s :-

(a) B/49774/AG/ECHS/Referral dated 01 Dec 2009

(b) B/49773/AG/ECHS/Rates/Policy dated 10 Jan 2011

(c) The guidelines for treatment of Oncology cases have been recently revised in CGHS by Ministry of Health & Family Welfare vide their office memorandum No.REC-! /2008/JD (Gr.)/CGHS/CGHS(P) dated 23 Jun 2011. Accordingly followingguidelines for treatment of Oncology will be implemented in ECHS :- Cancer Surgical

Procedures

(i) Rates of Tata Memorial Hospital (TMH), Mumbai (2009) as mentioned under ‘B’ category will be applicable for ECHS beneficiaries for treatment in

semi private ward with 10% decrease for general ward and 15%enhancement for private ward. Rates of TMH under ‘B’ category are at Appendix

‘A’.

(ii) The categorization of surgeries shall be same as per the categorization of

- 27 - TMH.

(iii) The duration of treatment for different categories of Surgery will be as follows

:-

(aa) Category – I - 1-2 days

(ab) Category – II - 3-5 days (7-10 days in respect of operations involving Abdominal/thoracic cavity)

(ac) Category – III, IV and V - 14 days

(d) Cancer Radiotherapy. Super specialty rates of CGHS Delhi for cancer

radiotherapy shall be applicable.

(e) Chemotherapy. Super specialty rates of CGHS Delhi shall be applicable for

Chemotherapy. The hospitals shall provide Chemotherapy medicines to ECHS beneficiaries at a discount of 10% on MRP.

85. Consultation. CGHS rates for NABH accredited hospitals will be applicable for

consultation for ECHS beneficiaries suffering from these diseases.

(a) Room Rent. Rates applicable for room rent (Accommodation Charges)

for different categories of wards will be as given below :-

(i) General Ward - Rs 1,000/- per day

(ii) Semi-private Ward - Rs 2,000/- per day

(iii) Private Ward - Rs 3,000/- per day.

(b) A hospital empanelled under ECHS, whose normal rates for treatment procedure / test are lower than the CGHS prescribed rates shall change as per the rates charged by them for that procedure / treatment from a non-ECHS beneficiary and will furnish a certificate to the effect that the rates charged by them from non-ECHS beneficiaries

(c) The categorization of surgical procedures into Categories – I, II, III IV & V.

- 28 -

- 29 -

86. Rates applicable for room rent (Accommodation Charges) for different categories of wards and entitlement of wards will be as per our letter No B/49773/AG/ECHS/Rates/Policy date 06 Jul 2011

- 30 -

87. For any day care procedure requiring short admission – a few hours to one day accommodation charge for one day as per entitlement shall be applicable, provided the patient has been admitted in a room as per his/her entitlement. 88. The Super-speciality rates of CGHS Delhi for Cancer Radio-therapy and Chemotherapy shall be applicable as CGHS rates for Cancer Radiotherapy and Chemotherapy. These are given at Appendix B. In case of Chemotherapy the rates prescribed are procedural charges only. Room rent, investigations and cost of medicines are reimbursable in addition to the procedural charges. 89. Consultation fee shall be as per CGHS rates applicable for NABH Accredited hospitals 90. Investigation rates shall be as per CGHS prescribed rates of concerned city. 91. Cost of Implants/stents/grafts is reimbursable in addition to package rates as per CGHS ceiling rates for implants/stents/grafts or as per actual, in case there is no CGHS prescribed ceiling rates. 92. The rates applicable for Anaesthesia, Operation Theatre and Surgery Charges under

categories – I, II, III, IV & V are given below :-

(a) ANAESTHESIOLOGY CHARGES ( Rates in Rupees)

(i) Anesthesia Fees - Category I Rs. 2,310

(ii) Anesthesia Fees - Category II Rs. 2,755

(iii) Anesthesia Fees - Category III Rs. 4,830

(iv) Anesthesia Fees - Category IV Rs. 5,775

(v) Anesthesia Fees - Category V Rs. 6,615

(b) SURGICAL ONCOLOGY – Operation Theatre (Hospital Service Charges)

(i) Minor OT - Service Charges Rs. 870

(ii) Minor OT - Drugs/Consumables (Without GA) Rs. 325

(iii) Minor OT - Drugs/Consumables (with GA) Rs. 540

(iv) Major OT - Service Charges – Less than 2 Hrs Rs. 3,465

(v) Major OT - Service Charges - 2 To 4 Hrs Rs. 5,775

a. Major OT – Service Charges - More than 4 Hrs Rs. 8,45

(c) SURGERY CHARGES

(i) Minor OT – Surgery Charges Rs. 870

(ii) Category I Surgery Rs. 2,755

(iii) Category II Surgery Rs. 6,930

- 31 - (iv) Category III Surgery Rs. 9,660

(v) Category IV Surgery Rs. 15,095

(vi) Category V Surgery Rs. 17,325

93. Charges prescribed above are applicable for semi-private ward. If the beneficiary is entitled for general ward there will be a decrease of 10% in these rates; for private ward entitlement there will be an increase of 15%. 94. The admissible amount for Cancer surgery shall be calculated as per the formula given below:-‘Admissible Amount = Room rent as applicable + Anesthesia charges (as per category) + OT charges (as per category)+ Surgery charges (as per category)+ investigations at CGHS rates + Cost of Medicines and Surgical Disposables’. 95. Dialysis: Package charge will include procedure and cost of consumables for dialysis. Investigations and other essential drugs (e.g. Inj Erythropoietin), if required, may be billed to ECHS as separate items, along with an essentiality certificate and supporting investigation reports. For any additional drug including Inj Erythropoietin should be supported by essentiality certificate issued by treating doctor. 96. Emergency Case Bills from Empanelled Facilities: Physical bills for emergency treatment will be forwarded to concerned Regional Centre for payment as per normal procedure laid down above. However, such bills will include an emergency certificate issued by the hospital and will be super-scribed with ‘EMERGENCY BILL- EMPANELLED FACILITY’ written in block capitals in Red. 97. Cardiac treatment. In the case of treatment undertaken for interventional cardiology, images with detail reports and real time images of CAG / PRE AND POST PTCA, duly signed by treating cardiologist, to be attached with the bill. Recommendation of concerned specialist is mandatory. POUCH/STICKER of stents/implants should be enclosed. Original invoice of stents/ implants with Nomenclature, Batch No., Lot No. / Sr. No./Ref. No, Expiry Date and Name of the Patient is to be provided by hospital. If the hospital is submitting a group invoice, then the hospital should attach an individual invoice issued in the name of the patient for that implant/ stents along with the group invoice. Any implant/stent should be clearly justified in discharge summary by the concerned doctor. The following check list specifically will be utilized accordingly in addition to routine documents:-

(a) Room rents/daycare charges as per CGHS rates

(b) Investigations/other procedures as per CGHS

(iii) Drugs as per actuals

(d) Consultation as per CGHS.

(e) Images with detail reports of CAG / PRE AND POST PTCA duly signed by

treating Cardiologist

(f) Surgical procedures as per CGHS/AIIMS rates as applicable.

POUCH/STICKER/WRAPPER of stents/implants should be enclosed

(g) Original invoice of stents/ implants with Nomenclature, Batch No., Lot No. / Sr.

No. /Ref. No, Expiry Date and Name of the Patient

(h) Any implant/ stent should be clearly justified in discharge summary by the

concerned doctor (j) Recommendation of concerned service specialist is mandatory.

