CGHS OM on Empanelment of Fresh hospitals under CGHS 22-12-25.pdf
F.No.5-34/CGHS/HEC(HQ)/2025 I/3826866/2025
F.No.5-34/CGHS/HEC(HQ)/2025
(Comp No. - 8375449)
भारत सरकार
ӡाӕ एवं प̬रवार कҠाण मंГालय
कͣ бीय सरकार ӡाӕ योजना महािनदेशालय
कͣ. स. ӡा.यो. भवन, िदҢी
िदनांक –22.12.2025
कायालय ͔ ϖापन/OFFICE MEMORANDUM
Subject: Fresh Empanelment of Private Hospitals under CGHS
In reference to the subject cited above and the notified applicable package
rates vide Office Memorandum (OM) F.No. 5-16/CGHS(HQ)/HEC/2024 (Part–
I) dated 03.10.2025, applications are hereby invited from Health Care
Organisations (HCOs) from both existing empanelled HCOs and new
applicants for empanelment under CGHS for treatment of CGHS Beneficiaries
as per the terms and conditions stipulated below:
1. Invitation for Applications: HCOs that satisfy the prescribed eligibility
criteria, expressly agree to the terms and conditions stipulated in the
Memorandum of Agreement (MoA) (Annexure–A), and unconditionally
accept the notified CGHS package rates shall be considered for
empanelment. The offer for empanelment is open to HCOs located in
cities already covered under CGHS, as well as those situated within the
municipal limits of district headquarters across India.
2. Mandatory Compliance for Existing HCOs (Partial Modification to
OM dated 03.10.2025):
a. In partial modification of para 4(c) of the Office Memorandum F.No.
5-16/CGHS(HQ)/HEC/2024 (Part–I) dated 03.10.2025, the
deadline for execution of the MoA for existing hospitals shall be on
or before 31st March 2026.
b. All currently empanelled Health Care Organisations (HCOs) are
hereby informed that they are required to submit fresh applications,
along with the prescribed application fee. Upon being found eligible
and approved by the HEC Committee, they shall execute the
Memorandum of Agreement (MoA) in accordance with the revised
terms and conditions.
c. Failure to comply with this requirement of fresh application will
result in the de-empanelment of the concerned HCOs, effective
from 1st April 2026.
3. CGHS Rates and Application Submission:
a. The CGHS rates applicable to various procedures and treatments
are available for download on the CGHS website:
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b. Applications from eligible hospitals (Annexure – B) must be
submitted through the dedicated portal: https://hem.nha.gov.in/.
Applicants should follow the steps detailed in Annexure C for
submission.
4. Structure of Differential Rates: Differential CGHS Rates are based on
accreditation status, hospital type, city classification, and Ward
entitlement of CGHS Beneficiary:
a. Accreditation Status: For Non-NABH / Non-NABL HCOs, package
rates shall be 15% lower than those applicable to NABH/NABL
accredited HCOs. (NABL stands for National Accreditation Board for
Testing and Calibration of Laboratories).
b. Super Speciality Hospitals: Rates for Super Speciality Hospitals
shall be 15% higher than those applicable to NABH-accredited
hospitals for the corresponding super specialities within the same city
category.
c. City Classification: Differential rates apply based on city tiers: i.
HCOs in Y (Tier-II) cities shall receive rates that are 10% lower than X
(Tier-I) city rates. ii. HCOs in Z (Tier-III) cities shall receive rates that
are 20% lower than X (Tier-I) city rates. iii. Y-Tier rates shall also be
applicable to HCOs located in the North-East Region, the Union
Territory of Jammu & Kashmir, and Ladakh.
d. Ward Entitlement Adjustment: subject to the provisions contained
in point (4.e.) below, revised package rates are notified for the semi
private ward. i. For the General ward, a 5% decrease in the applicable
rates will apply. ii. For the Private ward, a 5% increase on the
admissible claim amount will apply.
e. Uniform Rates: Rates for consultations, radiotherapy,
investigations, day-care procedures, and minor non-admission
procedures shall remain uniform across all wards, regardless of
entitlement.
f. Cancer Treatment: Existing CGHS rules and rates for cancer
surgeries shall continue to apply. Revised rates will, however, apply to
chemotherapy, investigations, and radiotherapy.
5. A fresh Performance Security, in the form of a Bank Guarantee issued
by any Scheduled Commercial Bank (as per the format at Annexure–D),
shall be submitted prior to empanelment. The Bank Guarantee shall
have a validity of 42 months and shall be furnished for the amount
applicable to the respective HCO and city category. In case the
Empanelled HCO is re-applying for empanelment, the Existing
Performance Security shall be released only upon submission of the
fresh Bank Guarantee. It is further clarified that top-up or
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enhancement of an existing Performance Bank Guarantee will not be
permitted.
6. The duly signed Memorandum of Agreement (MoA) and the Hospital
Policy for CGHS beneficiaries shall be submitted to the concerned
Additional Director of the City along with the Performance Security to
complete the empanelment process. (As defined in Table 4 of Clause
13.2 of Annexure A)
7. This issues with the approval of the competent authority.
-sd-
(Dr. Satheesh Y.H.)
Director CGHS
Enclosures:
1)Hospital Empanelment Document
2)Annexure A – Draft Memorandum of Agreement with Annexures
Annexure A.I – Admissible and Non-Admissible Items (Billing Guidelines)
Annexure A.II – Draft Format – Annual Report (Hospital)
Annexure A.III – Definition, Scope and Framework for Addressing Frauds
Annexure A.IV – Acronyms
Annexure A.V – Undertaking (Format)
Annexure A.VI – OPD undertaking and IPD Verification undertaking
Annexure A.VII – Summary of Tables and Flow Charts
Annexure A.VIII – Super Speciality Hospitals
Annexure B – Eligibility criteria for empanelment
Annexure C – Empanelment Procedure
Annexure D – Format for Performance Security
Annexure E – Draft Format - Hospital Policy for CGHS beneficiaries
To:
1) All empanelled Health Care Organisations through the CGHS website.
2) Addl. Director, CGHS(HQ)/ Addl. DDG(CGHS)/ Addl. Directors, CGHS
of Cities / Zone.
3) All CGHS Wellness Centres through the concerned AD, CGHS, with the
instruction to publicise through the Notice Board.
4) MCTC, CGHS with the request to upload the document on the CGHS
Website (www.cghs.mohfw.gov.in).
5) LACs/ ZACs through Addl. Directors, CGHS.
Copy of Information to:
1) PPS to Secretary (H&FW), MoHFW
2) PPS to AS&DG, CGHS
3) PPS to JS (MoHFW), CGHS
(Dr. Satheesh Y.H.)
Director CGHS
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F.No.5-34/CGHS/HEC(HQ)/2025 I/3826866/2025
EMPANELMENT OF PRIVATE HOSPITAL, EXCLUSIVE CANCER
HOSPITALS/SINGLE SPECIALTY HOSPITALS/EYE HOSPITALS/DENTAL
CLINICS/DIALYSIS CENTRES/CHEMOTHERAPY CENTRES, DIAGNOSTIC
LABORATORIES & IMAGING CENTRES UNDER CGHS 2025
Chapter I-CGHS OVERVIEW
1. CGHS Background and Scheme Overview
(i.) CGHS is a comprehensive contributory Health Scheme started in 1954
and caters to the healthcare needs of eligible beneficiaries covering all
four pillars of democratic set up in India namely Legislature, Judiciary,
Executive and Press. Its beneficiaries include serving/retired Central
Government employees, their dependents, Ex-Vice Presidents and their
families, Ex-Governors and Lt. Governors and their families, sitting and
former Members of Parliament, freedom fighters, Sitting Judges of
Supreme Court and High Court of Delhi and former Judges of Supreme
Court and High Courts and such other beneficiaries as notified by the
Government under the Scheme. CGHS is the model Health care facility
provider and is unique of its kind due to the large volume of beneficiary
base, and open-ended generous approach of providing comprehensive
health care.
(ii.) Presently approximately 42 lakh beneficiaries are covered by CGHS in 81
cities all over India and the endeavour is to include more cities to improve
the accessibility of the services.
Table 1- CGHS Covered cities/towns
1. Agra 22. Cuttack 43. Jodhpur 64. Pune
2. Agartala 23. Darbhanga 44. Kannur 65. Raipur
3. Ahmedabad 24. Dhanbad 45. Kanpur 66. Ranchi
4. Aizawl 25. Dehradun 46. Kohima 67. Rajahmundray
5. Ajmer 26.Delhi & NCR* 47. Kolkata ( including
Ishapore)
68. Saharanpur
6. Aligarh 27. Dibrugarh 48. Kochi 69. Shillong 7.Prayagraj(Allahabad) 28. Gandhinagar 49. Kota 70. Shimla
8. Ambala 29. Gangtok 50. Kozhikode (Calicut)
71. Silchar
9. Amritsar 30. Gaya 51. Lucknow 72. Siliguri (including Jalpaiguri)
10. Baghpat 31. Gorakhpur 52. Meerut 73. Sonipat 11. Bengaluru 32. Guwahati 53. Moradabad 74. Srinagar 12. Bareilly 33. Guntur 54. Mumbai 75. Thiruvanantpuram
13. Berhampur 34. Gwalior 55. Muzaffarpur
76. Varanasi (Banaras)
14.Bhopal 35. Hyderabad 56. Mysuru 77. Tiruchirappalli (Trichy)
15. Bhubaneshwar 36. Imphal 57. Nagpur 78. Tirunelveli
| 16. Chandrapur | 37. Indore | 58. Nashik | 79. Vadodara |
|---|
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F.No.5-34/CGHS/HEC(HQ)/2025 I/3826866/2025 17. Chandigarh 38. Itanagar 59. Nellore 80. Vijayawada
18. Chhatrapati Sambhaji Nagar (Aurangabad)
39. Jabalpur 60. Panaji 81. Vishakapatnam
19. Chennai 40. Jaipur 61.Panchkula
20. Chhapra 41.Jalandhar 62. Patna
| 21. Coimbatore | 42. Jammu | 63. Puducherry |
|---|
* Delhi NCR includes Delhi, Faridabad, Ghaziabad, Greater Noida, Noida, Gurgaon, Indirapuram, Sahibabad
(iii.) CGHS beneficiaries are classified based on their eligibility, with distinct card colour codes. Details as per the Table 2 below
Table 2. Beneficiaries, eligibility for credit and type of CGHS Cards:
Sr. No
Beneficiary category including beneficiaries from other cities.
Eligibility for Credit/ Cashless Treatment
Card
Identification
1 Pensioners holding CGHS Card, Ex-Members of Parliament, Freedom Fighters
Yes Green strip
2 Sitting Members of Parliament Yes Red strip
3 Serving CGHS/DGHS/ Ministry of H&FW Employees and their dependants
Yes Blue Strip
4 Serving Employees and their dependents of all other Departments having CGHS card (blue stripe) (other than CGHS/DGHS/Ministry of H&FW)
Credit to be given in emergency cases. Before the discharge a credit letter may be obtained from HOO/HOD of Beneficiary department. The letter shall certify the entitlement of beneficiary or beneficiary dependent along with details of submission of bill and payment process
Blue Strip
5 Pensioners of autonomous bodies
No Yellow Strip
| 6 | Pensioners of Air India | Yes. But BCA as decided by concerned authorities. Currently the BCA is UTIITSL | Orange Strip |
|---|
(iv). The CGHS card is valid across India, allowing CGHS beneficiaries and their dependents, including those from other cities, to receive treatment (OPD/IPD) at
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empanelled HCOs at CGHS rates. The hospital/ diagnostic centres shall agree to
charge CGHS rates to all Central Government Employees and Central government
pensioners on production of valid I-Card / Documentary proof even though
treatment is not sought as CGHS beneficiary.
2. CGHS Organogram/Contact Details:
(i.) The Central Government Health Scheme (CGHS) operates under the
Ministry of Health & Family Welfare (MoHFW), Government of India,
with a structured hierarchy. A detailed table containing CGHS contact
details, including headquarters, regional offices is mentioned in Table 3,
Table 4 and Table 5 for reference. This table provides city-wise contact
numbers and addresses of key CGHS offices. For the latest information,
refer to the official CGHS website: https://cghs.mohfw.gov.in/
Table 3 Contact Details of Directorate Of CGHS
Sl. No
Official post Address Contact Number
Official E-mail ID
1 AS & DG (Addl. Secretary and
Director
General)
Kartavya Bhavan 1 Mansingh
Road,New Delhi 110001
011-
23063693, 011-
23063687
asfr-mohfw@nic.in
2 Director, CGHS Room 101,CGHS Bhawan, Sector
13, R K Puram,
New Delhi
110066
011-
20863436
director
cghs@cghs.nic.in
| 3 | Additional Deputy Director General (ADDG) | Room 302, CGHS Bhawan, Sector 13, R K Puram, New Delhi - 110066 | 011- 20861930 | addghq.dl@cghs.nic.in |
|---|
Table 4. Contact Details of Office of Additional Director(HQ), Delhi & NCR
Sl.No. Official Post Address Contact Number
Official e-mail ID
| 1 | Additional Director (HQ) | CGHS Bhawan, Sector - 13 R. K. Puram New Delhi - 110066 | 011- 20863431 | adhq.dl@cghs.nic.in |
|---|
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2 Joint Director, Grievance (HQ)
Room 209,CGHS Bhawan, Sector - 13
R. K. Puram New Delhi - 110069
011-
20863450
jdgrhq.dl@cghs.nic.in
| 3 | CMO-HEC | Room 209 ,CGHS Bhawan, Sector - 13 R. K. Puram New Delhi - 110069 | 011- 20863450 | cmo-hec.dl@cghs.nic.in |
|---|
3. Administrative Divisions for Empanelment of Hospitals in District Headquarters Not Under CGHS Coverage
(i.) To ensure accessibility to quality healthcare for Central Government employees and pensioners in district headquarters not covered under CGHS, the government has established Administrative Divisions for hospital empanelment. These divisions categorize district headquarters based on regional control and administrative supervision. Details in Table 5 below. Only the hospitals located within the municipal limits of the district headquarters and fulfil the eligibility criteria shall be considered for empanelment.
Table 5 - Administrative Divisions
Sl.N o.