- 32 - (k) Cost of the Inj. Reopro and Inj. Integrallin not part of the package and is reimbursable in addition to package at actual rates [Auth: - c. org. letter no. B/49773/AG/ECHS/BILLS date 02 mar. 2005]

(l) Approval of M.D Central ORG. for expenditure exceeding Rs. 5 lakhs(As

applicable)

(m) Approval of SEMO/ CONCERNED SPECIALIST for unlisted procedure.(as

applicable)

(n) Wrapper of Anti Platelet drugs.(as applicable) 98. Organ Transplant Cases: -All such cases should take the special permission from

Service Specialist of AHR&R Organ Transplant Centre,DELHI CANTT.

Surgical procedure rates as per ECHS/CGHS/AIIMS/ACTUAL(if unlisted)

Copy of protocol for management of the case.

Approval of Senior Adviser AHR&R for unlisted procd.(if applicable)

Approvel of M D Central Org. for expenditure exceeding 5 lacs.(Mandatory)

99. Orthopedics cases: All orthopedics (Ortho) surgeries and joints replacement surgeries to be supported by pre and post reports and image. Diagnostic Bills 100. All laboratory/ radiology reports should be printed in hospital / diagnostic centre’s letter head and in original duly signed by the concerned specialist. Reports should be attached in sequence. 101. All investigations reports are mandatory even in package procedures. Package rates to

be considered as per CGHS/AIIMS rates and guidelines. 102. Medical management during package period- 0- 12 days to be considered as part of

package and extra billing will not be allowed. Diet Charges For Echs Patients Admitted To Hospital 103. ECHS patients admitted to hospitals are entitled to free diet subject to their basic pension not exceeding specified amounts as laid down vide Govt of India, Min of Defence letter No 22 (08)/06/US(WE)/D(Res) dt 05 Dec 2006. 104. Several queries have been received from the environment regarding methodology for

implementing the provision. The following clarifications are made :-

(a) Treatment in Empanelled Hospitals. Diet charges are included in the package for various procedures which are negotiated with hospitals. For treatment procedures with no prescribed package rate, ‘diet’ is included in ‘Room Rent’ charges. Hence att treatment in Empanelled hospital is inclusive of diet and no additional charges are to be levied for the same.

(b) Treatment in Service Hospital Diet is not charged separately for treatment in

Service Hospitals. However Hospital Stoppage’ at prescribed rates for ESM/dependents is charged from patients which is not reimbursable.

(c) Treatment in Govt Hospitals. Diet charges are payable by ECHS beneficiaries. Reimbursement of the same is admissible as per actual, subject to entitlement as per basic pension scale laid down vide Govt letter referred in Para 1 above. In all such cases, where diet charges are admissible, reimbursement will be from code head 365/00 (medical treatment related expenditure).

(d) Treatment in Emergency in Non Empanelled Hospital Reimbursement is admissible at CGHS rates. Hence CGHS stipulations as outlined at Para 1 (a) above are applicable, and diet charges’ cannot be admitted separately.

- 33 - Blood Bank Charges 105. Blood bank expenses need to be supported by vouchers/compatibility forms. Processing cost and compatibility tests are part of blood/ blood components charges. It is the responsibility of the empanelled hospital to arrange for the blood or blood products as the case may be. Under no circumstances patient or his/her relatives /attendants will be forced to arrange for the blood or blood product. The cost of whole blood is Rs.710/-(Auth.:Central Org. letter no. B/49778/AG/ECHS/GEN. dt.10 october 2007) Other blood components charges will be as per CGHS/AIIMS/ACTUAL if unlisted.(whichever is less) 106. Blood compatibility notes and blood transfusion vouchers needs to be submitted along

with the bill. 107. Anti-platelet therapy is payable in addition to any other procedural charge/package

charge. Bills From Non-Empanelled Hospitals 108. Bills of emergency cases from non empanelled hospital / facilities will be uploaded in the concerned polyclinic and forwarded to the Regional Centre ECHS concerned. Hard copies of same bills along with the following documents would be submitted to the Regional Centre for verification/ scrutiny and payment as per guidelines of ECHS:-

(a) Emergency certificate of hospital and EIR of the nearest Polyclinic.

(b) Photocopy of the card with date of membership

(c) Receipt of payment done with the signature and seal of the concerned authorities

(d) Final bill and detail bills of the entire treatment given during hospitalization with

the signature and seal of the concerned authorities

(e) Reports of Lab tests/ radiology/ specialized investigations if any

(f) Original invoice with Lot No/ Batch No./ Expiry Date and Name of the Patient

along with pouch/stickers/wrappers of stents/ implants if used

(g) Original Discharge Summary

(h) Application of patient/ AFV with address / bank details and contact No.

(j) Details of the advance taken for the treatment from concerned Stn. HQ ECHS CELL.

(k) Doctor’s prescription of medicine to be purchased from out side

(l) Relevant Contingent bill

Reimbursement of Medicine Bills 109. Reimbursement of medicine bills is permitted only for under mentioned specialty

treatment and the claim is to be preferred immediately on discharge from the hospital.

(a) Post operative cardiac surgeries and interventional cardiology

(b) Oncology.

(c) Post operative organ transplant

(d) Joint replacement

(e) Neuro- Surgery/ Neuro- medical cases [Auth.: Central Org. ECHS letter no.

B/41773/AG/ECHS DT. 25 MAY 2004] 110. Documents to be attached with the Bill of Medicine are as under:

(a) Photocopy of referral and discharge summary with prescription of the medicine.

(b) NA certificate from medical store of polyclinic/ service hospital

(c) Photocopy of ECHS CARD

- 34 - (d) Original bill

(e) Application of AFV with Address/ Bank detail/ Contact No.

111. Documents to be attached with Bill of Tests/procedures not available in service

hospital/ govt. hospital/ empanelled hospital and diagnostic centers:

(a) Certificate from Service Specialist that ‘delay in test/procedure likely to cause loss of life/limb/serious deterioration in patient’ condition’. Certificate from O/IC polyclinic that ‘test/ procedure is NA in service hospital/ govt. hosp./ empanelled hosp and diagnostic centers’ and clear endorsement of the case in EIR.

(b) Approval of SEMO.

(c) Original bill and reports of the test/ procedure done with the signature of auth.

Specialist.

(d) Application of AFV with address / bank details / telephone or contact .No. 112. In this connection Para 14 of Central Organization ECHS, letter No.

B/49774/AG/ECHS/Referral Dt 01 Dec 2009 may be referred for details. 113. Haemo-dialysis can also be permitted in a non-empanelled hospital when the facility in an empanelled hosp is not available to an ECHS member due to its limited capacity. The following check list of documents for Haemo-dialysis cases specifically will be utilized accordingly in addition to routine documents:-

(a) EIR should be raised by OIC Polyclinic with an endorsement stating that

Haemodialysis is not available in a Service/Empanelled hospital

(b) Bills are to be processed for a period of one month at a time Reimbursement of AIIMS bills will be processed as per AIIMS rates only (auth. Ref.

Central org. Letter no. B/49773/AG/ECHS/rates Dt. 16 sep. 2011) 114. In case ANY CLAIM preferred by an ECHS member is not recommended, it will not be rejected from any intermediate functionary due to any reason, whatsoever. Claim would be forwarded to central organization, ECHS review along with detailed reasons for rejection. (Auth :- Central. Org. ECHS, letter no, B/49774/AG/ECHS/POLICY dt 01 12 2008) Payment/reimbursement of Medical Expenses to Beneficiaries from two Sources i.e. Insurance Agencies and from the ECHS [ AUTH:-Cent. Org. letter no. B/49779/AG/ECHS dt .27 Jan 2010], Refer Ministry of Health and Family Welfare O.M. NO. S 11011/4/2003-

CGHS (P) date 19th

Feb’2009 copy enclosed) 115. The guidelines mentioned in the memorandum above will be followed for the reimbursement of medical claim to beneficiaries from two sources i.e. insurance agencies and the ECHS. 116. As per present policy issued vide this Organization letter under reference, ECHS members can submit claims pertaining to emergency treatment in non-empanelled hospitals either at Parent Polyclinic of Station where treatment occurred. 117. The Policy has since been reviewed and it has been decided that all claims for reimbursement of med expenses incurred for Emergency Treatment in Non-empanelled Hospitals henceforth will be submitted at the Parent Polyclinic only. 118. Emergency treatment will be permissible in any station where the emergency occurs. Emergency Info Report (EIR) will be generated from there. Subsequently, claims will be submitted to Parent Polyclinic for processing.

- 35 -

119. In case where it is not possible for ECHS member to submit claim at his Parent Polyclinic due to exceptional circumstances, the claim may be accepted at the Polyclinic of Station where treated, subject to approval of the Station Cadre of that Station (Auth: B/49773/AG/ECHS date

31 st

Aug’2006) Reimbursement Of Medical Bills Of Out Station Echs Members For Treatment In Delhi 120. With an aim to ease out additional loads from Polyclinics/ Regional Centre/SEMO/Station Head Quarter, Delhi Cantt. for out station ECHS beneficiaries it has been decided that bills

listed in Para 2(c) and (d) of Central Org. letter B/49773/AG/ECHS dt. 23rd

Feb.’2007 is also processed by concerned Polyclinics. However in cases where Advance is granted from Station HQ. Delhi, the bills will have to be processed by the same HQ. On Line Billing Process 121. On line billing process is now in vogue for cases admitted / diagnosed and treated at empanelled hospitals / facilities with effect from 01 Apr 2012. The procedure is depicted in detail in flow diagram me shown as under:

- 36 -

ON-LINE BILL PROCESSING IN ECHS ( LESS THAN 5 LAKHS )

Referral Polyclinics

Acceptance of Referral by Hospitals

Scanned Copy of Individual reimbursement

Empanelled Referral

/ Hospital /

Diagnostic / Acceptance of Referral by Hospitals

Dental

Centers/

Intimation of Admission bills

Clinics /

Laboratorie Upload scanned copy of bill on discharge

s

Observation/Queries/Clarification

Replies to above

Hard copy of hospital bill and

hard copies of additional Bill

documents / papers as required

Processi

Reimbursement bills

ng

Soft copy of bill (All)

Agency

Regional

Centre Verify hard copy with soft copy &

Jt Dir Worksheet with due justification &

(A&A) Recommendations for payment

Receiver/

Verifier) Observations if any

Jt Dir (HS)

Replies to above

Medical Observations if any

scrutiny &

recommendat

Replies to above

ions with

justification

Approval

for variation

ECS file of payments to hospitals on daily basis

Dir (CFA) Payment details

Approval

(justification

Cent Org

Unit I (MD) (Bills – 3 to

5 Lacs) Unit – II (Dy

MD)

Dir (Med)

(MO Unit

I & II) (Medical

scrutiny &

recommendat

ions with

justification

for variation)

Observation, if any

CFA (MD/ Dy MD) Approval

(Justification

for variation,

if any)

Dir (P & C) Convey CFA sanction to Regional Centers

Regional Centre

Payment

through ECS

to Hospitals

- 37 - ON-LINE BILL PROCESSING IN ECHS

Soft Copy of bills & worksheet with due Justification & recommended payment

Observation, if any

Bill Processing Agency

Approval

CFA Sanction (Soft copy)

Hard copy of CFA Sanction

Soft copy of CFA Sanction ECS File of payments to hospitals on daily basis

Payment details

122. The following essential actions will be taken for facilitating the billing process:

(a) Authentication of Billing documents prior to uploading for on line processing: The

documents not prepared on hospital letter head will be compulsarily authenticated by the

concerned authority of the hospital .However, following documents shall be signed with

- 38 - seal of the hospital/authority concerned along with countersignature of the OI/C Polyclinic concerned:-

(i) Emergency certificate,

(ii) Discharge summary will be signed by the treating doctor along

with countersignature of OI/C polyclinic.

(b) All bills by the accounts officer along with countersignature of OI/C polyclinic. 123. BILLS above 5 lakhs after processing will be sent by the Regional Centre to Central Organization ECHS along with worksheets of BPA and recommendations of Regional centers for further submission to MoD FOR SANCTION. 124. For all the cases wherein patient has stayed for extended period of stay has been approved by concerned authority, the days wherein the treatment is not justified or supported by necessary documents- investigation reports and bills should be deducted. Work Sheet 125. Work sheet of physical bills above Rs 5 lakhs duly completed and signed by the bill processor of BPA to be attached with the bill. The digital signatures of the bill processor along with date should be affixed on the worksheet.

(a) Reasons for disallowances to be clearly mentioned in the work sheet

(b) Rates, Code No, duration and reasons in detail for allowance/disallowance to be

mentioned in remark columns of worksheet (A Format of Work Sheet is attached)

(c) Hospital must provide the indoor case papers to the ECHS BPA as and

when required. 126. Bill Verification: Check for detailed bills and final bill along with all the documents

attached 127. Medical management prior to packages is admissible subject to supportive

investigation, treatment and detailed justification for delay in particular surgical procedure. 128. All emergencies will be treated on cashless basis till stabilization even if the specialty concerned for management of the case is not empanelled. Payments will not be recovered from ECHS patient in such cases. Issue Of Medical Eqpt/ Mechanical And Electronic Aids Prescribed For The

Echs Members 129. Medical equipments / Mechanical and Electronic aids prescribed for the ECHS members according will be dealt according to policy issued vide Govt. of India Min. of Defence letter No. 24 (8)/03/ US(WE)/D(Res) dated 19 Dec 2003 on the subject. Specified medical equipment can be prescribed for ECHS members under conditions laid down in Paras 9 (b), (e), (g) and (l) of GOI policy letter dated 19 Dec 2003 mentioned above. The detailed guidelines for issue of such prescribed medical eqpt to ECHS members are given in the succeeding paragraphs:

(a) Hearing Aids: Hearing aids should be purchased only if recommended by Govt. ENT Specialist/Service Specialist on the basis of audiometric and audio logical assessment. Replacement of hearing aid shall be allowed after 5 years on the basis ofcondemnation certificate issued by a technical expert and approval of ENT Specialist.Maintenance and repair is the responsibility of The beneficiary.

.

- 39 -

(c) Artificial Limbs/Appliances. ECHS members can obtain Artificial limbs/appliances through Armed Forces Medical Service institutions or empanelled facilities, once referred to the facility by the Polyclinic. When referred to Servicefacilities, Artificial Limbs/Appliance for ECHS members will be fitted at ArtificialLimb Centre (ALC) Pune, or Artificial Limb Sub Centres in the AFMS hospitals. TheArtificial limbs / appliances will be procured from ECHS funds sub allocated to ALC

Pune and Service Hospitals by the Office of DGAFMS. When treatment is undertaken in civil empanelled facilities, CGHS rates will apply. Expenditure over and above the

authorized CGHS rates, if any, will be borne by ECHS member. Payment will be made through the cash Assignment system by the Station Commander as per normal

laid down procedures for payment to empanelled facilities. (d) Glucometers and Nebulizer. Glucometers and Nebulizer will be issued to

members, when use of such equipment is considered absolutely essential on medical

grounds. The equipment will be supplied under following conditions:-

(i) Glucometer: ECHS members who are suffering from complications of

Diabetes mellitus may be issued glucometers on specific recommendation of the

Medical Specialist of the ECHS Polyclinic/Service Hospital/Empanelled Hospital. (ii) Nebulizers: ECHS members who are patients of Bronchial Asthma or respiratory conditions requiring regular administration of inhalation therapy by nebulizer may be issued Nebulisers on the specific recommendation of Medical Specialist in the ECHS Polyclinic/Service Hospital / Empanelled facility.