Administrative City & Districts Covered
Office Address of Additional Directors Outside Delhi
Contact Details Contact No. & email ID
1 Ahmedabad
(All the districts of
Gujarat, and Diu)
2 Bengaluru
(All the districts of
Karnataka)
3 Bhopal
(All Districts except
Jabalpur division of MP)
O/o Additional Director CGHS,2nd Floor, S. R. House, Opp. Mount Carmel School, Ashram Road, Ahmedabad 380009, Gujarat
O/o Additional Director CGHS Bangalore, 3rd Floor, E Wing, Kendriya Sadan, Koramangala, Bangalore 560034, Karnataka
O/o the Additional Director, CGHS Bhopal, Plot No. 23, 3rd Floor, Arera Hills, Near
Meteorological Department, Bhopal (M.P) - 462027
079-26587798,
ad.ah@cghs.nic.in
080-25538300,
cghsbng-ka@nic.in ad.ba@cghs.nic.in
0755 – 2550265, adcghs.bpl@cghs.nic.i n
| 4 | Bhuvaneshwar (All the districts of Odisha) | O/o Additional Director, CGHS Bhubaneswar, Unit IV, Old AG Colony, Bhubaneswar-751001, Odisha | 0674-2500127, ad.bh@cghs.nic.in |
|---|
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5 Chandigarh
(All the districts of
Punjab, Haryana,
Himachal Pradesh,
and districts of UT of Jammu & Kashmir
and Ladakh)
6 Chennai
(All the districts of
Tamil Nadu and
Puducherry and
Karaikal)
7 Dehradun
(All the districts of
Uttarakhand)
8 Delhi &NCR(All districts of New Delhi and NCR)
9 Guwahati
(All the districts of
Assam, Sikkim,
Mizoram, Arunachal
Pradesh, and
Nagaland)
10 Hyderabad
(All the districts of
Telangana, Andhra
Pradesh, and Yanam) 11 Jabalpur
(Districts in Jabalpur division of MP)
12 Jaipur
(All the districts of
Rajasthan)
13 Kanpur
(Districts of
Bundelkhand, UP)
O/o Additional Director CGHS Chandigarh, Room No. 427, 4th floor, Kendriya Sadan, Sector 9A, Chandigarh-160009
O/o Additional Director CGHS Chennai, E-2 C, Rajaji Bhavan, Besant Nagar, Chennai
600090
O/o Additional Director CGHS Dehradun,19-20, Navyug Enclave, Phase-III, Milan Vihar, GMS Road Dehradun CGHS Bhawan, Sector - 13 R. K. Puram New Delhi - 110066
O/o The Additional Director CGHS Guwahati, GMSD Complex, A.K. Azad Road, Gopinath Nagar Guwahati 781016, Assam
O/o Additional Director CGHS Hyderabad, Kendriya Swasthya Bhavan, Begumpet, Hyderabad -500016
O/o Additional Director, CGHS Jabalpur, 1544/A, First Floor, Napier Town, Home Science College Road, Jabalpur
482001, Madhya Pradesh O/o Additional Director CGHS Jaipur, Kendriya Sadan Parisar, Block-B, Ground Floor, Sector-10, Vidyadhar Nagar, Jaipur-302039,
Rajasthan
O/o Additional Director CGHS Kanpur, Plot No. 8-11, Ratan Lal Nagar, Kanpur-208022, Uttar Pradesh
0172 -2740716,
adchd@cghs.nic.in
044-23458400,
cghs-chennai@nic.in
0135-2979800,
jd.dd@cghs.nic.in
011-20863431
adhq.dl@cghs.nic.in
0361-2492698,
cghs.guwahati@gov.in
040-27902316,
adcghshyd@nic.in
0761-2405205,
cghsjab-mp@nic.in
0141-2235110,
ad.jp@cghs.nic.in
0512-2283499,
ad.kn@cghs.nic.in
| 14 | Kolkata (All the districts of West Bengal and Andaman Nicobar) | O/o the Additional Director, CGHS Kolkata, 6, Esplanade East (Ground Floor), Kolkata - 700069 | 033-22103922, ad.ko@cghs.nic.in |
|---|
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15 Lucknow
(Districts of central
UP)
16 Meerut
(Districts of Western
UP)
17 Mumbai
(Districts in Konkan
and Nashik division of Maharashtra and Goa, Daman, Dadra and
Nagar Haveli)
18 Nagpur
(Districts in Nagpur
and Amravati
divisions of
Maharashtra and
Districts of
Chhattisgarh)
19 Patna
(All the districts of
Bihar)
20 Prayagraj
(Districts of Eastern
UP)
21 Pune
(Districts in Pune and Aurangabad division
of Maharashtra)
22 Ranchi
(All the districts of
Jharkhand)
23 Shillong
(All the districts of
Meghalaya, Tripura
and Manipur)
O/o Additional Director CGHS Lucknow, B-114/115, Vibhuti Khand, Gomti Nagar, Lucknow
- 226010, Uttar Pradesh O/o Additional Director CGHS Meerut, Swasthya Bhawan, S K Road, Meerut-250002, Uttar Pradesh
O/o Additional Director CGHS Mumbai, Old CGO Building (Pratishtha Bhawan), Ground Floor, South Wing, 101, M.K. Road, New Marine Lines, Mumbai 400 020
O/o the Additional Director, CGHS, Swasthya Bhavan, Near T.V Tower Square, Seminary Hills, Nagpur - 440006, Maharashtra
O/o Additional Director CGHS Patna, 4th Floor, A Wing, GPOA Complex, Karpuri Thakur Sadan, Ashiana Digha Road, Patna-800025
O/o Additional Director CGHS Allahabad,2nd Floor, Sangam Place, Civil Lines, Allahabad (Prayagraj), Uttar Pradesh O/o Additional Director, CGHS Pune, Second Floor, Swasthya Sadan, Mukundnagar, Pune 411 037, Maharashtra
O/o Additional Director CGHS Ranchi, New A.G. Colony Doranda, Ranchi, Jharkhand O/o the Additional Director CGHS Shillong, Nongrim Hills, Shillong -793 003, Meghalaya
0522-2728989,
cghslko@nic.in
0121-2601426,
admeerut-cghs@nic.in
022-2018600,
ad.mum@cghs.nic.in
0712-2513723,
ad.ng@cghs.nic.in
0612-2565014,
ad.pa@cghs.nic.in
0532-2561310,
ad.al@cghs.nic.in
020-24262831,
ad.pu@cghs.nic.in
0651-2480147,
adcghs.ran
jhr@gov.in
0364-2520626,
ad.cghs-meg@gov.in
| 24 | Thiruvananthapuram (All the districts of Kerala and Mahe and Lakshadweep) | O/o of Additional Director CGHS Thiruvananthapuram, TC 25/1379(1) Charachira Road, Plamoodu Kowdiar PO Thiruvananthapuram-695003, Kerala | 0471-2449760, ad.tr@cghs.nic.in |
|---|
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4. Classification of Cities for Hospital Empanelment under CGHS
(i.) For the purpose of empanelment of hospitals, diagnostic centers,
and healthcare facilities under the Central Government Health
Scheme (CGHS) cities are classified into three categories: Tier 1, Tier
2, and Tier 3. This classification is based on HRA classification.
(change tier cities)
Table 6 – List of tier 1 and tier 2 cities
State/Union Territory
Tier 1
Category Cities
Tier 2 Category Cities
Andhra Pradesh & Telangana
Hyderabad Vijayawada, Warangal, Visakhapatnam, Guntur, Nellore
Assam Guwahati
Bihar Patna
Chandigarh Chandigarh
Chhattisgarh Raipur, Durg Bhilai Nagar Delhi Delhi
Goa Goa
Gujarat Ahmedabad Rajkot, Jamnagar, Vadodara, Surat, Bhavnagar
Haryana Gurgaon, Faridabad
Panchakula
Jammu & Kashmir
Srinagar, Jammu
Jharkhand Jamshedpur, Dhanbad, Ranchi, Bokaro Steel City
Karnataka Bengaluru Belgaum, Hubli-Dharwad, Mangalore, Mysore, Gulbarga
Kerala Kozhikode, Kochi, Thiruvananthapuram, Thrissur, Malappuram, Kannur, Kollam
Madhya Pradesh
Gwalior, Indore, Bhopal, Jabalpur, Ujjain
Maharashtra Greater Mumbai,
Pune
Nagpur, Aurangabad, Nashik, Amravati, Bhiwandi, Solapur, Kolhapur, Vasai-Virar, Malegaon, Nanded-Waghala, Sangli
Odisha Cuttack, Bhubaneswar, Raurkela Port Blair Port Blair (Andaman and Nicobar islands) Puducherry Puducherry
Punjab Amritsar, Jalandhar, and Jalandhar Cantonment, Ludhiana, Mohali (Sahibzada
Ajit Singh -SAS Nagar)
Rajasthan Jaipur, Jodhpur, Kota, Bikaner, Ajmer
| Tamil Nadu | Chennai | Coimbatore, Tiruchirappalli, Madurai, Erode, Salem, Tiruppur |
|---|
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Uttar Pradesh Noida, Ghaziabad
Lucknow, Kanpur, Agra, Allahabad (Prayagraj), Meerut, Varanasi, Bareilly, Moradabad, Aligarh, Gorakhpur, Saharanpur, Firozabad, Jhansi
Uttarakhand Dehradun
West Bengal Kolkata Asansol, Durgapur, Siliguri
| *All other cities and towns not classified under Tier 1 or Tier 2 are Tier 3 cities . |
|---|
Table 7 - Administrative City & Districts covered
Sl. No.
Administrative City & Districts Covered
Tier 1 Tier 2
1 Ahmedabad
(All the districts of Gujarat, and Diu) 2 Bengaluru
(All the districts of Karnataka)
Ahmedab ad
Bengalur u
Rajkot, Jamnagar,
Vadodara, Surat, Bhavnagar Belgaum, Hubli-Dharwad, Mangalore, Mysore,
Gulbarga
3 Bhopal
(All Districts except Jabalpur division of MP)
4 Bhuvaneshwar
(All the districts of Orissa)
5 Chandigarh
(All the districts of Punjab, Haryana, Himachal Pradesh, and districts of UT of Jammu & Kashmir and
Ladakh)
6 Chennai
(All the districts of Tamil Nadu and Puducherry and Karaikal)
7 Dehradun
(All the districts of Uttarakhand)
8 Guwahati
(All the districts of Assam, Sikkim, Mizoram, Arunachal Pradesh, and Nagaland)
Indore, Bhopal, Ujjain
Cuttack, Bhubaneswar, Raurkela
Srinagar, Jammu (*All the towns of UT of Jammu &
Kashmir and Ladakh
)Amritsar, Jalandhar, and
Jalandhar Cantonment,
Ludhiana, Mohali
(Sahibzada Ajit Singh -SAS
Nagar), Panchakula,
Chandigarh
Chennai Coimbatore, Tiruchirappalli, Madurai, Erode, Salem,
Tiruppur, Puducherry
Dehradun
Guwahati, *All the towns of Assam, Sikkim, Mizoram,
Arunachal Pradesh, and
Nagaland
9 Hyderabad
(All the districts of Telangana, Andhra Pradesh, and Yanam)
Hyderaba d
Vijayawada, Warangal, Visakhapatnam, Guntur, Nellore
| 10 | Jabalpur (Districts in Jabalpur division of MP) | Jabalpur |
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11 Jaipur
(All the districts of Rajasthan)
12 Kanpur
(Districts of Bundelkhand, UP)
13 Kolkata
(All the districts of West Bengal and Andaman Nicobar)
14 Lucknow
(Districts of central UP)
15 Meerut
(Districts of Western UP)
Jaipur, Jodhpur, Kota, Bikaner, Ajmer
Kanpur, Jhansi, Gwalior,
Kolkata Asansol, Durgapur, Siliguri, Port Blair
Lucknow, Agra, Bareilly, Gorakhpur,
Meerut, Moradabad, Aligarh, Saharanpur, Firozabad,
16 Mumbai
(Districts in Konkan and Nashik division of Maharashtra and Goa, Daman, Dadra and Nagar Haveli)
Greater Mumbai
Nashik, Goa, Sangli, Bhiwandi, Vasai-Virar
17 Nagpur
(Districts in Nagpur and Amravati divisions of Maharashtra and
Districts of Chhattisgarh)
18 Patna
(All the districts of Bihar)
19 Prayagraj
(Districts of Eastern UP)
20 Pune
(Districts in Pune and Aurangabad division of Maharashtra)
21 Ranchi
(All the districts of Jharkhand)
22 Shillong
(All the districts of Meghalaya,
Tripura and Manipur)
Nagpur, Raipur, Durg Bhilai Nagar, , Nanded-Waghala
Patna
Allahabad (Prayagraj), Varanasi,
Pune Aurangabad, Solapur, Kolhapur
Jamshedpur, Dhanbad, Ranchi, Bokaro Steel City
*All the towns of Meghalaya, Tripura and Manipur
| 23 | Thiruvananthapuram (All the districts of Kerala and Mahe and Lakshadweep) | Kozhikode, Kochi, Thiruvananthapuram, Thrissur, Malappuram, Kannur, Kollam |
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CGHS Referral System: All CGHS beneficiaries (in all CGHS Cities) shall be permitted for seeking OPD/IPD treatment at empanelled HCOs after being referred by any Medical Officer from any CGHS wellness Centre in India. Referrals are also valid at any of the HCO in any city. In emergency cases, HCO shall not insist for referral or endorsement from CGHS and shall provide cashless treatment including unlisted procedures/ investigations /implants to eligible beneficiaries based on the emergency certificate given by the treating specialist at empanelled hospital. Those eligible for credit shall be given credit. Various categories of referral are listed in
Table 8. Categories of Referrals
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| Referral Category | Definition (as per CGHS Guidelines) |
|---|---|
| e-Referral | The beneficiary will avail treatment at empanelled HCO after referral by CGHS Wellness Centre through the CGHS HMIS module. Only sign of Medical officer is mandatory and stamp is not mandatory |
| Manual Referral | Beneficiary may avail treatment along with manual referral document under the following circumstances 1. A referral issued by a CGHS Wellness Centre when the CGHS online module is unavailable (e.g., due to power or network or server outage etc.) 2. Permission issued by Office of Additional Director in case of In Patient only cards, Unlisted permissions,), or 3. When facility is obtained based on advice or referral issued by any Government specialist in accordance with CGHS rules/Guidelines. 4. Sign and Stamp of Medical officer / Concerned referral authority is mandatory for manual referrals |
| Non Referral | The beneficiary can avail treatment without referral under the following circumstances 1. Emergency admissions to a hospital. 2. Follow up consultations up to 5 more including cross consultations. 3. Essential Follow-up investigation/ Minor OPD procedures (Except CT, MRI, Nuclear scans ,OCT (eye), Physiotherapy and dental procedures ) as per the consultation /cross consultation advise and those not requiring admission and costing less than Rs 3000/-.These are to be availed in the same HCO where primary consultation was availed. 4. The patients above 70 years are eligible to avail direct consultation without prior permission from CGHS . 5. If treating physician advises any listed treatment or investigations during such consultation the same may be availed without any endorsement or permission or endorsement from CGHS or competent authority. . However Planned (non-emergency) unlisted procedures/investigations /implants require referral from CGHS or competent authorties. |
5. Table 9. Details on Frequently used terms
| S NO | Description | Details |
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1 Room Rent / Ward Charges
2 Nursing
Charges
3 Equipment Charges
4 Day Care Charges
Means all charges towards providing an environment to deliver care and shall comprise of but not limited to accommodation charges, nursing charges, registration charge, air bed, water bed, alpha bed , flowtron charges ,luxury tax, surcharge, air conditioning, facility Charges, HVAC charges, water & electricity charges, housekeeping charges, infection control/CSSD, biomedical waste management, portable/bedside/emergency service charges, laundry charges, patient identification band, bed sheet, patient gown, visitor passes, duty doctor charges, patient diet and dietician charges, any certificate charges, etc. It also includes attendant bed charges in case of private ward and above.
Shall comprise of but not limited to charges related to Medication Administration, IV cannulation, IM/IV injection, Ambulation (Mobilisation) of patient, Ryles tube feeding, Suction Charges, ICD/any catheter/bed sore care, oral care, tracheostomy care, personal hygiene, sponge bath, monitoring, health education, etc. Nursing charges are part of ward charges and hence cannot be charged separately or collected from the patient.
Charges towards C-arm, OT equipment, DVT pump, infusion pump, portable X-ray or any other machine charges or their rental charges are also part of room rent charges/surgical procedure. Hence, they are not payable separately.
“Day Care Charges” refer to the accommodation charges where in the patient is treated and monitored for up to 6–8 hours, typically in the emergency or casualty unit, chemo therapy ward. It includes components similar to ward charges. The rate is fixed at ₹1,500, irrespective of hospital, city, or accreditation status.
| 5 | ICU/CCU/ICC U/PICU/MICU / HDU/NICU / Isolation Charges | Shall include similar charges as applicable to providing care in a critical care unit or Isolation ward. ICU rate (Rs 5400/- ) is the same for all categories of ward entitlement and across all hospitals irrespective of tier of the city. The ICU charge includes monitoring charges ; it excludes ventilator charges (ventilator, if used, is billed separately as per CGHS rate). . |
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7 CGHS Package Rate
8 Blood Charges (PRBC/Whole
Blood/FFP/Cr
yoprecipitate/
SDP/RDP etc.)