(e) Approval by the Senior Advisor and Consultant in Medicine, under whose

jurisdiction the ECHS Polyclinic is located, will be obtained for above items. (f) The O I/C Polyclinic will thereafter initiate procurement action for the eqpt as per local purchase procedures. The following documents will be submitted to the Station Commander for this sanction, through the SEMO/SMO/PMO.

(i) A brief case summary and advice of the medical specialist of

the Polyclinics/Service Hospital/Empanelled Hospital.

(ii) Recommendation of the Senior Adviser and Consultant

(iii) Quotation from vendors

- 40 -

(iv) Comparative Statement

(v) Comment from O I/C Polyclinic stating that the amount is within

the prescribed CGHS rates. (g) Payment for the item to the vendor will be made by cheque through the Cash Assignment by the Station Commander. The item will be issued to the ECHS member and a receipt obtained. The receipt will be attached with the case file and preserved for audit purposes. Details of the issue will also be entered in the patient record in the Polyclinic computer and in his smart card (h) The cost of maintenance of equipment will be borne by the ECHS member. Replacement of the equipment is only permitted after 5 years on production of condemnation certificate by the O I/C Polyclinic and recommendation for continuation of treatment by the Medical Specialist. (j) CIPAP/BIPAP Machines When a CIPAP/BIPAP machine is recommended for any

ECHS member by Specialist of a Service Hospital /Empanelled Hospital, a statement of

case will be forwarded by the OI/C Polyclinic. The Statement of Case will include basic

investigation report and Sleep Lab report of the Service Hospital/Empanelled Hospital. Recommendations of a Service Specialist and approval by the Senior Advisor and

Consultant of the concerned specialty, under whose jurisdiction the Polyclinic is located will

be obtained in all such chase. The O I/C Polyclinic will thereafter initiate procurement

action for the eqpt as per local purchase procedures. The following documents will be submitted to the Station Commander for his sanction through the SEMO/SMO/PMO:

(i) A brief case summary, basic investigation reports, sleep lab report and

advice of the medical specialist of the Service Hospital/ Empanelled Hospital.

(ii) Recommendation of Service Medical Specialist, Senior Adviser and

Consultant

(iii) Quotations from vendors

(iv) Comparative statement.

(v) Payment for CIPAP/BIPAP machines will be made by cheque to the vendor through the Cash Assignment by the Station Commander. Actual cost of CIPAP/BJPAP machines or CGHS rates, whichever is lesser, will apply. Expenditure over and above the authorized CGHS rate will be borne by the ECHS member. The CIPAP/BIPAP machine will be issued to the ECHS member and a receipt obtained. The receipt will be attached with the case file and preserved for audit purposes. Details of the issue will also be entered in the patient’s record in the Polyclinic computer and or his smart card.

(vi) The cost of upkeep and maintenance of the CIPAP/BIPAP machines will

be borne by the ECHS member

(vii) A CIPAP/BIPAP machine will only by issued once in a life time to the

member. (k) Spectacles: Cases requiring spectacles will be dealt as under:-

(i) Spectacles will not be provided under ECHS system except

post operatively in case of conventional operation of cataract.

(ii) Cost of spectacles in such cases will be limited to Rs 200/- only.

- 41 -

(iii) In all such cases the patient will submit the bills for reimbursement towards cost of spectacles to the O I/C Polyclinic who will forward it to the SEMO/SMO/PMO giving date of conventional cataract surgery and on recommendation by the Medical Officer of the Polyclinic or Eye Specialist of Service/Empanelled Hospital.

(iv) The payment will be made by the Station Commander from his Cash

Assignment.

(v) Records of the patient will be updated after the payment is completed. Replacement of Spectacles will be admissible once in there years on the advice of the Medical Officers of the Polyclinic ort empanelled Consultant

(l) Other Medical Equipment For Domiciliary Use No other equipment is authorized for issue to ECHS members at present. Other Medical Equipment, as and when included for issue to patients, will be intimated to all concerned (Authority: Central Org. ECHS letter No.B/49770/AG/ECHS/Hearing Aid 27 Jul 2005)

130. Ambulance charges: No ambulance charges are admissible. 131. Traveling allowance: The following procedure will govern the movement of patient to

referred clinics:-

(a) Traveling allowance for journeys undertaken for medical treatment (both ways) is admissible to ECHS beneficiaries for treatment in another city, if such treatment is not available in the same city and referral is advised by ECHS Medical Officer/Specialist. Amount admissible will be limited to rail fare in entitled classes as applicable at the time of retirement, by shortest/main route or actual expenditure, which ever is less.

(b) One attendant or escort who is required to travel along with the patient will also be entitled to travelling allowance if the Medical Officer attending the patient certifies in writing that it is unsafe for the patient to travel alone and such attendant escort is necessary to accompany the patient. Amount as admissible to the patient is reimbursable. (c) The claim for reimbursement of traveling expenses will be submitted to the

Officer-in-charge Polyclinic with the following documents: -

(i) Application from ECHS members.

(ii) Photocopy of Smart Card/ ECHS registration slip

(iii) Referral No. of the polyclinic

(iv) Name of place and hospital referred to

(v) Contingent bill

(vi) Tickets of the patient and attendant (if applicable) 132. Dental Treatment: Dental treatment including referral will be as per laid down procedures for other medical cases. Dentures will be permitted only if advised by Dental Officer at ECHS Polyclinic or service Dental Officer. A particular type of partial/complete denture will be permitted on one time basis only for each member/dependent of the Scheme as per CGHS rates.

- 42 -

Manual Processing Of Bills 133. The procedure for the manual processing of bills is out lined in succeeding paragraphs as under which may be resorted to as and when required under instructions of the Central Organization ECHS:-

(a) Action at Polyclinics, SEMOs, Station HQs and Regional Centers ECHS:-

(i) The bills will be examined by the OIC Polyclinic for authentication and

verification of rates charged.

(ii) On receipt of bills at the Polyclinic, the OIC Polyclinic will verify the particulars of the patient and cross check against the original referral records /emergency treatment records of the Polyclinic.

(iii) It will be verified if the tests/procedures conducted by the empanelled facility

were the same for which the referral was made and that no major deviation took

place without prior approval of the Medical Officer of the Polyclinic.

(iv) The rates charged will be compared with approved rates and amount approved for payment will be endorsed by the OIC. For purposes of vetting of bills, OIC Polyclinic may seek advice/assistance of Medical / Dental Officers of the Polyclinic.

(v) The OIC Polyclinic will thereafter prepare a cover note with all relevant details. The cover note together with bills/documents will be forwarded by the OIC to the Senior Executive Medical Officer (SEMO) for technical examination.

(vi) The SEMO will consider the following issues while examining the Bills for

correctness:-

(aa) Nature of treatment given will be checked as to whether or not the treatment / investigation were as per ECHS Polyclinic referral and were appropriate.

(ab) Those Standard clinical practice guidelines were followed by the

concerned Hospital/ Dental / Diagnostic center.

(ac) That medicines/drugs and consumables were provided as per

requirement and necessity.

(ad) Ratify the rate verification done by the OIC Polyclinic.

(b) The SEMO will submit the recommendations for sanction of the Station Commander . If the bill amount is beyond the financial powers authorized to the Station Commander, sanction of Competent Financial Authority (CFA) will be obtained prior to payment, and case will be projected up the static chain of command to the appropriate CFA. However, in order not to delay payments to empanelled facilities, the CFA will forward approvals directly to Station Headquarters. Payments will be made by cheque to the empanelled facilities after receipt of sanctions and will be attached to the bills and subject to post-audit. Financial limits of CFA are as under:-

Ser. Rank /Appointment Financial limit per transaction

No

1 Station Commander

(a) Lt Col/Col Rs.20, 000/-

- 43 -

(b) Brig Rs.50, 000/-

2 Sub Area Commander Rs 1, 00,000/-

3 Area Commander Rs 2, 00,000/-

4 Army Commander Rs 4, 00,000/-

5 Vice Chief Of Army Staff Rs 5, 00,000/-

6 Ministry of Defence >Rs 5, 00,000/-

Other Terms And Conditions 134. The Hospital/ Dental/ Diagnostic Centre shall provide the agreed upon services to cases referred from ECHS Polyclinics on a Referral slip duly authenticated and stamped as mentioned in Para 4 above. The Hospital/ Dental or Diagnostic centre would not refuse admission/treatment or investigations to referred cases on flimsy grounds. 135. The Hospital/ Dental or Diagnostic centre shall raise bills in the prescribed format to the

ECHS Polyclinic in respect of the ECHS members treated on completion of treatment/discharge of

the patient. The rates for tests and treatment would be charged as per mutually agreed rate list

and approved by ECHS. Under no conditions will rates exceed the rates laid down by the CGHS

for the particular zone. ECHS will make payments only as per approved/ CGHS rates. Expenditure

in excess of approved / package deal rates would be borne by the beneficiaries. 136. The Hospital will not be at liberty to revise the rates suo- motto. 137. The Hospital/Nursing Home or Diagnostic centre would not refer the ECHS cases further to other institute, and if it does so, it will be at their own arrangements, and ECHS would not be responsible to the other institute for any liability. Payment in such cases would also be restricted to approved rates only. Excess charges incurred over and above the approved rates may be recovered from the patient with his/ her prior consent. 138. The Hospital/Nursing Home or Diagnostic centre shall provide access to the financial and

medical records for assessment and review by medical and financial auditors of the ECHS as and

when required and the decision of ECHS on necessity or requirement shall be final. 139. Any liability arising out of or due to any default or negligence in provision or performance of

the medical services shall be borne exclusively by the Hospital/Nursing Home or Diagnostic

centre, which alone shall be responsible for the defect / deficiency in rendering such services. 140. During In-patient treatment of the ECHS beneficiaries, the Hospital shall not ask the members to purchase separately the medicines from outside but bear the cost on its own, as the package deal rate fixed for the ECHS includes the cost of drugs, surgical instruments and other medicines etc. 141. On approval of the facility for empanelment a Memoranda of Agreement (MOA) will be signed between the Hospital/Nursing Homes or Diagnostic centre and ECHS. The MOA shall remain in force for a period of one year from the date of its execution, extendable on mutual agreement. The MOA may be terminated by either party serving one calendar month’s notice in writing. 142. The ECHS shall be at liberty at any time to terminate this agreement on giving 24 hours notice in writing to the Hospital for breach of any of the terms and conditions of this Agreement and the decision of the ECHS in this regard shall be final

- 44 - 143. Any dispute or difference arising between the Hospital/Nursing Home or Diagnostic centre and ECHS shall be referred to an arbitrator to be appointed by mutual consent of both parties therein 144. All other conditions listed in the MOA will be complied with by both the parties, that is,

the Empanelled facility and ECHS. 145. The patient interest should be the main concern at all the levels dealing them with due courtesy, compassion and competence both from professional aspects as well as from administrative aspects with synergy of actions. 146. Complaint from the patients or polyclinic staff if any will be suitably dealt by the OIC

Polyclinic under advice of Senior MO/ MO of the polyclinic as the case may be.

Important Ruling Letters Explanatory Diagrammes, Flow Charts Of Various Activities

And Check Lists

150. Important Ruling letters issued by the Central Organization ECHS. 151. Relevant explanatory diagram’s, flow charts of various activities and check lists as applicable as ready reference to facilitate the administration are also provided at the end of this SOP. Review Of Document

Prepared By Signatures Date

Reviewed & Approved By Signatures Date

ANNEXURE 1

- 45 -

CHECKLIST FOR SUBMISSION OF CLAIM DOCUMENTS Claim No.: __________________________Name of the patient: ________________________

Name of the Beneficiary: ______________A/Claimed: ________________________________

ECHS Card No.______________________Name of the Hospital:________________________

Date of Admission:____________________Date of Discharge:__________________________

S.No Required Documents Availability Remarks Page Page No No

Yes/No From To

1 Admission Intimation

a) Proof of membership/Photocopy of ECHS membershipCard

b) Referral Form

c) Emergency Certificate by treating Hospital

d) Admission Case Note

2 Bill Submission

a) Original bill

1) Summary of Bill

2) Itemized bill

b) Prior Approval/Justification for not obtaining

Prior Approval

c) MOA ( Covering the period of Hospitalizations)

along with Annexure-II

d) Page numbering of case file

e) MRP Certificate from empanelled hospital/

Polyclinic/Regional Center

f) Discharge/Case Summary/Patient record by

treating hospital and Death summary if applicable

g) Investigation reports

- 46 -

h) Original Invoice +Sticker of Implantable

devices along with outer pouch

i) PTCA- Pre and Post PTCA Images with

CD Details

f) Cardiac Implant- Dealer’s Invoice with

post procedure Chest X-Ray

g) Joint Replacement- Pre and Post X-ray image & report with satisfactory working certificate by treating surgeon

h) Patient Feedback Form

3 Miscellaneous- other Documents

- 47 -

ANNEXURE 2

FINAL BILL SUMMARY Claim No.: ____________________________Name of the patient: ______________________________

Name of the Beneficiary: ________________A/Claimed: _____________________________________

ECHS Card No.________________________Name of the Hospital: ____________________________

Date of Admission:______________________Date of Discharge:_______________________________

S.No Billing Details Amount

Group I ( Procedure, Accommodation & Consultation )

1 Procedure

2 Accommodation

3 Consultation

Group II ( Diagnostics )

4 Pathology

5 Radiology & Imaging

6 Other Specialized Investigation if any

Group III ( Pharmacy )

7 Medicines

8 Consumables

9 Implants Group IV ( Miscellaneous )

Total

- 48 -

ANNEXURE 3

ITEMISED BILL SUMMARY Claim No.: ___________________________Name of the patient:______________________ Name of the Beneficiary: _______________A/Claimed: ______________________________ ECHS Card No._______________________Name of the Hospital: ______________________ Date of Admission: ____________________Date

of Discharge:__________________________

S.No Billing Details Date Code Quantity Amount

Group I ( Procedure, Accommodation & Consultation )

1 Procedure-

a) b) c) 2 Accommodation

a) ICU

b) Ward

3 Consultation

a) Name of Doctor

b) Name of Doctor

c) Name of Doctor

Group II ( Diagnostics )

4 Pathology

a)

b)

c) 5 Radiology

a)

- 49 -

b)

c) 6 Other Specialized

Test a)

b)

c)

Group III ( Pharmacy )

1 Batch No.

Date Of Expiry

2 Batch No.

Date Of Expiry

3 Batch No.

Date Of Expiry

4 Batch No.

Date Of Expiry

5 Batch No.

Date Of Expiry

Group IV ( Miscellaneous )

1

2

3

- 50 -

ANNEXURE 4

ZONAL JURISDICTION OF CGHS RATES

SER STATE CGHS RATE APPLICABLE DISTRICTS

NO

1 Jammu & Kashmir Delhi

2 Himachal Pradesh Delhi

3 Punjab Delhi

4 Haryana Delhi

5 Delhi Delhi

6 Uttar Pradesh (Sub Area: All UP except Luck now

districts under Allahabad and Meerut )

7 Allahabad (Sub Area: All districts under Allahabad

Allahabad )