9 Provision of Medicines
&
Consumables
Lump sum cost of inpatient treatment/daycare/diagnostic procedure for which a CGHS beneficiary has been permitted by the competent authority or for treatment under emergency from the time of admission to the time of discharge, including (but not limited to): (i) Registration charges (ii) Admission charges (iii) Accommodation charges including patient's diet (iv) Operation charges (v) Injection charges (vi) Dressing charges (vii) Doctor/consultant visit charges (viii) ICU/ICCU charges (ix) Monitoring charges (x) Transfusion charges and Blood processing charges (xi) Anaesthesia charges (xii) Operation theatre charges (xiii) Procedural charges/surgeon’s fee (xiv) Cost of surgical disposables and all sundries used during hospitalization (xv) Cost of medicines and consumables/disposables (xvi) Related routine and essential investigations (xvii) Physiotherapy charges etc. (xviii) Nursing care charges ,(xix) O2 charges , Ventilator charges as routinely required if any etc. In case a beneficiary is required to undertake multiple surgical procedures in one OT session, the procedure with highest rate shall be considered as the primary package and reimbursed at 100%, thereupon the 2nd (next highest rate) surgical procedure shall be reimbursed at 50% of package rate, 3rd and subsequent surgical procedures shall be reimbursed at 25% of the package rate.
Refers to Donor screening, Patient Screening and component or whole blood processing and preparation charges including /Blood Irradiation/Leuco Filtration etc
During treatment, HCOs must provide all necessary consumables, including surgical sundries and medications, from their pharmacy for both inpatients and OPD patients undergoing procedures like POP application, dilation and curettage, wound dressing, etc. within the package rate, fixed by the CGHS which includes the cost of all the items and will not ask the beneficiary or his/her attendant to purchase separately .HCOs are not allowed to charge for surgical sundries and can only collect payment for non
admissible items.
| 10 | Additional Stay Charges | No additional charge on account of an extended period of stay shall be allowed if that extension of stay is due to infection acquired as a consequence of a surgical procedure or due to any improper procedure/medical negligence and is not justified. |
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| 11 | Consultation fees | Consultation Charges of Rs 350/- and Rs 700/- are payable for specialist and super specialist consultations respectively in OPD including consultation in emergency / casualty room. However, the indoor consultations shall be payable at the rate of Rs 350/- for all indoor consultations for both superspecialist and specialist consultation. Outpatient consultations provided by Super Specialists holding DM/MCh /DNB SS qualifications shall be governed uniformly across all categories of empanelled hospitals, including both multispecialty and super specialty hospitals. The consultation fee shall remain the same irrespective of whether the consultant is in-house or a visiting specialist. The consultation fee is inclusive of the cost of examination consumables such as paper gloves, unsterile gloves, or examination gloves, if used during the examination of the patient. For Eye consultations, the fee shall also cover the cost of procedures such as Refraction, Auto Refraction, Non Contact Tonometry, and 90D Lens Examination (Fundus Examination). These shall not be charged separately. · Each consultation will be considered valid for a period of 7 days, provided it pertains to the same specialty. · An enhanced consultation fee of Rs. 700/- shall be applicable for outpatient psychiatry consultation. |
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Chapter 2: Empanelment of HCO
With a view to provide comprehensive health Care facilities to CGHS beneficiaries, CGHS is empanelling private hospitals, exclusive Eye hospitals / Centres, exclusive Dental Clinics, Cancer Hospitals/units, diagnostic laboratories and imaging centres The eligible private health Care Organizations seeking empanelment and having prescribed infrastructure and staff and willing to accept the rates of various treatment procedures/ investigations notified by CGHS and other conditions as detailed below and Memorandum of Agreement (MOA) may apply for the same.
1. Under the CGHS Empanelment Scheme 2025 the Multi-speciality Hospitals, Exclusive Cancer Hospitals/Super Specialty Hospitals/Exclusive Single Speciality Hospitals/Eye Hospitals/Dental centres/Dialysis Centres/Chemotherapy Centres , Diagnostic Laboratories & Imaging Centres accredited by National Accreditation Board for Hospitals and Health Care providers (NABH) or its equivalents such as Joint Commission International (JCI), ACHS (Australia), National Health Systems Resource Centre (NHSRC) or by any other accreditation body approved by International Society for Quality in Health Care (ISQua) shall be considered for empanelment under NABH category (for information on ISQUA Recognised Accreditation Bodies refer to https://ieea.ch/awards/) Even non- NABH accredited HCOs can also apply for empanelment under the NON- NABH category . However, entry level NABH accreditation or QCI recommendation is
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mandatory for empanelment with CGHS. These HCOs shall be empanelled at
NON-NABH/ NON NABL rates.
2. All Hospitals seeking empanelment under the super-speciality category
irrespective of the city shall compulsorily be fully accredited by NABH or its
equivalent bodies.
3. The Standalone Diagnostic Laboratories & Imaging Centres shall be
compulsory be accredited by NABL. However, for Tier III, North east states,
and Jammu and Kashmir even NON NABL laboratories but having entry level
NABL certification or QCI recommendation shall be empanelled subject to the
condition that full NABL accreditation shall be obtained within one year failing
which they shall be removed from empanelment.
4. NABH (or equivalent ) accredited Dialysis centres shall be empanelled under
NABH category .While those having entry level accreditation or QCI
recommendation shall be empanelled under NON NABH category.
5. Since currently , there are no NABH or its equivalent standards for Chemo
centres these centres shall be empanelled under NON NABH category subject
to the condition that they will obtain QCI recommendation within 6 months
failing which they shall be removed from the list of empanelled HCOs under
CGHS.
6. HCOs desirous of getting empanelled with CGHS shall pay the prescribed non
refundable application fee (Rs 25000/- for Super Speciality Hospitals and Rs
10000/- for other Hospitals and Rs 5000/- for Laboratory and diagnostic
centres , Eye Hospitals, Dental Centres, Chemo therapy Centres and Dialysis
centres ) online in bharat kosh .These HCOs shall mandatorily attend the pre
empanelment meeting to understand terms of MOA including the policies and
procedures of CGHS .Those accepting all the terms shall only be considered
for empanelment. CEO/head of facility of such HCO,s shall be registered on
User Management Portal (UMP portal- https://ump.pmjay.gov.in/) .
Subsequently the HCO apply for empanelment through hospital Engagement
Module (HEM portal) – hem.nha.gov.in).
7. After the application is approved by the empanelment committee, the
Healthcare Organization (HCO) must sign the Memorandum of Agreement
(MOA) (Annexure A) within specified time and submit the MOA along with
the duly signed hospital policy document (Annexure E) & the prescribed
Performance Bank Guarantee (PBG- valid for minimum of 42 months )
(Annexure D), to the office of the Additional Director of the respective city for
CGHS cities outside Delhi, or to the office of AD(HQ) for Delhi NCR. within 2
weeks from the date of approval of the application.The copies of are also to be
submitted in HEM Portal.
8. Differential rates shall be applicable to the HCOs empanelled under CGHS
depending on the NABH and NABL accreditation, Super speciality status of
the HCO and geographic location of HCO i.e. Tier I, Tier II .and Tier III cities.
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The HCOs having full NABH or NABL shall be entitled for NABH or NABL rates
respectively. If the laboratory services are included in the scope of full NABH
accreditation, then NABL rates are applicable to laboratory services and there
is no need to have separate NABL accreditation. Similarly, if the imaging
services are part of scope of NABL accreditation, NABH rates are applicable
for imaging services and there is no need to have separate NABH accreditation.
The hospitals empanelled under super speciality category shall meet all the
requisite criteria and are entitled for super speciality rates.
9. It is the HCO responsibility to have valid accreditation certificates and also
uploading the same in HEM portal for approval.
10. The Healthcare Organization (HCO) will be empanelled for a period of
three years, covering all available facilities (OPD and IPD). There will be no
empanelment for selected services. All services (OPD and IPD) must be
provided at CGHS rates, regardless of whether the facility is outsourced or in
house. If a hospital adds new facilities or services, it must inform CGHS and
provide these services to beneficiaries at CGHS-approved rates and guidelines.
11. There will be no discrimination towards CGHS or any Central
Government beneficiaries when providing treatment. In fact, they will be given
priority.
12. CGHS beneficiaries cannot be denied consultation or treatment by any
consultant, whether in-house or visiting. They have the right to access
treatment at all available facilities, including outsourced ones, and from any
in-house or visiting consultant, at CGHS rates. If a facility is available at the
hospital but not offered to CGHS beneficiaries, the hospital will be removed
from the CGHS panel.
13. The beneficiaries are entitled for various kinds of ward based on their
basic pay or level of pay as summarized in Table 9
Table 10 -The various categories of wards
S.
Categories Description Room No
Charges
1 General Ward
General ward is defined as a hall / Room that
Rs 1500
accommodates four to ten patients.
| 2 | 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. 2-way IP based nurse call system and Room has to be Air conditioned | Rs 3000 |
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| 3 | Private Ward | Private ward is defined as a hospital room where a single patient is accommodated and which has an attached toilet (lavatory and bath). The room should have furnishings like wardrobe, dressing table, bed-side table, sofa set, etc. as well as a bed for the attendant. The room has to be air conditioned. 2-way IP based nurse call system. | Rs 4500 |
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14. Beneficiaries must be provided with the wards they are entitled to. No
patient shall be denied treatment due to the nonavailability of the entitled
category of ward. If the entitled category is not available, treatment may be
provided in a higher-category ward until the entitled ward becomes available,
and the HCO shall charge at the entitled rate, even if the treatment was given
in a higher-category ward. Under no circumstances is treatment in a lower
than-entitled category ward allowed.
15. HCO’s shall agree to abide by CGHS rates, guidelines or any other law
as applicable to HCO’s. HCO shall also mandatorily cooperate with health
authorities i.e. Central / State in times of Calamities (Natural/Man-Made),
disasters, epidemics, pandemics etc.
16. As Health Facility Registration ID (HFR ID) is mandatory to onboard on
HEM portal , all HCOs are mandatorily to obtain their Health Facility
Registry (HFR) ID ie register on ABDM prior to submitting the empanelment
application. The HFR ID can be generated through the official portal at
https://facility.ndhm.gov.in/. The HCO are encouraged to attain ABDM M3
compliance as early as possible from the date of empanelment. HCOs that
are already M3 compliant at the time of application shall be eligible for 20%
reduction in the Performance Bank Guarantee (PBG) amount payable . HCOs
that achieve M3 compliance shall be eligible for a refund of 20% of the PBG
amount.
17. The Applicant Health care Organization must enter details of all
available facilities and investigations including those of outsourced facilities.
The HCO shall also upload under hospital tariff card with schedule of charges
the hospital rates for general public for all treatment procedures /
investigations/ facilities available in excel format. They must certify that they
will adhere to CGHS rates and that the rates charged to CGHS beneficiaries
will not exceed those charged to non-CGHS patients or the general public.
Therefore, the applicable rates shall be the CGHS rates or the hospital’s actual
rates, whichever is lower.
18. The qualifications, Health Care Professional Registration ID (HPR ID
to be created under ABDM), Medical Council Registration Number and Mobile
of all consultant are to be entered mandatorily in the HEM portal . The details
of even the visiting consultants in all departments shall be provided. The copy
of the list also to be uploaded in the HEM portal under Consultant List with
Speciality.
19. The Healthcare Organization (HCO) shall mandatorily register as a
Convergence Partner on the “consumerhelpline.gov.in” portal at the time of
application, enabling consumer complaints to be addressed directly through
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the Consumer Helpline system.The proof to be submitted manually and also
upload to the HEM portal.
20. e-Medical / e-Ayush Visa Compliance: Every HCO empanelled under
CGHS shall also register on the Government of India’s IVFRT (Immigration,
Visa, Foreigners Registration & Tracking) (portal at
http://indianfrro.gov.in/frro/medicalvaluetravel) at the time of application
enabling to generate and issue all medical-treatment invitation letters for
foreign nationals exclusively through this portal, ensuring the correctness of
every data field so that Indian Missions and FRRO/FRO offices can verify the
invitation online before granting an e-Medical or e-Ayush Visa, and comply in
full with the Standard Operating Procedure set out in Ministry of Home Affairs
Letter No. 25022/46/2022-F.I dated 14 June 2024; any failure to register or
to follow the IVFRT workflow shall constitute a material breach of this MOA
attracting penalties.
21. Applicant Health care Organizations must have EMR/ EHR as per the
standards notified by Ministry of Health & Family Welfare
22. Empanelled Health Care Organisations (HCOs) shall strictly refrain
from any unethical, fraudulent, or discriminatory practices—such as inflated
billing beyond CGHS package rates, unbundling procedures to increase costs,
unjustified refusal of treatment to entitled beneficiaries, submission of false
or altered documents, forgery, or discriminatory behaviour by staff—and any
such violation shall invite strict penal action including suspension or removal
from the CGHS panel, recovery of overcharged amounts, and legal proceedings
as per applicable laws.
23. The diagnostic and imaging reports shall have a unique identifier
number which shall be verifiable.
24. The HCOs are advised to adhere to Standard Treatment Guidelines and
Antibiotic policy.
a) Prescriptions issued by Specialists of empanelled hospitals in respect of
medicines must also mention the generic name of the drug and shall not
insist on any specific brand to the patients.
b) Specialists of empanelled hospitals shall not prescribe medicines of
equivalent value or items that come under the category of nutritional
substances/food supplements.
c) The reports indicating resistance to routine antibiotics shall be examined
by the designated antibiotic committee. The hospital must adhere to its
antibiotic policy and ensure the judicious use of high-end antibiotics,
including antifungal agents. These should be used primarily based on the
recommendations of a designated committee. Any misuse of antibiotics will
be treated as fraudulent activity.
d) Use of IV Albumin should be adhered to standard prescribed guidelines
25. Practice Evidence based Medicine: Medicine is a branch of science and
it should be practiced scientifically only.
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a) Investigations and treatment provided to the patient must be based on the
differential diagnosis and provisional diagnosis arrived at on the basis of
complaints, history of the patient and clinical examination findings which
must be clearly documented.
b) Investigations which are repeated must add value to the treatment or
commensurate with the treatment.
c) Well established form of therapy should be used. Procedure/ drug on trial
should not be used.
d) The practice of advising costly drugs / treatment procedure should be
avoided when a cheaper and equally effective alternate therapy is available
e) If a new or newer form of drug / procedure is used, it should be specifically
indicated for that particular patient because of the decisive superiority over
the existing drug / procedure
f) Tests / Medications /Procedure irrelevant Or Not in Line with Diagnosis
including recommended Dosage Is Not Payable
26. CGHS will provide chemotherapy medicines and certain other
injections wherever possible, and the empanelled HCOs must accept and
administer these medicines to CGHS beneficiaries, regardless of the brand.
27. The HCO shall charge for any other costly drugs/consumables or
unlisted Implants based on the GST purchase invoice from the external
vendor, reflecting the hospital's actual purchase cost. HCO shall enclose GST
invoice (from external vendor ), outer pouch and sticker. HCO shall also
enclose a letter from the treating doctor that a particular implant (detailed
specification of implant like make, size, material made of etc is to be
mentioned) is used in the patient and it is functioning satisfactorily.
28. The hospital administrative authorities not below the rank of Director
shall attend without fail all the meetings convened by CGHS in regard to
CGHS policies. The HCO will be primarily responsible for ensuring that all
relevant staff members are well-trained in CGHS guidelines, rates, and
policies. This includes nodal officers, managers on duty across all shifts, staff
working at the CGHS kiosk, front desk, and reception—both during regular
hours and evening/night shifts—as well as billing officials. The HCO is
responsible for updating the name designation and contact details of CEO
/Signing Authority, Nodal officers, MODs etc whenever there is change.