8 Meerut (Sub Area: All districts under Meerut) Meerut

9 Uttaranchal Dehradoon Sub Area /Lucknow

10 Bihar Patna

11 Jharkhand Patna

12 Orissa Patna

13 West Bengal Kolkata

14 Sikkim Kolkata

15 Assam Kolkata

16 Meghalaya Kolkata

17 Mizoram Kolkata

18 Tripura Kolkata

19 Manipur Kolkata

20 Nagaland Kolkata

21 Arunachal Pradesh Kolkata

22 Madhya Pradesh Jabalpur

23 Chattisgarh Nagpur

24 Rajasthan Jaipur

25 Gujarat Ahmedabad

26 Maharashtra Mumbai (Mumbai & Thane Pune All

Maharashtra except Districts

listed against Mumbai and Nagpur )

27 Nagpur All distrcits under jurisdiction of Station

HQs Kamptee

28 Goa Bangalore

29 Karnataka Bangalore

30 Kerala Trivandrum

31 Tamil nadu Chennai

32 Andhra Pradesh Hyderabad

33 Chandigarh

34 Andaman & Nicobar Islands Chennai

35 Pondicherry Chennai

36 Lakhwadeep Islands Chennai

37 Daman Diu Pune

38 Dadra & Nagar Haveli Pune

- 51 - ANNEXURE 5

EX-SERVICEMEN CONTRIBUTORY HEALTH SCHEME

ECHS POLYCLINIC………… (Station)

REFERRAL FORM

Part I OPD Regn No……………………Date…………… ECHS Card No………………………………….…. Name of patient………………………..…Age………Relationship with ESM ………….

Service No…………….…Rank …………..….. Name of ESM………………..……………. Brief Clinical Notes Provisional Diagnosis............................................... Vide Referral Serial No ………………….the above named is referred for (a) Admission ………………………………………… (Specify) (b) Investigation ………………………………………… (Specify) (c) Consultation for……………………………………... (Specify) Referred to ……………………………………………………………………………………. (Specify Hospital, Nursing Home, Diagnostic Centre)

Signature of Med Officer Place: Dated: (with stamp)

Part 2

SUMMARY OF THE CASE ( To be completed by the empanelled hospital, nursing home, diagnostic centre and consultant ) Clinical Summary/ Investigation Reports (for Diagnostic centers) Final Diagnosis ………………………………….. ICD Code No ………………………….. Treatment summary Place: …………. (Signature and Stamp) Date: …………..

Part 3 Final Disposal (a) Admission to …………………………………………………………… (Specify Hospital, Nursing Home, Diagnostic Centre) (b) To follow treatment as specified. Place: Signature of Med Officer ECHS Dated: (with stamp)

- 52 -

CHECK LIST OF MEDICAL DOCUMENTS BILLS ABOVE 4 LAKHS CASES

Name _________________as____________________ Date of Empanelment_______________

Name of ECHS Member _______________________________________________________

Ser Description Availability Flag

No Yes/No/NA 1 Proof of Membership (Photocopy of smart card/Regn A

receipt

2 Referral form B

3 Discharge/ case summary C

4. Cover Note D

5. Bill in Original E

6 Worksheet of recommendation of Regional Centre F

7 Emergency Certificate (if applicable) G

8 “Emergency Treatment in an Empanelled Hosp” H superscripted in RED on all bills (if applicable)

9 Sanction letter of Medical Advance deaen (if applicable) J

10 Prior ‘Approval‘ (Appx ‘A) K

11 Justification of Prior Approval not obtained (if applicable) L

12 MOA M

Date : Processing Officer

- 53 -

TIME CHECK SLIP ECHS POLYCLINIC DELHI CANTT-10

Bill ID No______________ Rank__________________ Name__________________________

ECHS Registration No________________________ Discharge Date ________________

Ser Name of Office Date Date No of To Whom Sig of Remarks

No Received Dispatched Days dispatched OIC/Offr

taken

1 ECHS Polyclinic

DC-10

2 SEMO

3 Stn HQ

4

5

6

7

8

9

10

11

12

13

14

- 54 -

CHECK LIST FOR REIMBURSEMENT OF HOSPITAL BILLS LIST OF DOCUMENTS TO BE SUBMITTED WITH INDL BILLS FOR

REIMBURSEMENT OF EXPENSES ON ACCOUNT OF ADMISSION IN

EMPANELLED HOSPITALS 1. Cover note (Yes / No / NA) 2. Photo copy of ECHS Card membership receipt (Particulars and (Yes / No / NA) photo of individual should be legible)

3. Emergency info report issued by nearest polyclinic on receipt (Yes / No / NA) of information with in 48hrs of admission.

4. Emergency admission certificate issued by treating hospital. (Yes / No / NA) 5. Referral in original.(for AIIMS and Govt Hosp, duplicate for Med (Yes / No / NA) bill)

6. Hospital admission/discharge summary. (Yes / No / NA)

7. Final bill of hospital. (Yes / No / NA)

8. Detailed day wise breakdown of final hospital bill at ser 7 (Yes / No / NA) above.

9. Reimbursement cert for outdoor/indoor patient (Yes / No / NA)

10. (Cert A/B as applicable) issued by AIIMS. (Yes / No / NA)

11. Photo copy of ECHS Cell Stn HQ letter under which advance (Yes / No / NA) payment has been made to AIIMS.

12. Photocopy of AIIMS letter under which balance amount if any (Yes / No / NA) has been returned back to ECHS Cell

13. Certificate from dialysis centre that the individual was on (Yes / No / NA) dialysis from ____ to _____

14. Treating Doctors prescription of medicines to be purchased (Yes / No / NA) from outside.

15. Medicine bills in original duly stamp and signed by the Hospital (Yes / No / NA) and the Patient and Paid stamp from purchased med store.

16. NA Certificate duly signed by OIC ECHS medical store (Yes / No / NA)

17. Reports of all tests/investigations (Yes / No / NA) 18. Stent pouch & Invoice to be att (where applicable) (Yes / No / NA) 19. Application from indl giving the following details- (Yes / No / NA) a. Brief details of the case and expenditure incurred (Yes / No / NA) b. Tele/Mob No/home address (Yes / No / NA) c. Bankers address and A/C No, MICR and IFSC code. (Yes / No / NA) (Yes / No / NA) 20. Medicine Certificate for above 2 lacs duly signed by Hospital. (Yes / No / NA) 21. Waiver from Stn HQ for delay submission (Yes / No / NA)

22. Contingent bill duly completed and signed on revenue stamp. (Yes / No / NA) Note: complete Original document is required for re-imbursement.

(Signature of Billing Clk)

- 55 -

CHECK LIST FOR REIMBURSEMENT OF HOSPITAL BILLS LIST OF DOCUMENTS TO BE SUBMITTED WITH INDL BILLS FOR REIMBURSEMENT OF EXPENSES ON ACCOUNT OF EMERGENCY

ADMISSION IN NON EMPANELLED HOSPITALS

1. Check list. (Yes / No / NA)

2. Cover note duly completed (part 1,2&3) (Yes / No / NA) 3. Photo copy of ECHS Card membership receipt (Particulars and

photo of indl should be legible) (Yes / No / NA) 4. Emergency info report issued by nearest polyclinic on receipt of info with in 48hrs of admission. (Yes / No / NA)

5. Emergency admission certificate issued by treating hospital. (Yes / No / NA)

6. Hospital admission/discharge summary. (Yes / No / NA)

7. Final bill of hospital. (Yes / No / NA)

8. Detailed day wise breakdown of final hospital bill at ser 7 above. (Yes / No / NA)

9. Summary of medicine bills. (Yes / No / NA) 10. Treating Doctors prescription of medicines to be purchased from

outside. (Yes / No / NA) 11. Medicine bills in original duly stamp and signed by the Hospital

and the Patient and Paid stamp from purchased med store. (Yes / No / NA)

12. Photo copies of all bills. (Yes / No / NA)

13. Reports of all tests/investigations ` (Yes / No / NA)

14. Stent pouch & Invoice to be att (where applicable) (Yes / No / NA)

15. Application from indl giving the following details- (Yes / No / NA)

(a) Brief details of the case and expenditure incurred (b) Tele/Mob No/home address (c) Bankers address and A/C No, MICR and IFSC code.