29. The hospital will issue discharge medications for up to 7 days and bill
towards the same will be enclosed along with the credit bill to be submitted to
NHA in case beneficiaries eligible for cashless facility subject to following
conditions
(i.) Only the essential medicines in generic form for continuity of treatment
will be issued by the hospital on request of the beneficiary.
(ii.) No nutritional supplements, tonic, cough syrup, vitamins; injections
will be issued by the hospitals. These are not allowed.
(iii.) No non drug items/equipment/appliances will be issued.
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(iv.) The total cost of such medicines issued by the hospital must not exceed
Rs.2000/- in any case. In case of beneficiaries where the treatment is
provided on a cash basis, the amount will be collected towards the
discharge medications as mentioned above. Beneficiary will claim from
his/her department.
30. No advance payment/deposit shall be collected from beneficiaries
eligible for cashless.
31. During treatment, HCOs must provide all necessary consumables,
including surgical sundries and medications, from their pharmacy for both
inpatients and OPD patients undergoing procedures like POP application,
dilation and curettage, wound dressing, etc. HCOs are not allowed to charge
for surgical sundries.
32. The HCO shall not levy a separate registration fee, as all CGHS
beneficiaries are considered deemed registered with the empanelled HCO.
33. The HCO shall provide discharge summaries, investigation reports, or
image films/CDs/DVDs and shall not charge any fees for issuing discharge
summaries, investigation reports, or image films/CDs/DVDs.
34. The applicant healthcare organization must have the capability to
submit all claims and bills electronically to the NHA. It must also maintain
dedicated equipment, software, and connectivity for such submissions.
Additionally, the HCO must have digital provisions for geotagging, Aadhaar
enabled biometric services, and any other technological requirements
necessary for verifying and processing CGHS beneficiaries' claims. All
documents, including bills, ICPs, reports, and invoices, must be submitted in
a machine-readable format, such as OCR-enabled PDFs/Excel formats. The
HCO shall periodically reconcile claim settlements, including pending claims
35. The HCO shall submit its Hospital policy for CGHS patients, duly
signed by the CEO / head of the facility /signing Authority. (authorized by the
board). It is the responsibility of the HCO to update the policy document
periodically in accordance with orders issued by CGHS from time to time.
36. Unique Email ID in the name of CGHS shall be created by every HCO
and the same shall be used for communicating with CGHS and other CGHS
stakeholders. This mail ID shall be active till the HCO is empanelled with
CGHS and shall be accessible to all those who are concerned with CGHS as
all the circulars shall also be sent to this mail ID.
37. CGHS reserves the right to revise rates / guidelines of new or existing
treatment procedure(s) / investigation(s) from time to time even during the
period of empanelment.
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38. HCO shall display the following information at prominent places in the
HCO premises
a) The list of credit eligible beneficiaries (Pensioners Serving Ministry of
health employees, all serving employees and their dependents having
CGHS card during emergency)
b) Details of two Nodal officers along with their designation, Mobile number,
email ID and location of their office within the HCO premises. One of them
at least shall be of the rank of Medical Superintendent.
c) The contact details of Manager on Duty (MOD) for all the shifts.
d) Grievance redressal mechanism for all beneficiaries.
e) CGHS Rates of most common 10 procedures
(i.) Balloon coronary Angioplasty/PTCA
(ii.) CABG
(iii.) Total Knee Joint Replacement
(iv.) Total Hip Joint Replacement
(v.) Normal delivery with or without episiotomy & perineal repair
(vi.) Caesarean section
(vii.) Laparoscopic Cholecystectomy
(viii.) Laparoscopic appendicectomy
(ix.) Transurethral Resection of Prostate (TURP)
(x.) Phaco with foldable IOL
39. HCO shall submit Name and address of their bankers ,mandate form
duly signed by the HCO/cancelled cheque and Photo copy of PAN Card and
GST details.
40. The details of any other center/s or Branch/es of the said HCO
Organization, empanelled with CGHS or having applied for empanelment with
CGHS in the same city or another city to be submitted.
41. Laboratories with branches in the same cities or within the
empanelment jurisdiction of the ADs may operate as collection centers.
However, the bill must be generated and claimed from the empanelled branch.
42. In this background, willing hospitals, exclusive Eye hospitals / Centres,
exclusive Dental Clinics, Cancer Hospitals/units, Chemotherapy, Dialysis
centres, diagnostic laboratories and imaging centres are invited to submit
their applications for empanelment under CGHS. The applications shall be
submitted to the AD (HQ) in case of CGHS Delhi & NCR and Additional
Director, CGHS of concerned City in respect of other cities.
CHAPTER 3- Category of HCO
A. Empanelment of Multi-Specialty Hospitals, Exclusive Cancer
Hospitals/Single Specialty Hospitals and Super Specialty in all CGHS
covered cities and District Head-Quarters.
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1. MINIMUM NUMBER OF BEDS REQUIRED as certified in the registration
certificate of the state Government
a. Tier 1 City……………… 50 beds.
b. Tier II and Tier III Cities …... 30 beds.
2. CATEGORIES OF HEALTHCARE ORGANIZATIONS:
a. Multi-Specialty Hospitals: Multi-specialty hospitals are healthcare
facilities equipped with the necessary infrastructure, medical staff, and
personnel to provide comprehensive primary, secondary, and tertiary
care, including emergency services. These hospitals must be registered
with the appropriate authorities.
b. Standalone Single-Specialty Hospitals: Single-specialty hospitals are
healthcare facilities designed to provide primary, secondary, and tertiary
care, including emergency services, but are limited to a specific specialty
such as Orthopaedics, Cardiology, Nephrology, Psychiatry, Oncology
(Cancer), etc. These hospitals must also be registered with the appropriate
authorities. In case of emergencies, they should be capable of providing
necessary emergency care or treatment in other specialties as per CGHS
rates and guidelines. Cancer hospitals having all treatment facilities for
cancer - surgery, Chemotherapy and radio-therapy (approved by BARC /
AERB) shall only apply for empanelment.
c. Super-Specialty Hospitals: To qualify as a super-specialty hospital for
CGHS empanelment, the following criteria must be met:
i. The hospital must have a minimum of 200 beds.
ii. It must be NABH accredited or hold an equivalent accreditation such
as Joint Commission International (JCI) of the USA, ACHS of Australia,
or any other accreditation recognized by the International Society for
Quality in Health Care (ISQua).
iii.NABL Accreditation mandatory for in house laboratories.
iv. Should mandatorily have CGHS empanelled treatment facilities for all
the following Super Specialties
1. Nephrology and Urology (including Renal Transplantation).
2. Neurosurgery,
3. Cardiothoracic Surgery,
4. Medical Oncology,
5. Surgical Oncology
6. Radiation Oncology
7. Transplant facilities.
8. Endocrinology.
9. Specialized Orthopaedic Treatment facilities that include Joint
Replacement Surgery
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10.Gastroenterology and GI-Surgery/Transplantation.
All the above mentioned specialities services should be in -house only .In case of
outsourced or any tie-up the facility will not be considered for the eligibility of
superspecilaity category. All the services other than the above like General medicine
,Gynaecology ,Ophthalmology ,ENT , etc available in the Super speciality Hospital
have to be invariably extended to CGHS without any exception.
All three hospital categories should be mandatorily equipped with emergency services
and shall have operation theatres commensurate with services being provided.
The Hospital shall submit the list of all consultants including visiting doctors along
with application .
Hospitals, including multi-specialty hospitals, single-specialty hospitals, and
exclusive cancer centers, shall be empanelled under the following categories:
1. NABH or Equivalent -Accredited Hospitals
Hospitals applying under this category must be accredited by the National
Accreditation Board for Hospitals and Healthcare Providers (NABH) or an
equivalent accreditation body such as Joint Commission International (JCI),
ACHS (Australia), National Health Systems Resource Centre (NHSRC), Quality
and Accreditation Institute or any other organization approved by the
International Society for Quality in Health Care (ISQua)[
If laboratory services fall within the accredited scope of the hospital, a separate
NABL (National Accreditation Board for Testing and Calibration Laboratories)
certification is not mandatory.
NABH and NABL rates shall apply to these hospitals, including for
radiotherapy and chemotherapy. However, for cancer surgeries, existing
CGHS cancer rates shall be applicable.
Super Speciality Category shall compulsorily be accredited by NABH and
NABL or their equivalents. CGHS Super-specialty rates shall be applicable,
while existing CGHS cancer rates shall be applicable for cancer procedures.
2. Non-NABH Accredited Hospitals
(a) Hospital seeking under NON-NABH category in Tier 1 cities shall mandatorily
have Entry-Level or shall have QCI (Quality Council of India) recommendation.
(b) In Tier II, Tier III and North Eastern States, UT of J&K, Non-NABH/NABL
accredited healthcare organizations (HCOs) without QCI recommendation or entry
level NABH accreditation may still be provisionally empanelled. However, they must
obtain QCI recommendation, entry-level NABH accreditation, or full NABH
accreditation (or an equivalent certification) within 6 months from the date of
empanelment.
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(c) Failure to obtain the required accreditation within the stipulated time frame will
result in removal from the CGHS Panel.
(d) Non-NABH/ NON NABL rates shall apply to these hospitals.
(e) If a NON-NABH HCO has a separate NABL certification for its in-house
laboratory, NABL rates shall be applicable for laboratory services, but imaging
services shall be paid at non-NABH rates.
Table 11
Criteria Category Of City
Multi-Specialty/Single Speciality /Exclusive Cancer Hospitals
Super-Specialty
Accreditation Tier I, Tier II and Tier III
1. NABH NABH Or Equivalent Body
and North
Eastern State
*
Rates
Applicable
2. Entry Level NABH Is Mandatory
3. In The Absence Of the above QCI Recommendation is required to stay on the Panel of CGHS. *
NABH Rates or Non-NABH Rates as applicable to city (tier of city) of the Hospital
Accreditation
Mandatory
NABH Super Specialty Rates as applicable to city (tier of city) of the Hospital
Bed Capacity Tier 1 50 200
Tier II and Tier III and North
Eastern State
30 100
Turnover Tier 1 ₹4 Crores ₹6 Crores
Tier II and Tier III and North
Eastern State
₹2 Crores ₹3 Crores
PBG* Tier 1 ₹20 Lakhs ₹25 Lakhs
Tier II and Tier III and North
Eastern State
₹10 Lakhs ₹12 Lakhs
| Application Fee | Tier I, Tier II and Tier III and North Eastern State , J &K and Ladhak | ₹10000 | ₹25000 |
|---|
*In Tier II, Tier III and North Eastern States, UT of J&K, HCOs without any accreditation or QCI recommendation shall be provisionally empanelled subject to the condition that they must obtain QCI recommendation, entry-level NABH
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accreditation, or full NABH accreditation (or an equivalent certification) within 6
months from the date of empanelment
**ABDM- M3 compliant hospitals will a 20% discount on the Performance Bank
Guarantee
B. Empanelment of Diagnostic Laboratories & Imaging Centres / Eye
Hospitals/Dental Clinics/Dialysis Centers /Chemotherapy Centers in all
CGHS covered cities and District Head Quarters)
i) Eligibility Criteria for Diagnostic Laboratories & Imaging Centres
The stand alone Diagnostic Laboratories & Imaging Centres shall be
compulsory be fully accredited by NABL in all cities. However, for Tier
III, North east states, and Jammu and Kashmir and ladhak even NON
NABL laboratories but having entry level NABL certification or QCI
recommendation shall be empanelled subject to the condition that full NABL
accreditation shall be obtained within one year failing which they shall be
removed from empanelment.
1. The minimum patient volume requirement is 100 per day for Tier I City
and 50 per day for Tier II, Tier III, and North Eastern States.
2. The Standalone laboratory shall have full time pathologist and a
quality manager .
3. There shall be other consultants like Microbiologist , Radiologist
commensurate with available services
4. It shall mandatorily have fully automatic five part anayser , fully
automatic biochemistry analyser, harmone analyser and micro biology
processing unit.
5. It shall also have other equipments commensurate with available
services
6. If a laboratory also provides imaging services (e.g., CT, MRI, USG, etc),
it must submit a NABH accreditation certificate for imaging services. If
NABH accreditation is unavailable, non-NABH rates shall apply for
imaging services unless the scope of NABL includes imaging services.
7. Labs with branches in the same cities or within the empanelment
jurisdiction of the ADs may operate as collection centers. However, the bill
must be generated and claimed from the empanelled branch.
ii) Exclusive Eye Hospitals/ Centers:
a) Exclusive eye hospitals shall compulsorily be fully accredited
by NABH in all cities. However, for Tier III, North east states,
and Jammu and Kashmir and ladhak even NON NABH eye
hospitals but having entry level NABH certification or QCI
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recommendation shall be empanelled subject to the condition that
full NABH accreditation shall be obtained within 6 months failing
which they shall be removed from empanelment.
b) Minimum of 6 beds is required for empanelment of exclusive Eye
Hospitals/centres for tier 1. However Minimum of 5 beds is required
for eye hospitals or centres located in other cities (Tier 2, Tier 3,
North Eastern states and union territories of Jammu and Kashmir
and Ladhak
iii). Exclusive Dental Clinics
c) The exclusive dental clinics having full NABH shall be
empanelled under NABH category while those having entry level
accreditation certificate or QCI recommendation certificate
shall be empanelled under NON NABH category .
d) No minimum bed strength is prescribed for empanelment of
exclusive Dental Clinics However dental centres performing maxillo
facial surgeries should have minimum of 10 beds.
e) Minimum of 4 dental chairs is required for Tier 1 cities while
Minimum of 2 dental chairs is required for dental centres located
in other cities (Tier 2, Tier 3, North Eastern states and union
territories of Jammu and Kashmir and Ladhak).
iv). Stand-alone Dialysis Centres
The stand Alone dialysis centres having full NABH shall be empanelled
under NABH category while those having entry level accreditation
certificate or QCI recommendation certificate shall be empanelled under
NON NABH category. However, for tier 2, tier 3, North eastern and Jammu
and Kashmir, the centres not having any accreditation or QCI
recommendation may be provisionally subject to the condition that they will
obtain full accreditation or QCI certification within 6 months failing which the
centre shall be removed from the list of empanelment .
f) Min 10 dialysis machines with beds in tier 1 cities and 6 dialysis
machines with beds in non-metro wit in other cities (Tier 2, Tier 3,
North Eastern states and union territories of Jammu and Kashmir
and Ladhak).
g) Minimum of one dialysis Machine with bed shall be reserved for
Sero positive patients
h) Dialysis carried out under supervision of nephrologist (Details to be
uploaded in HEM portal)
i) There shall be trained nursing staff and trained technologist.