16. Contingent bill duly completed and signed on revenue stamp. (Yes / No / NA)

17. Medicine Certificate for above 2 lacs duly signed by Hospital. (Yes / No / NA)

18. Waiver from Stn HQ for delay submission (Yes / No / NA) Note: complete Original document is required for re-imbursement.

(Signature of Billing Clk)

4. Application from indl giving the following details :- (Yes / No / NA)

(a) Brief details of the case and expenditure incurred

(b) Tele No/home address

(c) Bankers address and AC No

(d) Details of advance taken from ECHS Cell Stn HQ if any.

5. Photo copy of ECHS Card. (Particulars and photocopy (Yes / No / NA)

of Indl should be legible)

6. Referral in original.(part I,II III) (Yes / No / NA)

7. Hospital admission/discharge/Death/case summary (Yes / No / NA) 8. Reimbursement cert for outdoor/indoor patient

(Cert A/B as applicable) issued by AIIMS. (Yes / No / NA)

9. Final bill of hospital (Yes / No / NA)

10. Summary of medicine bills purchased from outside. (Yes / No / NA)

11. Treating doctors prescription of medicines purchased from outside (Yes / No / NA)

12. NA Certificate issued by OIC ECHS medical store for medicine (Yes / No / NA)

prescribed in OPD / on discharge from hospital.

13. Medicine bills in original duly signed by indl and stamped and (Yes / No / NA)

signed by AIIMS on the reverse side

14. Reports of all tests/investigations (Original) (Yes / No / NA)

15. Photo copy of ECHS Cell Stn HQ letter under which advance (Yes / No / NA)

payment has been made to AIIMS.

16. Photocopy of AIIMS letter under which balance amount (Yes / No / NA)

if any has been returned back to ECHS Cell

17. Photo copies of all bills duly signed. (Yes / No / NA)

18. Stent Pouch & Invoice to be att (where applicable) (Yes / No / NA)

19. Waiver for delay submission (Yes / No / NA) Note: complete Original document is required for re-imbursement.

(Signature of Billing Clk)

57

CHECK LIST FOR REIMBURSEMENT OF MEDICINE BILLS CHECKLIST OF

DOCUMENTS TO BE SUBMITTED FOR REIMBURSEMENT OF PURCHASE OF

MEDICINES PRESCRIBED ON DISCHARGE FROM HOSPITAL OR IN OPD

1. Check list (Yes / No / NA)

2. Cover note duly completed (part 1, 2&3) (Yes / No / NA) 3. Photo copy of ECHS Card membership receipt (Particulars and photocopy of indl should be legible) (Yes / No / NA)

4. Photo copy of referral (Yes / No / NA)

5. Hospital discharge summary/OPD card as applicable. Yes / No / NA)

6. NA Certificate duly signed by OIC ECHS medical store (Yes / No / NA) 7. Original medicine/consumables bills with paid stamp from

purchased Medical store. (Yes / No / NA)

8. One photo copy of all bills (Yes / No / NA)

9. Application from indl giving the following details:- (Yes / No / NA)

(a) Brief details of the case and expenditure involved

(b) Home address, Tele /Mob number

(c) Bankers address and A/C No

10. Contingent bill to duly signed on revenue stamp (Yes / No / NA)

11. Any other related document. (Yes / No / NA)

Note: complete Original document is required for re-imbursement.

(Signature of Billing Clk) 57

58

CHECK LIST FOR REIMBURSEMENT OF DIALYSIS BILLS LIST OF

DOCUMENTS TO BE SUBMITTED FOR REIMBURSEMENT OF EXPENDITURE

INCURRED ON DIALYSIS IN NEW DELHI

1. Check list (Yes / No / NA)

2. Cover note duly completed (pages 1&2) (Yes / No / NA)

3. Photo copy of ECHS Card. (Particulars and photocopy (Yes / No / NA)

of individual should be legible)

4. Referral in original duly completed (part I,II&III) (or) EIR (Yes / No / NA)

5. Certificate from dialysis centre that the individual was on (Yes / No / NA)

dialysis from ____ to _____

6. Dialysis centre bills in original and one photo copy (Yes / No / NA)

7. Application from individual giving the following details:- (Yes / No / NA)

(a) Brief details of the case and expenditure incurred

(b) Tele/Mob No/Home address

(c) Bankers address and A/C No

8. Contingent bill duly signed on revenue stamp (Yes / No / NA)

9. E-Payment Detail (Yes / No / NA)

Note: complete Original document is required for re-imbursement.

(Signature of Billing Clk) 58

59

CHEK LIST FOR DOCUMENTS FOR BILLING FOR CARDIAC TREATMENT 1. Cardiac treatment. In the case of treatment undertaken for interventional cardiology, images with detail reports of CAG / PRE AND POST PTCA. duly signed by treating cardiologist to be attached with the bill. Recommendation of concerned specialist is mandatory. POUCH/STICKER/WRAPPER of stents/implants should be enclosed. Original invoice of stents/ implants with Nomenclature, Batch No., Lot No. / Sr. No./Ref. No, Expiry Date and Name of the Patient is to be provided by hosp. If the hospital is submitting a group invoice, then the hosp. should attach an individual invoice issued in the name of the patient for that implant/ stents along with the group invoice. Any implant/stent should be clearly justified in discharge summary by the concerned doctor. 2. The following check list specifically will be utilized accordingly in addition to

routine documents:

(a) Room rents/daycare charges as per CGHS rates.

(b) Investigations/other procedures as per CGHS.

(c) Drugs as per actuals.

(d) Consultation as per CGHS.

(e) Images with detail reports of CAG / PRE AND POST PTCA duly signed by

treating Cardiologist.

(f) Surgical procedures as per CGHS/AIIMS rates as applicable.

POUCH/STICKER/WRAPPER of stents/implants should be enclosed.

(g) Original invoice of stents/ implants with Nomenclature, Batch No., Lot No. / Sr.

No. /Ref. No, Expiry Date and Name of the Patient.

(h) Any implant/stent should be clearly justified in discharge summary by the

concerned doctor.

(j) Recommendation of concerned service specialist is mandatory. 59

60

REIMBURSEMENT OF EXPENDITURE INCURRED ON INVESTIGATION/TEST

CONDUCTED IN NON-EMPANELLED FACILITIES WITH SPECIAL PERMISSION

1. Cover note duly completed (Part 1,2,&,3,) (Yes/No/ NA)

2. Check list (Yes/No/NA)

3. Contingent bill duly filled and signed (Yes/No/NA)

on revenue stamp.

4. Application from individual giving the following details. (Yes/No/NA) (a) Brief details of the case and expenditure involved. (b) Home address, Telephone/Mobile No. (c) Bankers address and A/C No. 5. Photocopy of ECHS Card

(particulars of individual should be legible) (Yes/No/NA)

6. Referral in Original. (Yes/No/NA)

7. Recommendation of service specialist. (Yes/No/NA)

8. Approval for specialized test/treatment/procedure at non (Yes/No/NA) empanelled facility. 9. Bills in duplicate (include original bill)duly signed by patient. (Yes/No/NA) 10. Investigation reports and any other related document. (Yes/No/NA)

Note: complete Original document is required for re-imbursement.