(Details to be uploaded in HEM portal)
j) In case of any emergency the centre shall stabilise the patient and
refer to nearby CGHS empanelled Hospital after following protocols
as applicable to transfer of patient.
k) The HCO shall have Tie up with nearby hospital preferably CGHS
empanelled hospital. (Details to be uploaded in HEM portal)
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l) Should have separate storage room for consumables, waiting area
and toilets
m) Treatment Room/ Minor OT ,Emergency cart, Oxygen supply
defibrillator available within the facility
n) There should be a Full Time RMO (Allopathy)
o) Basic Lab services should be available.
p) All services including emergency treatment at hospital (tie up) shall
be provided at CGHS rates.
q) There should be inhouse pharmacy
v). Stand Alone Chemotherapy Centre - The Chemo centre should have QCI
recommendation certificate to get empanelled under CGHS. However, for tier
2, tier 3, North eastern and Jammu and Kashmir, the Stand-alone
Chemotherapy Centres not having QCI recommendation may be permitted to
be empanelled subject to the condition that they shall obtain QCI
recommendation within 6 months failing which they shall be removed from
empanelment.
r) Minimum beds 10 in metro and 6 beds in non-metro
s) Full time RMO (Allopathy)
t) All chemo shall occur under supervision of medical oncologist
u) Trained nursing staff
v) Biosafety cabinet compulsory
w) Basic Lab services should be available.
x) In case of any emergency the centre shall stabilise the patient and
refer to nearby CGHS empanelled Hospital after following protocols
as applicable to transfer of patient. The HCO shall have Tie up with
nearby hospital preferably CGHS empanelled hospital.
y) All services including emergency treatment at hospital (tie up) shall
be provided at CGHS rates.
z) Treatment Room / Minor OT ,Emergency cart, Oxygen supply
defibrillator available withing the facility
aa) Inhouse pharmacy should be there
bb) NON-NABH /NON NABL rates are applicable to these centres
Table 12
| Criteria | Category of City | Exclusive Eye Hospitals | Exclusive Dental Clinics | Chemotherapy Centres/Dialysis Centres | Laboratory And diagnostic Centre |
|---|
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Rates
Applicable
NABH Or
Non-NABH Rates Based on Tier I, Tier II and Tier 3 city
NABH Or Non-NABH Rates
Based on Tier I, Tier II and Tier 3 city
Non-NABH Rates Based on Tier I, Tier II and Tier 3 city
NABL / NON
NABL Based on Tier I, Tier II and Tier 3 city
For imaging
services NABH /NON-NABH
rates depends on scope of NABL
Bed
Capacity
Tier I City 6 4 chairs 10 beds Patient Sample size 100/day
Tier II and tier III and North East States
5 2 chairs 5 beds Patient sample size 50/day
Turnover Tier I City ₹50 lakhs ₹50 lakhs ₹50 lakhs ₹2 Cr
Tier II and tier III and North East States
₹25 lakhs ₹25 lakhs ₹25 lakhs ₹1 Cr
PBG Tier I City ₹4 Lakhs ₹4 Lakhs ₹4 Lakhs ₹4 Lakhs
Tier II and tier III and North East States
₹2 lakhs ₹2 lakhs ₹2 lakhs ₹2 lakhs
| Application Fee | All cities | ₹5000 | ₹5000 | ₹5000 | ₹5000 |
|---|
**ABDM-compliant hospitals will receive 20% discount on the Performance Bank Guarantee
GENERAL ELIGIBILITY CRITERIA FOR:
PRIVATE HOSPITAL, EXCLUSIVE CANCER HOSPITALS/SINGLE SPECIALTY HOSPITALS/EYE HOSPITALS/DENTAL CLINICS/DIALYSIS
CENTRES/CHEMOTHERAPY CENTRES,
1. The health care Organizations must fulfil the requirements as mentioned in PART I and PART II of this document depending on the category under which the Multi-specialty Hospital/Exclusive Cancer Hospitals/Exclusive Single Specialty Hospitals/Super speciality hospital/Eye Hospitals/Dental Clinics/Dialysis Centres/Chemotherapy Centers is seeking empanelment and submit copies of the required documents.
2. The health care Organization must have been in operation for at least one year. Copy of audited balance sheet, profit and loss account for the last financial year (Main documents only- summary sheet) The business from CGHS in the last financial year should not exceed more than 50% of the total
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business. A certificate to this effect from the Chartered Accountant is to be
given by the applicant Health Care Organization. The HCO shall submit a
certificate to this effect to every concerned AD of the City (AD HQ in case of
Delhi and NCR) and also in Hospital empanelment Portal (HEM).
3. State registration certificate / Registration with Local bodies, wherever
applicable.
4. Copy of NABH Accreditation/Entry-level NABH/QCI recommendation
whichever applicable.
5. List of All specialists and super specialists (both inhouse or visiting) along with
qualifications and HPR ID to be submitted.
6. HCO shall submit proof of having registered as a Convergence Partner on the
“consumerhelpline.gov.in” portal (managed by Dept. of Consumer Affairs)
within one month of signing this Agreement.
7. The HCO shall register on the Government of India’s IVFRT (Immigration, Visa,
Foreigners Registration & Tracking) portal
https://indianfrro.gov.in/frro/medicalvaluetravel and submit proof .
8. Bharatkosh payment receipt of application fee (non-refundable) as mentioned
below for respective category of HCO
9. Undertaking from hospital
10.Applicant Health care Organizations must certify that they are fulfilling all
special conditions that have been imposed by any authority in lieu of special
concessions such as but not limited to concessional allotment of land or
customs duty exemption.
11.Copy of all statutory requirements including that of Waste Management.
a. Fire Clearance certificate and details of Fire safety mechanism as in place
in the Healthcare Organization. Exclusive Eye centres, exclusive dental
Clinics, Dialysis Centres/Chemotherapy Centres, have to enclose a
certificate regarding fire safety of their premises.
b. Applicable Registrations and Approvals like PNDT / AERB certification etc
for all the machines like USG machines, CT machines, MRI machines, PET
facility, radiotherapy facility etc
c. Certificate of Registration for Organ Transplant facilities & IVF/other
assisted reproductive treatment procedures, wherever applicable.
d. Existing QCI certificate should have validity of 1 year at the time of
application.
12.The Applicant Health care Organization must submit details of all available
facilities and investigations including those of outsourced facilities. This HCO
shall also submit the comparative rates with CGHS rates for all treatment
procedures / investigations/ facilities available with them as charged to
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General Public. They must certify that they will adhere to CGHS rates and
that the rates charged to CGHS beneficiaries will not exceed those charged to
non-CGHS patients or the general public. Therefore, the applicable rates shall
be the CGHS rates or the hospital’s actual rates, whichever is lower.
13.The applicant healthcare organization must provide an undertaking agreeing
to the terms and conditions outlined in the Memorandum of Agreement, the
policy document, and the application, all of which shall be considered integral
parts of the application document.
14.Applicant Health care Organizations must certify that they shall charge as per
CGHS rates and that the rates charged by them are not higher than the rates
being charged to other non CGHS patients /general public. Hence the
applicable rates shall be the CGHS rates or actual hospital rates whichever is
lower.
15.Applicant Health care Organizations must agree for implementation of EMR/
EHR as per the standards notified by Ministry of Health & Family Welfare
within six months of their empanelment.
16.Facilities & Equipment: The HCO must have modern and well-maintained
facilities, equipment, and technology with valid licenses, ensuring that no
outdated or obsolete equipment is used.
CHAPTER 4- CGHS Empanelment & De-Empanelment
The Additional Director of respective cities shall constitute a Hospital empanelment
committee (HEC) under the chairman ship of Additional director and 2 senior doctors
as members. The details of the committee shall be duly notified.
1)Responsibilities of the Hospital Empanelment Committee (HEC)
Conduct pre-empanelment briefings for the HCO’s CEO/Head, Finance,
Billing, and other key teams.
Evaluate and approve empanelment of hospitals, diagnostic centres, and
other facilities on a regular schedule, preferably quarterly.
Ensure physical inspections of HCOs to verify on-ground facts against
submitted documents and flag any discrepancies.
Organize training for CGHS Nodal Officers and HCO staff who handle CGHS
beneficiaries (HCO Nodal Officers, reception/billing staff, and Manager on
Duty).
Review complaints and recommend appropriate actions, including penalties,
de-empanelment, blacklisting, or other legal measures.
Consider and address suggestions or grievances submitted by HCOs.
Keep the list of empanelled HCOs current and ensure it is promptly updated
and widely circulated.
2) The Empanelment procedure
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Step 1— Payment of the Application fee
Health Care Organizations (HCOs) seeking empanelment with CGHS are required to
pay the prescribed application fee (refer to Table 11 and 12) through the Bharatkosh
portal at https://bharatkosh.gov.in/. The HCO representatives with Bharat kosh
receipt shall approach office of additional director expressing their willingness for
empanelment on a letter head signed by head of facility/ CEO.
Step 2 . Pre empanelment Briefing :
There shall be mandatory pre-empanelment briefing of HCO by HEC making them
aware of
a. CGHS , beneficiaries , referral system, MOA terns , CGHS rates , definition
of ward charges , package rates . admissible and non admissible items ,
procedures to be followed in case of unlisted procedures , information to be
displayed in the HCO premises, reports to be submitted to CGHS , definition
of fraud and penalties, etc .
b. Eligibility criteria for empanelment, procedure of applying in (Hospital
Engagement portal) HEM, Rates applicable, documents to be enclosed etc
The HEC committee shall ensure that all the staff likely to deal with CGHS
beneficiaries are to mandatorily attend the meeting. This shall include head
of facility, staff at reception, billing , finance officials , Manager on duties .
Since some of the policies of CGHS and hospital may vary, it is important for
the head of facility who frames policies for said HCO to understand the CGHS
policies, MOA and accept the same in total. The practice of empanelling HCO
based on HCO marketing officials request alone is to be avoided.
At the end of the briefing the committee shall ensure that HCO has accepted
all CGHS policies, MOA terms and shall abide by the same.
If HCO authorities seek additional time to decide on the matter, their
application shall be returned to HCO till the time they fully accept the CGHS
policies and procedures.
Minutes of such briefing must be signed and recorded.
Step 3- HCO shall apply in HEM portal by filling relevant details and uploading all
requisite documents . The creation of logins for uploading in HEM portal is
mentioned in flow chart in the annexure
Step 4 — Document Scrutiny (quarterly): The committee shall examine the
applications submitted and application may be returned back to HCO if any
deficiencies noted.
Step 5 — Physical Inspection of the HCO : The Physical inspection shall be
carried out by any of the HEC member or any other GDMO as nominated by
additional director
Existing HCOs:
o Non-NABH/Non-NABL/QCI: Physical verification is mandatory.
o NABH HCOs: Physical inspection is also mandatory but the same may be
conducted at any time within 6 months.
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Newly empanelled hospitals: Physical inspection is mandatory for all
HCOs including accredited HCOs.
Step 6— Signing the Memorandum of Agreement (MoA)
After approval, the hospital must sign the MoA within 15 days.
HCO shall submit PBG, Hospital policy document for CGHS Beneficiaries
and MOA (Hard copies to Additional Director office of respective city/ Zone
Upload the signed MoA, Policy document and PBG (42 months validity) to
the HEM portal within 24 hours.
Step 7 — Create System Logins (within 2 days): The HCO shall create
following logins with help of office of Additional Director as per the flow chart
( Annexure C)
Step 8 — Empanelment Notification: the empanelment notification shall be
issued within 24 hours of creating logins. A training shall be arranged in handling
of TMS portal by NHA officials covering registration of patient , pre authorisation ,
bill submission , responding to queries , reconciliation of payments etc .
Step 8 -Notification shall be uploaded to web site apart from widely
circulating the same.
Process Timeline (at a glance)
Step Process Timeline
1 Payment of Application fee At any time
2 Pre-empanelment meeting Before the scheduled
HEC meeting
3 Application in HEM portal along with creation of HEM logins
Before the scheduled HEC meeting
3 Document scrutiny by Committee Once every quarter
4 Sign MoA and submission of MOA, PBG and policy documents
5 Upload signed MoA , Policy document and PBG on HEM
Within 15 days
Within 24 hours after signing
6 Create TMS MEDCO ID Within 2 working days
| 7 | Empanelment notification on CGHS website | Within 2 working days |
|---|
3) Disciplinary Proceedings & De-Empanelment.: The HEC committee also responsible for examination of complaints received by any mode and recommend action to be taken. The deviations / unethical practices / violations of terms of agreement noted during regular audits or data analytics are also to be inquired.
a. Rationale for Disciplinary Proceedings and De-empanelment
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Disciplinary proceedings/de-empanelment may be conducted for an empanelled
Healthcare Organisation (HCO) under the scheme if they fail to meet and uphold the
necessary criteria agreed upon during empanelment or indulge in wrongful acts
during treatment.
The key objectives of CGHS are:
to increase empanelment,
to ensure that quality care is provided to the beneficiaries, and
to curtail unnecessary leakages in the form of fraud and abuse which may
bring disrepute to the scheme.
Disciplinary proceedings/de-empanelment processes have been introduced
primarily as a deterrence and control mechanism in the scheme to ensure that:
medically appropriate quality treatment is provided to beneficiaries at all
times, and
all wasteful and unnecessary expenditure is curtailed.
b. Institutional Structures for Disciplinary Proceedings and De-empanelment
The institutional structures established for empanelment will also be responsible
for disciplinary proceedings/de-empanelment.
c. Process for Disciplinary Proceedings and De-empanelment
c.1. Investigation of Suspect Claims/Hospitals
Cases to be examined include:
1. Cases where specific complaints from beneficiaries are received.
2. Cases flagged by Claim Processing Doctors (CPD) or Sanctioning Authorities
(SAs) or cases flagged as suspicious in NHA portal.
3. Regular review of bills of HCOs. The suspect cases shall be flagged.
The cases shall be examined for:
billing patterns,
unbundling of procedures,
billing as unspecified procedure when equivalent code is available,
irrational usage/billing of consumables or medicines,
forging of documents,
forging of invoices,
collection of amount from beneficiaries, etc.
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Based on the need, the records at hospital or those with beneficiaries may also be
checked. This could be done by the HEC committee alone or, if needed, assistance
of any recognized external agency may also be sought.
Investigation of the case, including submission of report, will be done within 10
working days of flagging the case. All attempts will be made to close the case within
the above-mentioned period by AD, CGHS. In case of any delay, a report must be
submitted to the Director, CGHS, citing the reasons for the same.
c.2. Show-Cause Notice to the HCO
Based on the investigation report received, if the AD, CGHS observes that
there is sufficient evidence/suspicion of the HCO indulging in malpractices, a
show-cause notice shall be issued to the HCO online through HEM portal or
to the HCO’s registered email ID provided at the time of empanelment or via
hard copy (by hand/registered post/speed post) within 7 days from receipt of
investigation report.
In the show-cause notice sent to the HCO, it should be explicitly
communicated to not contact the beneficiaries in question as this would lead
to tampering of evidence, as per the applicable laws. In case any such
tampering is found, legal action may be taken accordingly.
The receipt of the registered/speed post or acknowledgement of receipt by
HCO (in case delivered by hand) should be kept by the committee as proof by
the AD.
HCO shall respond to the show-cause notice within 5 working days from the
date of receipt. The response will be sent to the AD at the email ID provided
in the show-cause letter or the address specified for registered post along with
supporting evidence collected as per the applicable laws of India.
In case the response is not received within 5 working days, the HCO will be
suspended. All its operations will be blocked under CGHS through its web
portal, for a specified time frame not exceeding 6 months or till a decision has
been taken on the proceedings, so that no new pre-authorizations can be
raised by the HCO. However, the treatment of existing patients will continue
as usual till they are discharged.
The notification of suspension will be sent through email and registered/speed
post. All attempts shall be made to send the notification within 2 working days
of the decision and in case of any delay, a report must be submitted to the
Director, citing the reasons for the same.
In case the HCO’s response to the show-cause notice is found satisfactory, it
will continue to function as usual. However, if the response is not found
satisfactory, further information or evidence may be requested through email.
The HCO shall provide the requested documents/information within 3
working days through email, failing which the HCO may be suspended for a
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specified time frame not exceeding 6 months or till a decision has been taken
on the proceedings.
During suspension, the HCO will not be allowed to conduct any new pre
authorizations. All admitted patients under the scheme will be provided
continued treatment as usual till they are discharged.
The notification of suspension will be sent through email and registered/speed
post. All attempts will be made to send this notification within 2 working days
of the decision taken by AD. In case of any delay, a report must be submitted
to the Director, citing the reasons for the same.
If the above-mentioned timelines are not met, then either party can approach
the competent authority as per the grievance redressal guidelines.
If there is no documentary evidence to suggest that the show-cause notice was
received or the HCO denies having received the show-cause notice, the AD
may share the notice again either through physical delivery or registered email
ID and receive an acknowledgement of the receipt. HCO will have to respond
within 3 working days from the date of receipt of the show-cause notice.
Beneficiaries needing continued care beyond current pre-authorization may
be referred to another hospital to ensure there is no disruption of services.
c.3. Detailed Investigation of HCO
A detailed investigation will be carried out in case the HCO is suspended due
to the reasons mentioned above or if a serious complaint has been filed by the
beneficiary.
A detailed investigation may include:
o field visits to the HCO,
o examination of case papers,
o talking with the beneficiaries (if needed),
o examination of hospital records, etc.
All attempts will be made to complete the investigation and submit the report
within 10 working days of show-cause issued. In case of any delay, a report
must be submitted to the Director, citing the reasons for the same.
All statements of the beneficiaries will be recorded in writing in the language
known to the beneficiary and ensured that the said statement is read over to
the beneficiary for confirmation. The statement will be self-attested by the
beneficiary via signature or thumb impression for use as evidence. Wherever
possible, video recording will be taken and, if possible, a copy of photo identity
proof of such beneficiary will be maintained.
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If the detailed investigation reveals that the report/complaint/allegation
against the hospital is not valid and no malpractices are detected, suspension
will be revoked and operations as usual will be initiated. All attempts will be
made by AD to revoke the suspension within 5 working days of the
investigation report submitted. In case of any delay, a report must be
submitted to the Director, citing the reasons for the same.
If the detailed investigation reveals that the suspicion/alleged malpractice on
the part of HCO is valid and further new cases are detected, the AD may
recommend suspension for a specified time, not exceeding 6 months.
However, if the original cause of suspicion/alleged mischievous activities on
the part of HCO is not valid but additional malpractices are identified, a new
show-cause notice will be issued to the HCO. All attempts will be made to
issue the show-cause notice within 7 working days of noticing such
malpractices. The HCO will not be allowed more than 10 working days to
respond, and a similar process of investigation will be followed. The time
duration may be decided by the AD on a case-to-case basis.
4. Suspension of the HCO
Suspension may arise in the following situations:
i. Suspension after show-cause notice
o For HCOs where adequate evidence of malpractices is present and the
HCO is not able to provide satisfactory justification, the AD may
suspend the hospital for a specified time, not exceeding a period of 6
months.
ii. No response to show-cause notice
o In case the HCO does not provide any response to the show-cause
notice within the stipulated time as outlined above, the HCO may be
suspended for a specified time, not exceeding 6 months.
o If the response is received during suspension period, the SHA may
review the response, and if found satisfactory then the suspension may
be revoked.
iii. Direct suspension along with show-cause
o If the AD obtains irrefutable evidence that the actions of the HCO have
or may cause grievous harm to the patients’ health or life, AD may
immediately suspend the HCO for a specified time, not exceeding 6
months.
o The suspension must be accompanied with a show-cause notice,
allowing the HCO time of 5 working days to respond to it.
o In such case, AD will share the notice along with detailed
justification/reason for suspension with the Director.
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o The AD will also conduct a detailed investigation in such cases as
outlined above.
iv. Suspension due to non-payment of penalty
o If the penalty is levied on the HCO for an offence and it fails to submit
the penalty amount within the stipulated time, AD may adjust the
penalty with the pending payment to the HCO.
o If the pending amount after the adjustment of dues is not paid by the
AD, a reminder may be sent to the HCO.
o Upon no response, the AD may decide to suspend the HCO till the
amount is recovered.
In all cases outlined above:
The notification of suspension will be sent through email and registered/speed
post.
All attempts will be made to send the notification within 3 working days of
decision.
In case of any delay, a report must be submitted to the Director, citing the
reasons for the same.
Once the HCO is suspended (or de-empanelled), different scenarios shall be managed
as mentioned below:
I. Suspicious cases
All the paid and unpaid cases shall be promptly investigated within 15
working days of suspension/de-empanelment, confirmed as fraud or not fraud
and recovery shall be finalized for confirmed fraudulent cases which are
already paid, and the unpaid fraudulent cases shall be rejected.
II. Unpaid cases
All unpaid cases shall be mandatorily audited within 15 days of
suspension/de-empanelment.
The audit shall be completed before payment and payment shall be based on
clearance by audit and adjudication on merit.
Claims adjudication of all cases shall be done on merit as per package booked
and case papers submitted by HCO as in normal process of adjudication.
AD will ensure that the payment of all unpaid claims is released only after
making the recoveries as mentioned in point 1 and recovery of penalties as
required to be levied.
A Final Settlement Letter clearly mentioning the recovery and/or penalty and
its adjustment from pending claims shall be sent to the suspended/de
empanelled HCO.
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If the matter of suspension or de-empanelment has been taken to court by the
HCO or is sub-judice, in such event, the claims under the sub-judice case
jurisdiction shall not be considered for above guidelines till the matter is
finally concluded in court of law. The rest of claims (not forming part of court
case) shall be handled as per above guidelines.
The HCO may file an appeal against suspension to review the order along with
the submission of necessary evidence and an undertaking of not repeating
similar instances of malpractices within 30 working days of suspension.
The AD may decide to revoke the suspension after examining the evidence and
undertaking submitted by HCO.
In case the HCO is unable to refute the same with evidence, the AD will present
the case to empanelment committee to initiate the de-empanelment
proceedings against the HCO.
5. Presentation of Case for De-empanelment
Presentation of case for de-empanelment may be initiated by AD after
conducting proper disciplinary proceedings as outlined above.
The committee will meet within 30 working days; an emergency meeting could
be scheduled in exceptional circumstances of the case being referred.
All relevant documents including the detailed investigation report will be
submitted to the COMMITTEE either at the time of case filing or at least 10
working days prior to the meeting.
The COMMITTEE must ensure that the HCO has been issued a show-cause
notice seeking an explanation for the alleged malpractice.
HCO will be provided a fair opportunity to present their case with necessary
evidence at the meeting conducted by COMMITTEE.
If the COMMITTEE finds that the complaint/allegation against the HCO is
valid, it will order de-empanelment of the HCO based on appropriate legal
advice along with additional disciplinary actions like penalties, FIR etc. as it
may deem fit.
In case the COMMITTEE does not find adequate supporting evidence against
the HCO, it may revoke the suspension of the HCO or reverse/modify any
other disciplinary action taken by AD against the HCO, while making clear
observations and reasons underlying the final decision.
All attempts shall be made to take the final decision within 30 working days
of 1st COMMITTEE meeting and in case of any delay, a report must be
submitted to the Director, citing the reasons for the same.
All attempts shall be made to implement any disciplinary proceeding as
decided by COMMITTEE within 30 working days of the decision taken by
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COMMITTEE and in case of any delay, a report must be submitted to the
Director, citing the reasons for the same.
If either party is not satisfied by the decision of COMMITTEE, they can
approach the competent authority as per the grievance redressal guidelines.
6. Actions to be Taken after De-empanelment
Once the hospital has been de-empanelled, a letter/email will be sent to the
HCO regarding the decision at registered address/registered email ID of the
HCO within 3 working days of the decision.
Once de-empanelled, new pre-authorisations will be disabled and the existing
pre-authorizations/treatment will have to be completed.
A decision may be taken by the COMMITTEE to ask the AD to either lodge an
FIR in case there is suspicion of criminal activity or take such other
permissible legal action under applicable laws of India.
In case of confirmed act of professional misconduct and violation of medical
ethics, the appropriate professional medical bodies/NMC at the national/state
level should be informed of the details of the case, the treating doctor and the
hospital involved. The NMC and State Medical Council should take it up and
take appropriate action as per the Code of Medical Ethics Regulation, 2002
and/or such necessary action as may be required as per the applicable laws.
This information will be sent with other Insurance Companies, ESIC, ECHS,
IRDAI and other relevant regulatory bodies and to NHA.
Depending on nature of offence, the Additional Directors shall also write to
NABH/NABL or other accrediting bodies or even to state licensing authorities
for revoking licenses or accreditations.
A list of de-empanelled hospitals will be enlisted on CGHS website. The list
should be prominently displayed and easily accessible on the website to
ensure beneficiary awareness. AD may notify in the local media about the
entities where malpractice is confirmed, and the action taken against the HCO
engaging in malpractices.
The period of de-empanelment would be for 2 years, unless stated otherwise.
Once de-empanelled, the HCO cannot seek re-empanelment until completion
of 2 years from the date of such de-empanelment. Healthcare service providers
will not be allowed to change their names and re-apply. The concerned local
teams will keep a check on such practices.
In case COMMITTEE decides to re-empanel an HCO within a period of 2 years,
the same may be flagged in the system through HEM portal. The reason for
re-empanelment of HCO will also be documented in the HEM web portal.
If it is a hospital chain, only the concerned branch will get de-empanelled
while the other hospitals will continue to function.
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Based on the severity of the offence, COMMITTEE may de-empanel the HCO
for more than 2 years or may blacklist an HCO. In such cases, the
COMMITTEE will inform AS & DG Health and Family Welfare of its decision
along with a detailed explanation/recorded reason for the same.
7. Timeline for Disciplinary Proceedings and De-empanelment
Stage / Activity Timeline
Investigation of suspect claims Within 10 working days of
flagging the cause
Issuance of show-cause notice Within 7 working days of
submission of the investigation
report
Response to show-cause notice by HCO Within 5 working days
Clarification response from HCO (when further information/evidence is sought)
Issuance of suspension / show-cause notice related decision (communication out)
Detailed investigation along with submission of investigation report
Within 5 working days
Within 2 working days of decision
Within 10 working days
Response to suspension by HCO Within 5 working days HCO can file an appeal against suspension Within 30 working days
| Final decision to suspend / suspend with fine / revoke suspension / de-empanel | Within 30 working days of the 1st COMMITTEE meeting |
|---|
8. Gradation of Offences
Based on the investigation report/field audits, the following gradation of penalties may be levied by the COMMITTEE. However, this tabulation is intended to be as guidelines rather than mandatory rules. These penalties are recommendatory in nature and the AD may inflict larger or smaller penalties depending on the severity/regularity/scale/intentionality on a case-to-case basis. If any hospital is found to be involved in unethical practices/malpractices/severe offence, then legal action may also be taken by AD.
Case / Issue First Offence
Second Offence
Third Offence
| Collecting money from beneficiaries towards admissible items or those bundled under other items | Full refund + penalty of 5× amount collected, | Same as first offence + hospital suspension. | De empanelment / blacklisting / forfeiture of |
|---|
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like packages,
investigations/consultations or on the pretext of
outsourced service or visiting consultant
Refusal of credit facility to eligible beneficiaries
Charging in excess of CGHS rates
Billing for services not provided
Upcoding / Unbundling / Unnecessary procedures
payable to CGHS within 7 working days.
Full refund + penalty of 5× amount collected, payable to CGHS within 7 working days.
Full refund + penalty of 5× excess amount
collected, payable to CGHS within 7 working days.
Claim
rejection + penalty of 5× the
claimed
amount.
Claim
rejection + penalty up to 10× the excess
amount
(based on
severity).
Same as
first offence + hospital suspension.
Same as
first offence + hospital suspension.
Claim
rejection + penalty of 10× the
claimed
amount + hospital
suspension.
Claim
rejection + penalty up to 20× the excess
amount + hospital
suspension.
bank
guarantee.
De
empanelment / blacklisting / forfeiture of bank
guarantee.
De
empanelment / blacklisting / forfeiture of bank
guarantee.
De
empanelment / blacklisting / forfeiture of bank
guarantee.
De
empanelment / blacklisting / forfeiture of bank
guarantee.
| Wrongful beneficiary identification | Claim rejection + penalty up to 5× the claimed | Claim rejection + penalty up to 10× + hospital | De empanelment / blacklisting / forfeiture of |
|---|
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| amount if hospital found in connivance. | suspension if connivance established. | bank guarantee. |
|---|
9. Additional Actions by Additional Directors
In addition, keeping in view the laws of the land and nature of offence committed,
the Additional Directors are to take the following actions wherever it warrants:
1. Blacklisting of HCO for empanelment with CGHS.
2. Writing to licensing authorities to revoke trade licence.
3. Writing to accreditation authorities to revoke accreditation.
4. Filing FIR in case of criminal offence.
5. Communicating to Medical Council if a particular physician is involved in
unethical practices contrary to Code of Medical Ethics.
6. Assisting beneficiary in filing consumer complaint with consumer forum.
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Annexure A
Memorandum of Agreement
(to be printed on Rs. 100/- non-judicial stamp paper and notarised )
(Empanelment of Private Health Care Organisation under CGHS)
This Agreement is made on the ____ day of ______ 202_. It is executed BY AND
BETWEEN:
a. The President of India, acting through the Additional Director, Central
Government Health Scheme (CGHS), Ministry of Health & Family Welfare,
Government of India, having its office at
_________________________________________________, [Name of City] (hereinafter
referred to as “CGHS”, which expression shall, unless repugnant to the
context, include its successors and assigns) of the First Party.
AND
b. [___________Name of the Health Care Organization____________________], a
[type of facility: Private Hospital / Exclusive Cancer Hospital / Single
Specialty Hospital / Eye Hospital / Dental Clinic / Dialysis Centre /
Chemotherapy Centre / Diagnostic Laboratory / Imaging Centre] located at
__________________________
________________________________________________________________(hereinafter
referred to as the “Health Care Organization” or “HCO”, which expression
shall, unless repugnant to the context, include its successors and permitted
assigns) of the Second Party.
WHEREAS:
1. The Central Government Health Scheme (CGHS) provides comprehensive
medical care facilities to Central Government employees, pensioners, and
such other categories of beneficiaries as decided from time to time.
2. The CGHS, for the benefit of its beneficiaries, intends to empanel private
health care organizations – including private hospitals (multi-specialty and
single-specialty), exclusive cancer hospitals/units, eye hospitals/centres,
dental clinics, dialysis centres, chemotherapy centres, diagnostic laboratories,
and imaging centres – in [__Name of City__________] to provide treatment and
diagnostic facilities under the CGHS.
3. The HCO named above is desirous of being empanelled under CGHS in [Name
of City] and has agreed to provide all available treatment and diagnostic
facilities (including those outsourced by the HCO) to CGHS beneficiaries and
other eligible central government beneficiaries at the rates and on the terms
and conditions prescribed by CGHS. The HCO has provided a list of all
facilities and services, including outsourced facilities available in its
organization (including specialities like dental care, physiotherapy, laboratory
diagnostics, imaging, etc.), which is attached to this Agreement (or listed in a
separate Annexure), and has confirmed that it meets the requisite criteria for
empanelment under CGHS.