Signature of Billing Clk)

60

61

CANCER TREATMENT

(Checklist) The following check list specifically will be utilized accordingly in addition to

routine documents: -

1. Room rents/daycare charges as per CGHS rates b)

2. Investigations/other procedures as per CGHS

3. Drugs as per actual

4. Consultation as per CGHS

5. Radiotherapy/chemotherapy as per CGHS SUPER SPECIALITY rates

6. Surgical procedures as per TATA MEMORIAL HOSP. RATES

7. Photo copy of the referral is permitted for chemotherapy and radiotherapy

8. Recommendation of concerned service specialist is mandatory

9. Photo copy of the previous discharge summary and link up with original referral is

mandatory

10. Approval of M.D Central ORG. for expenditure exceeding Rs. 5 lakhs(As applicable)

11. Approval of SEMO/ CONCERNED SPECIALIST for unlisted

procedure(as applicable)

The summary of the case and the bills should specify the following: -

1. Protocol for management of the case.

2. Radiotherapy – Type of course and charges for complete course.

3. Chemotherapy - Number of cycles of chemotherapy.

61

62

CARDIAC TREATMENT

(Checklist) The following check list specifically will be utilized accordingly in addition to

routine documents:

1. Room rents/daycare charges as per CGHS rates.

2. Investigations/other procedures as per CGHS.

3. Drugs as per actual.

4. Consultation as per CGHS.

5. Images with detail reports of CAG / PRE AND POST PTCA duly signed by

treating Cardiologist.

6. Surgical procedures as per CGHS/AIIMS rates as applicable.

POUCH/STICKER/WRAPPER of stents/implants should be enclosed.

7. Original invoice of stents/ implants with Nomenclature, Batch No., Lot

No. / Sr. No. /Ref. No, Expiry Date and Name of the Patient.

8. Any implant/stent should be clearly justified in discharge summary by the

concerned doctor.

9. Recommendation of concerned service specialist is mandatory.

10 Cost of the Inj. Reopro and Inj. Integrellin not part of the package and is

reimbursable in addition to package at actual rates [Auth: - c. org. letter no.

B/49773/AG/ECHS/BILLS date 02nd

March 2005]

11. Approval of M.D Central ORG. for expenditure exceeding Rs. 5 lakh(As

applicable)

12. Approval of SEMO/ CONCERNED SPECIALIST for unlisted

procedure.(as applicable) 62

63

63

64

HOSPITAL BILL SUBMISSION

COMMON ASPECTS: ALL BILLS

� Referral Original & Endorsed by Service

Spl Validity Pd (30 days) Emergency Referral Part I signed by OIC & MO, Part II completed & signed by Spl of Hosp

� ECHS Card / Regn Slip Photocopy attested by OIC Validity Pd of Regn Slip (60 days)

� Discharge Summary

To be in original Any deviation from referral to be justified by Spl of Hosp Hosp beyond 12 days in Non-Pkg cases, approval from SEMO

Bills

Final and Detailed bill in dupl (signed by patient and Accts Offr of

hosp) Each item to be prefixed by CGHS / AIIMS code No and rates Affix revenue stamps for amt >Rs 5,000.00

EMPANELLED HOSPITAL BILLS

LISTED PROCEDURE � Approval of CFA where required

� CFA � Request for approval as per

performa (Appx A) to be

submitted to SEMO through

polyclinic by concerned hospital

UNLISTED PROCEDURE � Approval of CFA where required � CFA

� Request for approval as per

performa to be submitted to

SEMO through polyclinic by

concerned hospital

64

65

65

66 LISTED PROCEDURES- CFA

Ser No Treatment / Procedure Approving Auth

1. Treatment proc > Rs 5 lakhs Central Org ECHS

2. Angioplasty with 2 coronary stents Not reqd

3. Angioplasty with >2 coronary stents SEMO

4. Angioplasty with 2 medicated stents Cl Spl or Sr Advsr

5 Angioplasty with >2 medicated stents Sr Advsr (Card) or Conslt / Sr Conslt

(Med)

6. Bi ventricular pacemaker Conslt / Sr Conslt (Med)

7. AICD combo device Sr Conslt (Med)

8. Maj test or proc not mentioned in referral MO concerned Polyclinic

UNLISTED PROCEDURES- CFA

Ser No Treatment / Procedure Approving Auth

1. Treatment proc < Rs 1 lakh SEMO/PMO/CMO

2. Treatment proc - Rs 2-4 lakhs Classified specialists

3. Treatment proc > Rs 4 lakhs Senior adviser 66

67

NON-EMPANELLED HOSPITAL/ INDIVIDUAL BILL

Treatment Emergency

at AIIMS Admission

Dialysis in Unlisted essential

Non Procedure

Empanelled

Medicines prescribed

on discharge from

hospital

67

68 TREATMENT AT AIIMS

If Advance taken, photocopy of ECHS Cell Stn HQ letter under which same paid

to AIIMS

Doc’s prescription of med to be purchased from outside

Reimbursement cert for Outdoor / Indoor patient issued by AIIMS (Cert A/B)

Detailed day wise breakdown of Final Bill and Summary of Medicine Bill in

duplicate duly stamped and signed by the hosp & the patient

Reports of all tests / investigations and stent pouch to be att where applicable

Application from individual to include - Brief details of case and expenditure incurred includes amt of advance taken - Tele No and home address

- Bankers address and acct No

Contingent bill duly completed & signed with revenue stamp

DIALYSIS AT NON EMPANELLED HOSP

Cert from Dialysis centre giving the period of dialysis with date

Bills of Dialysis centre in duplicate and any other related document

Reports of all tests / investigations to be attached where applicable

Application from individual to include - Brief details of case and expenditure incurred - Tele No and home address

- Bankers address and acct No

Contingent bill duly completed & signed with revenue stamp 68

69 UNLISTED ESSENTIAL PROCEDURE

Certificate from Service Specialist that “delay in test / proc likely to cause loss of

life / limb / serious deterioration in patient’s condition”

Cert from OIC Polyclinic that “test / proc is NA in Service / Empanelled / Govt

Hosp” and clear endorsement of circumstances of the case in EIR

Approval from SEMO for a/m tests / proc Bills in duplicate and any other related document Reports of all tests / investigations to be attached where applicable Application from individual to include

- Brief details of case and expenditure incurred - Tele No and home address

- Bankers address and acct No

Contingent bill duly completed & signed with revenue stamp

MEDICINES BILLS

Permitted only for u/m specialty treatment when prescribed to be taken immediately on discharge from hospital

- Post operative cases of major cardiac surgery / interventional cardiology - Oncology

- Post operative organ transplant, joint replacement & neuro surgery / neuro cases (

Auth – Central Org letter No B/41773/AG/ECHS date 25th

May 04)

Photocopy of referral, hosp discharge summary / OPD card as applicable Cert from OIC Med Store that “medicine is NA” Bills in duplicate and any other related documents

Application from individual to include - Brief details of case and expenditure incurred

- Tele No and home address

- Bankers address and acct No

Contingent bill duly completed & signed with revenue stamp

69

70

EMERGENCY ADMISSION

Information of Admission by treating hosp within 48 hr of emergency admission

– Emergency Info Report initiated by nearest polyclinic

Detailed day wise breakdown of Final Bill and Summary of Medicine Bill in dupl

duly stamped and signed by the hosp & the patient

Reports of all tests / investigations and stent pouch to be att where applicable

Application from individual to include

- Brief details of case and expenditure incurred - Tele No and home address

- Bankers address and acct No

Contingent bill duly completed & signed with revenue stamp

70

71

MOVEMENT OF BILLS

Hospital Individual

Polyclinic

BPA

Regional

Centre

Soft Copy Hard Copy

CFA

PAYMENT 71

72 ECHS BILL PROCESSING & SETTLEMENT

72

73

73

74

74