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NOW, THEREFORE, in consideration of the mutual promises and covenants
contained herein, the Parties hereby agree as follows:
Clause 1:
Definitions and Interpretations
1.1 For the purposes of this Agreement, the following terms shall have the
meanings assigned below, unless the context otherwise requires:
a. “Agreement” means this Memorandum of Agreement, including its recitals,
Clauses, Annexures, schedules, supplements, appendices, and any
amendments or modifications thereto as may be mutually agreed in writing.
b. “Authorization Letter/Referral” means an official document or permission
(such as a referral letter or credit letter) issued by CGHS or the competent
authority like Head of office (HOO)/ Head of Department (HOD) of employee
department, Specialist of Government Hospital etc authorizing a CGHS
beneficiary to receive specified medical consultation, investigation, or
treatment at an empanelled HCO. This Agreement sets out the situations in
which you must obtain a referral or permission letter.
c. “Blood Charges (PRBC/Whole Blood/FFP/Cryoprecipitate/SDP/RDP
etc.)”: refers to Donor screening, Patient Screening and component or whole
blood processing and preparation charges including /Blood Irradiation/Leuco
Filtration etc.
d. “CGHS Beneficiary” shall mean serving Central Government employees,
Freedom Fighters, sitting Members of Parliament, former Members of
Parliament, Central Government pensioners, employees of specified
autonomous or statutory bodies, and their eligible dependents with a valid
CGHS card. Beneficiaries are entitled to avail healthcare services at
empanelled Health Care Organisations (HCOs) at prescribed CGHS rates. The
categories eligible for cashless treatment are as specified in Table 3. The
hospital/ diagnostic centres shall agree to charge CGHS rates to all Central
Government Employees on production of valid I-Card / Documentary proof
even though treatment is not sought as CGHS beneficiary.
e. “CGHS Card” means the identity card issued to a CGHS beneficiary by the
competent authority, which serves as proof of eligibility under the Scheme.
Table 1. Categories of CGHS Cards:
Category of CGHS Beneficiary Colour Coding of
CGHS Card
Pensioners, Ex-Members of Parliament, Freedom
Fighters…etc. Green Strip
Sitting Members of Parliament
Red Strip
| Serving Employees and their dependents of various ministries of Government of India eligible for CGHS Facility | Blue Strip |
|---|
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Serving/Pensioners of Autonomous Bodies of the
Government of India/Journalists Yellow Strip
| Pensioners of Air India | Orange Strip |
|---|
f. “CGHS Rates” means the rates notified by CGHS for various medical
investigations, procedures, treatment packages, and surgeries. These include
CGHS General Rates (for most treatments and procedures) and CGHS Cancer
Rates (applicable specifically to cancer surgeries). For cancer surgeries, the
CGHS Cancer Rates shall apply; for all other treatments (including
chemotherapy, radiotherapy, and stereotactic surgeries), CGHS General Rates
apply. Differential rates are applicable based on Type of city, NABH status,
super specialty status and ward entitlement of patient. In all cases, the
chargeable rate to the beneficiary shall be the CGHS prescribed rate or the
HCO’s rate for general public (Beneficiaries not covered under this scheme),
whichever is lower. (Other terms in Clause 4) . For specialised high-end
procedures like liver transplant, cochlear implantation, DBS implant, Heart
transplant, Lung transplant etc, Office memoranda issued by CGHS are
applicable
g. “Conservative or Medical Management” refers to non-surgical treatment in
cases where no specific CGHS package rate exists. In cases of
conservative/medical management where no package rate is prescribed,
reimbursement shall be made by applying the notified CGHS item-wise rates
for each component, such as ward charges, consultation charges,
investigation charges, oxygen charges, ventilator charges, etc. The cost of
admissible medicines and admissible consumables shall be reimbursable at
actuals. For IPD consultations, the specialist under whose care the patient is
admitted shall be regarded as the primary consultant. Consultation charges
for the primary consultant shall be admissible for up to a maximum of two
consultations per day. In exceptional circumstances, where the patient’s
clinical condition requires the opinion or management of additional
specialists, consultation charges for such specialists may be allowed at the
rate of one consultation per day per specialist, subject to adequate
justification being duly recorded.
h. "Consultation Charges" refer to the fixed, all-inclusive fees payable to
empanelled HCOs for specialist and super specialist medical consultations
provided to CGHS beneficiaries, either in outpatient (OPD) or inpatient (IPD)
settings. These charges are uniform across empanelled HCOs, regardless of
whether the consultant is in-house or visiting, and are inclusive of
examination-related consumables. The HCO shall not levy any other fee, like
a registration fee for CGHS beneficiaries, while availing consultation with any
consultant. Each OPD consultation remains valid for 7 days for the same
speciality.
i. “Coverage/benefit” means the extent of healthcare services a CGHS
beneficiary is entitled to receive under CGHS, subject to the Scheme’s terms,
conditions, and limitations.
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j. “Day Care Charges” refer to the accommodation charges where the patient is
treated and monitored for up to 6–8 hours, typically in the emergency or
casualty unit, or chemotherapy ward. It includes components similar to ward
charges. The rate is fixed at ₹1,500, irrespective of hospital, city, or
accreditation status.
k. “De-recognition” (of an HCO) means the cancellation of the empanelled status
of the HCO under CGHS (and termination of this Agreement) due to violations
such as unethical practices, fraudulent activities in treatment or billing,
failure to adhere to required quality standards, or any breach of the terms and
conditions of this Agreement, after due inquiry and process by the competent
authority.
l. “Emergency” means any sudden condition, injury or symptom which requires
immediate medical attention to prevent serious harm, disability, or loss of life.
In an emergency, as determined by prudent clinical judgment, urgent
treatment is warranted, and the absence of immediate care would be life
threatening or pose a serious risk to the patient’s health.
m.“Empanelment” means the enrolment of the HCO under CGHS for providing
specified medical treatment and/or diagnostic services to CGHS beneficiaries,
for a defined period, in accordance with the terms of this agreement.
Empanelled facilities are authorised by CGHS through this Agreement to treat
CGHS beneficiaries and to raise claims for reimbursement as per CGHS rules.
n. “Equipment Charges” refers to charges towards C-Arm, OT equipment, DVT
pump, infusion pump, portable X-ray or any other machine charges are also
part of ward charges/surgical package rates. Hence, they are not payable
separately.
o. “Health Care Organisation” or “HCO” means the private health care facility
empanelled under CGHS pursuant to this Agreement. It encompasses the
specific hospital, clinic, or centre (whether a multi-speciality hospital, single
speciality hospital, exclusive cancer hospital/unit, eye hospital/centre, dental
clinic, dialysis or chemotherapy centre, diagnostic laboratory or imaging
centre, as applicable) that is party to this Agreement and provides medical
investigation, treatment, and care to human patients.
p. “ICU/CCU/ICCU/PICU/MICU/HDU/NICU Charges” shall refer to
accommodation charges for providing care in a critical care unit, including
monitoring charges. ICU rate (Rs 5400/-) is payable irrespective of hospital,
city or accreditation status.
q. Investigation charges – Shall refer to all-inclusive cost towards the
investigation and shall include cost of consumables like vacutainer,
lancet, ECG electrodes, Glucometer strips etc. The charges remain the
same irrespective of the methodology used.
r. “Isolation ward charges “Shall refer to accommodation charges for providing
care where in patient needs to be isolated and shall include charges related to
PPE (gloves, masks, gowns, etc.) apart from other charges mentioned under
ward charges. Isolation ward charges of Rs 5400/- is payable irrespective of
hospital, city or accreditation status.
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s. “Nursing Charges” means charges related but not limited to Medication
Administration, IV cannulation, IM/IV injection, Ambulation (Mobilisation) of
patient, Ryles tube feeding, Suction Charges, ICD / any catheter/ bed sore
care, oral care, tracheostomy care, personal hygiene, sponge bath, monitoring,
health education, etc. Nursing charges are part of ward charges and hence
cannot be charged separately or collected from the patient.
t. “Package Rate” (under CGHS General rates) refers to a rate that is all
inclusive for a particular treatment or procedure under CGHS. Unless
specified otherwise, a CGHS package rate (especially for surgical or procedural
interventions) includes the lump-sum cost of inpatient treatment or defined
day-care treatment from the time of admission to the time of discharge. It
encompasses, but is not limited to, the following components:
i. Accommodation charges, including the patient's diet
ii. Admission charges
iii. Anaesthesia charges
iv. Cost of medicines and consumables/disposables
v. Cost of surgical disposables and all sundries used during
hospitalisation
vi. Doctor/consultant visit charges
vii. Dressing charges
viii. ICU/ICCU charges
ix. Injection charges
x. Monitoring charges
xi. Nursing care charges
xii. O2 charges, Ventilator charges as routinely required if any etc.
xiii. Operation charges
xiv. Operation theatre charges
xv. Physiotherapy charges etc.
xvi. Procedural charges/surgeon’s fee
xvii. Registration charges
xviii. Related routine and essential investigations during the admission of
patient
xix. Transfusion charges and Blood processing charges
xx. Equipment Charges including Flowtron, Infusion pump, syringe pump
etc.
The rates remain the same irrespective of technique or methodology, or access used.
The Hospital shall not treat procedures that are unlisted or levy additional charges
mentioning a different methodology or technique
u. “Party” means either CGHS or the HCO as a signatory to this Agreement, and
“Parties” means both collectively.
v. “Ward Charges” means all charges towards providing an environment to
deliver care and shall comprise of but not limited to accommodation charges,
registration charges if any, nursing charges, registration charge, air bed, water
bed, alpha bed, flowtron charges, DVT pump, luxury tax, surcharge, air
conditioning, facility Charges, HVAC charges, ward equipment Charges, water
& electricity charges, housekeeping charges, infection control/CSSD,
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biomedical waste management, portable/bedside/emergency service charges,
laundry charges, patient identification band, bed sheet, patient gown, visitor
passes, duty doctor charges, patient diet and dietician charges, any certificate
charges, etc. It also includes attendant bed charges in case of a private ward
and above.
(Note: Any other terms used in this Agreement, if not explicitly defined herein, shall
have the meaning ascribed to them in the prevailing CGHS guidelines or in general
usage under the Scheme. Headings in this Agreement are for reference only and shall
not affect the construction of the clauses.)
Clause 2:
Empanelment, Eligibility and Scope of Services
2.1 Empanelment & Eligibility:
2.1.1 The HCO confirms that it meets all the eligibility criteria for empanelment
under CGHS applicable to its category/status of accreditation of healthcare
facility and the city classification in which it is located.
2.1.2 These criteria include (but are not limited to) minimum hospital bed strength,
Hospital/Health care facility infrastructure, availability of requisite medical
equipment and specialities, employment of qualified medical and paramedical
personnel, minimum annual patient turnover, and quality accreditations (such
as NABH for hospitals or NABL for laboratories), etc, as stipulated by CGHS
guidelines.
2.1.3 The specific eligibility requirements as applicable have been verified as per
CGHS norms prior to signing this Agreement. The HCO undertakes to maintain
these standards and criteria throughout the tenure of empanelment.
(A summary of the empanelment eligibility criteria and requirements is provided in
CGHS’s empanelment guidelines and may be referred to in Annexure or relevant
CGHS notification for record.)
2.2 Scope of Services: By entering into this Agreement, the HCO shall make
available all the facilities/treatments/investigations (including all in-house and
outsourced facilities) to CGHS beneficiaries. The list of specialities, departments, and
services available at the HCO has been disclosed by the HCO and is attached to this
Agreement. All such services, including outsourced services, shall be provided at
CGHS-approved rates and under CGHS guidelines, without causing any hindrance
or inconvenience to patients or their wards.
a. If the HCO offers advanced or specialized procedures (such as In-Vitro
Fertilization (IVF)/Assisted Reproductive Techniques, organ or tissue
transplant services, etc.) or any treatment that requires special licensing,
accreditation, or government authority approval, the HCO warrants that it
possesses valid registration/license from the relevant State/Central
authority/statutory bodies to provide such services. Proof of such
authorisation shall be provided to CGHS upon request.
b. If, after empanelment, the HCO adds new specialities, services, or facilities,
the HCO shall promptly notify CGHS of such additions. Any new facility or
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service (including newly acquired equipment or newly introduced treatment
modalities) shall also be extended to CGHS beneficiaries at CGHS rates or
rates for the general public, whichever is lower.
c. If it is established that an Empanelled Health Care Organisation (HCO) has
wilfully denied or withheld access to any diagnostic or treatment facility that
is available within its premises from a CGHS beneficiary or has referred the
beneficiary to an external facility despite in-house availability of the required
service, such conduct shall be deemed a serious violation of the terms of
empanelment (Ref: Annexure A.III and Clause 14 of MoA). Such action shall
make the HCO liable for immediate removal from the CGHS panel, in addition
to any other action deemed appropriate under the applicable law, rules and
guidelines.
d. Agree to conduct annual health check-up for Group ‘A’ central
government officers aged ‘40’ and above and for other categories of CGHS
Beneficiaries as specified by the government. The Hospital shall agree for
conducting all investigations / diagnostic tests/consultations etc of the
Central Civil Services Group A‟ officers of above 40 years of age and other
categories of CGHS beneficiaries as specified by government from time to time
as per the prescribed protocol, subject to the condition that the hospital shall
not charge more than what has been CGHS has finalised from time to time for
conducting the prescribed medical examination of the male officers and female
officers of Central Government who come to the hospital/ institution with the
requisite permission letter from their Department/ Ministry / competent
authority. Permission or endorsement from CGHS as issued in regular
treatment cases is not required.
2.3 EMPANELMENT WITH OTHER CENTRAL GOVERNMENT DEPARTMENTS
AND AUTONOMOUS BODIES: The HCO shall agree to extend empanelment on the
same terms and conditions as outlined in this Agreement to any other Central
Government department, organization, or Central Public Sector Undertaking,
without seeking higher charges
Clause 3:
Duration of Agreement
3.1 Initial Term: This Agreement shall come into force on the date mentioned above
and shall remain in force for a period of three (3) years from the date of approval of
the empanelment, unless earlier revoked or terminated in accordance with the
provisions hereof.
3.2 Extension of Empanelment: The empanelment (and this Agreement) may be
extended for an additional period of one (1) year beyond the initial 3-year term,
subject to the HCO’s satisfactory performance and fulfilment of all the terms and
conditions of this Agreement during the initial term, and only with the mutual written
consent of both Parties. Any such extension shall be on the same terms and
conditions, unless otherwise modified.
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3.3 Continuity Until Renewal/Termination: If the CGHS notifies revised terms or
invites renewal applications upon or before the expiry of the initial term (or extended
term), the HCO may apply for renewal/continuation of empanelment as per
prevailing policy. In the absence of renewal, or if the HCO does not wish to continue,
this Agreement shall expire at the end of its term. Notwithstanding expiration or
termination, patients already admitted at the HCO prior to the expiry/termination
shall continue to receive treatment under CGHS terms until discharge, and the terms
of this Agreement shall be deemed to remain in force in respect of those beneficiaries
until their discharge and settlement of related claims.
Clause 4
CGHS Rate and Financial Terms
4.1. Uniformity of Rates for In-House and Outsourced Services
4.1.1. The CGHS package rates shall apply uniformly to all medical services provided
by the Empanelled Health Care Organization (HCO), whether such services are
rendered directly in-house or outsourced through third parties.
4.1.2. Under no circumstances shall the HCO charge rates exceeding the CGHS
approved package rates by citing outsourcing as a justification. Differential pricing
based on the modality of service delivery (in-house vs. outsourced) is strictly
prohibited.
4.2. NABH Accreditation Scope – Applicability of Rates
4.2.1. Hospitals accredited by the National Accreditation Board for Hospitals and
Healthcare Providers (NABH) or its equivalent 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 (ISQUA) shall be eligible
to claim CGHS-approved NABH rates only for those medical specialties and services
that are explicitly covered under the hospital’s scope of accreditation.
4.2.2. For all other specialties or services not included in the NABH-accredited scope
(or equivalent accreditation scope), the applicable non-NABH CGHS rates shall
apply, irrespective of the hospital's overall accreditation status.
4.3. Rates for super speciality hospitals shall be 15% higher than those applicable
to NABH-accredited hospitals for the corresponding Super specialties within the
same city category. (Annexure A.VIII)
4.4. Ward Entitlement-Based Adjustment
4.4.1. All CGHS package rates are structured based on entitlement to a Semi
Private Ward.
4.4.2. The following adjustments shall apply to beneficiaries based on their entitled
ward category:
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a. For General Ward entitlement: a reduction of 5% shall be applied to the package
rate.
b. For Private Ward entitlement: an increase of 5% shall be applied to the package
rate.
4.4.3. Notwithstanding the above, the rates for Investigations, Minor OPD
Procedures , Dental procedures, Physiotherapy, and Radiotherapy shall remain
uniform across all entitlements.
4.5. Multiple Surgical Procedures in One OT Session
4.5.1. In cases where multiple surgical procedures are performed in a single
operative session, reimbursement shall be as follows:
a. The primary procedure (i.e., the one with the highest rate) shall be
reimbursed at 100% of the applicable package rate.
b. The second procedure (ie the one with second highest rate) shall be
reimbursed at 50% of its respective package rate.
c. Third and subsequent procedures shall be reimbursed at 25% of their
respective package rates.
4.5.2. For identical procedures performed on different anatomical sites (e.g.,
bilateral cataract or knee replacement), the second procedure shall be reimbursed at
50%.
4.5.3. If an additional procedure is performed within the post-operative package
period of an earlier procedure, it shall be reimbursed at 75% of the applicable
package rate.
4.5.4. The HCO shall not itemize charges or bill separately for individual steps
involved in a surgical procedure; the package rate shall be considered all-inclusive,
in line with standard clinical protocols.
4.6. Implants and Consumables
4.6.1. Charges for implants :An implant is a medical device implanted in a body to
replace a missing biological structure, support a damaged biological structure, or
enhance an existing biological structure like lenses, stents, meshes, valves shall be
reimbursed in addition to the package rates. The amount payable in case of listed
implants is the CGHS ceiling rate or the actual purchase price mentioned in the GST
purchase invoice from external vendor. However, all consumables and medicines,
including guidewires and catheters, are deemed inclusive within the package rate
and shall not be charged separately.
4.6.2. In cases involving unlisted implants, reimbursement shall be limited to the
actual GST purchase invoice amount from an external vendor . The HCO to submit
GST purchase invoice from external vendor. The invoice of the in house
pharmacy/agency will not be considered as a valid invoice for reimbursement. A
letter/ certificate from treating doctor indicating detailed specifications of the implant
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like make , type , size , model , and number used shall be submitted along with the
claim.The treating doctor shall also certify the satisfactory functioning of the implant
4.6.3. The use of drug-eluting balloons used in lieu of stents shall be reimbursed
at actual invoice rate.
4.7. Unlisted Procedures and Investigations
4.7.1. For procedures or investigations not included in the CGHS package list, the
prevailing CGHS guidelines for unlisted procedures shall be applicable.
4.7.2. Such procedures shall be reviewed and updated periodically by CGHS as per
evolving clinical and policy considerations.
4.8. Consultation Charges- Applicable to all empanelled hospitals (in-house or
visiting consultants)
Table 2 Summary of consultation
S.
No.
Type of Consultation
Payable Fee (₹)
Conditions / Remarks
1 Outpatient (OPD) – Specialist
2 Outpatient (OPD) – Super Specialist (DM/MCh)
3 Outpatient (OPD) – Psychiatry
4 Inpatient (IPD) – Specialist/Super
Specialist
₹350 * Includes emergency and casualty consultations
₹700 Application for super specialist holding recognised DM/Mch qualification and offering consultation in respective super speciality field.
₹700* Flat enhanced rate for psychiatric consultations
₹350 Flat rate across all specialities
| 5 | Eye Consultation | ₹350 | Includes Refraction, Auto Refraction, Non-Contact Tonometry, and 90D Lens Examination (Fundus Examination). These shall not be charged separately |
|---|
● An OPD consultation is valid for seven days within the same specialty, and the fee is identical whether the consultant is in-house or visiting. No separate registration fees shall be levied for availing any kind of consultation at the HCO.
4.9. Cancer Surgery Package Rates and Admissible Charges 4.9.1. Applicability
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The applicable rates for cancer-related surgical procedures shall be governed by
Office Memorandum No. S-11045/36/2012-CGHS(HEC) dated 7th September
2015, categorizing surgeries from Grade I to VI with specific rates for:
a. Anaesthesia
b. Operation Theatre (OT) charges
c. Surgeon’s fees
4.9.2. Accreditation-Based Adjustment
a. If the HCO is not accredited by the National Accreditation Board for Hospitals
and Healthcare Providers (NABH) or equivalent accreditation, a 15%
deduction shall apply on applicable Anaesthesia, Operation Theatre (OT)
charges, Surgeon’s fees
4.9.3. Ward Entitlement Adjustment
The following adjustments also apply on Anaesthesia, Operation Theatre (OT)
charges, Surgeon’s fees based on the CGHS beneficiary’s ward entitlement:
a. General Ward: 10% deduction from Semi-Private ward rates
b. Private Ward: 15% enhancement over Semi-Private ward rates
4.9.4. Treatment Duration
The HCO must ensure that treatment and hospitalization periods for cancer
surgeries conform to the standard duration norms for Surgical Grades I to VI as
specified in the applicable OM.
4.9.5. Calculation of Total Admissible Amount
The admissible amount for Cancer surgery shall be calculated as per the formula
given below:
Ward charges as applicable + Anesthesia charges (category charges after
adjustment based on accreditation status and ward entitlement ) + OT charges
(category charges after adjustment based on accreditation status and ward
entitlement) + Surgery charges (category charges after adjustment based on
accreditation status and ward entitlement) + Investigations at CGHS rates +
Cost of Medicines and Surgical Disposables.
4.10. Chemotherapy Charges
4.10.1. The package rate for chemotherapy procedures shall be applicable solely to
procedural charges (professional charges towards administration of chemotherapy/
immunotherapy drug).
4.10.2. Charges towards accommodation (day care charges), relevant investigations,
Medicines are reimbursable separately, as per CGHS norms. If for any justified
reason, if the patient was given chemotherapy in ward instead of chemotherapy ward,
ward charges as per entitlement are applicable
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4.10.3. Wherever feasible, CGHS shall supply anti-cancer medicines. In the event of
non-supply by CGHS, the empanelled HCO shall procure and administer the
required medicines. In such instances HCO shall submit the carton/outer
pouch/vial reflecting batch no, manufacturing date and expiry date and MRP. Cost
of such medicines shall be limited to 70% of MRP. HCOs cannot charge any amount
from CGHS patient.
4.11. Reimbursement of Ambulance Charges for CGHS Beneficiaries:
Ambulance charges shall be reimbursable subject to the following conditions:
4.11.1. The treating doctor certifies in writing that transport by any mode other
than an ambulance would pose a serious risk to the patient’s life or would
significantly aggravate their medical condition; and
4.11.2. The ambulance journey is undertaken within the same city.
4.11.3. State government fixed rates for ambulance will be reimbursed, in case no
rates available for any state, then nearest state or delhi rates will be allowed.
Clause 5:
General Obligations of the Empanelled Health Care Organisation
5.1. The Health Care Organisation (HCO) agrees to fully abide by the following
obligations throughout the period of empanelment under CGHS:
5.1.1 Compliance with CGHS Rules and Law: The HCO shall adhere to all CGHS
guidelines, orders, and instructions issued by the Ministry of Health & FW/CGHS
from time to time, as well as all applicable central, state and local laws and
regulations relevant to the running of the health care facility. The Health Care
Organisation (HCO) shall be solely responsible for remaining updated with all
applicable policies, guidelines, and directives issued by the Central Government
Health Scheme (CGHS), including, but not limited to, revised rates, procedure
inclusion/exclusion criteria, approved treatment packages, and prescribed billing
formats. The HCO must always ensure strict and continuous adherence to these
CGHS norms.
5.1.2 Standards of Services and Accreditation: The HCO shall always maintain
high-quality and standards of healthcare in the services it provides to CGHS
beneficiaries, equivalent to that provided to any other patient. It is the duty of the
HCO to obtain, maintain, and renew all statutory registrations, licenses, and
certifications required for its operation (such as hospital/nursing home
registration, PNDT Act registration for radiology, Blood Bank license if applicable,
AERB approvals for radiology equipment, etc.). The HCO shall also endeavour to
maintain quality accreditation standards (e.g. NABH for hospitals/NABL for labs
or other equivalent accreditations) during the tenure of empanelment. In
particular, the HCO must keep its NABH/NABL accreditation status (or
equivalent accreditation as the case may be) valid. If any required accreditation
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or certification lapses or is not timely renewed, the HCO shall immediately inform
CGHS. If the HCO fails to renew or loses its NABH/NABL accreditation during the
empanelment period, it will be deemed a non-accredited facility for the purpose
of CGHS payments (i.e. CGHS shall apply the lower, non-accredited rates for bills
from such date) and may also be subject to further action as per this Agreement
(including suspension or termination of empanelment at CGHS’s discretion). The
HCO shall ensure no degradation in infrastructure, manpower or quality of
service during the term of empanelment that would render it below the
initial eligibility criteria.
5.1.3 Non-Assignment and change of ownership The empanelled HCO shall not
assign or subcontract the Agreement, or any part of its obligations or services
under this Agreement, to any other party without prior written consent of CGHS.
The HCO cannot transfer the empanelment to a different entity, or a different
location of the hospital/clinic not originally empanelled. Any change in
management or ownership of the HCO shall be communicated to CGHS in
advance as per the rules laid down. Even if the assignment is permitted by CGHS
in writing (at its sole discretion and on such conditions as CGHS deems fit), the
original HCO (assignor) shall remain liable for the performance of obligations
under this Agreement and any such arrangement shall not absolve the HCO of
its responsibilities and liabilities hereunder. If HCO is a partnership or a company
and it undergoes dissolution, winding-up or liquidation, this Agreement shall
stand terminated as of that date, and CGHS must be notified. Termination in
such case does not absolve the outgoing entity (or its legal heirs in case of
proprietorship) from liabilities incurred during the Agreement period. In the case
of HCO takeover, the liabilities shall also get transferred to the new ownership.
5.1.4 Registration in Health Facility Registry (ABDM): The HCO shall register
itself with the Ayushman Bharat Digital Mission (ABDM) Health Facility Registry
and obtain a unique Health Facility (HFR) ID prior to or at the time of
empanelment. The HFR ID must be provided in the empanelment application and
kept active. Furthermore, within 1 year from the date of this empanelment, the
HCO shall achieve at least ABDM “M3” compliance (meaning the HCO’s systems
are integrated with ABDM to the level required by CGHS for sharing data, etc.).
Compliance with the digital initiatives of the Government in healthcare is a
mandatory obligation. (For instance, “M3” compliance implies the HCO can share
Outpatient and Inpatient medical records to patients’ Personal Health Records
with consent, etc., as per ABDM protocols.)
5.1.5 Consumer Grievance Registration: The HCO shall register as a Convergence
Partner on the “consumerhelpline.gov.in” portal (managed by the Department of
Consumer Affairs) within one month of signing this Agreement. By doing so, any
consumer/patient complaints lodged on that portal regarding the HCO (including
complaints by CGHS beneficiaries) will be directed to the HCO for prompt
resolution. The HCO shall regularly check and address grievances received
through this or any other public grievance system.
5.1.6 Adherence to Standard Treatment Guidelines: The HCO is obligated to
practice evidence-based medicine and follow Standard Treatment Guidelines
(STGs) and protocols as may be prescribed by the Ministry of Health & Family
Welfare, Government of India, or generally accepted in medical practice. The HCO
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shall also institute and follow a rational Antibiotic Policy in line with
national/international guidelines to prevent misuse of antimicrobial / Antifungal
agents. The reports indicating resistance to routine antibiotics shall be examined
by the designated antibiotic committee. The usage of higher antibiotics and
antifungals shall be primarily according to the recommendations of a designated
committee. Any misuse of antibiotics will be treated as fraudulent activity (Ref:
Annexure A.III and Clause 14 of MoA). The use of IV albumin shall be as per
the standard prescription guidelines. The HCO and its doctors must ensure
judicious use of investigations and therapies, consistent with the clinical needs
of the patient.
5.1.7 Ethical & Rational Treatment Practices: The HCO shall not undertake any
treatment or procedure that is experimental or not approved by the relevant
regulatory bodies. The HCO shall not prescribe or administer any drug/treatment
that is not approved for use by the Indian regulatory authorities (e.g., DCGI for
drugs) or any treatment that lacks scientific evidence of efficacy for the given
indication. Use of advanced or expensive techniques (such as robotic surgery,
etc.) must be justified by clear advantages to the patient and not driven by
commercial considerations without scientific merit. The HCO should, as far as
possible, utilize established and proven techniques for treatment; any new or
newer form of drug or procedure (if not broadly accepted as standard of care)
should be used only if it is unequivocally in the patient’s interest with
demonstrated superiority over existing options, and its use must be specifically
indicated with proper informed consent.
5.1.8 Clinical Trials and Unapproved Therapy: The HCO shall not enrol CGHS
beneficiaries in any clinical research or trial of investigational drugs/devices
without explicit permission of CGHS and the informed consent of the patient, and
in no event shall CGHS be billed for the cost of any investigational therapy or
device. The HCO also shall not use medications or treatments that are not
approved by the FDA/DCGI or any relevant authority
5.1.9 Prescription Practices: All doctors at the HCO shall prescribe medicines and
investigations only as necessary and indicated for proper diagnosis and
treatment. The HCO’s specialists shall also mention generic names of medicines
and shall not insist on any specific brand of medication when writing
prescriptions for CGHS beneficiaries. The HCO and its specialists also shall not
prescribe vitamins, supplements, or other items of doubtful therapeutic value as
“medicines” if they are essentially nutritional supplements or supportive items
not admissible under CGHS. Prescribing costly drugs or high-end therapies
should be avoided when an equally effective, cheaper alternative is available. All
prescriptions must be duly signed and stamped by the treating specialist.
5.1.10 No Unwarranted Procedures or Investigations: The HCO affirms that
no unnecessary or unwarranted diagnostic tests, procedures, or surgeries will be
recommended or performed on CGHS beneficiaries. Every investigation or
treatment advised must be commensurate with the patient’s complaints, history,
provisional or confirmed diagnosis, and should be a standard of care for that
condition. Repetition of investigations should be only if clinically warranted (e.g.,
to monitor progress or if results may change). Splitting/Unbundling of a single
procedure into multiple procedures for billing purposes is strictly prohibited. If at
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any point it is found that the HCO indulged in over-prescription of diagnostics or
procedures without clinical justification, or in “upcoding” (misrepresenting a
procedure as more complex than performed), it will be treated as a fraudulent
activity and dealt with as per the penalty provisions of this Agreement (Ref:
Annexure A.III and Clause 14 of MoA). .
5.1.11 Acceptance of CGHS-supplied drugs under the Restricted
medicines category; Empanelled Health Care Organisations (HCOs) shall accept
and administer chemotherapy medications, supplied by CGHS under the
Restricted Medicines category (list available on CGHS Website
www.cghs.mohfw.gov.in). If the required drug is not supplied by CGHS, the HCO
shall procure and administer it to the beneficiary. The HCO shall enclose the
carton/outer pouch/vial reflecting batch no, manufacturing date and expiry date
and MRP. Cost admissible for the purpose of claims of such medicines used in
the treatment of CGHS beneficiaries shall be limited to 70% of MRP. HCOs cannot
charge more than that amount from CGHS nor collect the discounted amount
from the beneficiary.
5.1.12 Use of Approved Implants: The HCO shall mandatorily use
Indian-manufactured implants, stents, graft, medical devices, and disposables of
certified standard quality for CGHS beneficiaries. The HCO shall use imported
implants only in the instance where Indian implants are not available. The cost
of any implant/stent/graft is reimbursable separately in addition to package
rates, only up to the ceiling rate notified by CGHS or the actual purchase cost
mentioned in GST purchase invoice from external vendor. If the beneficiary, after
being informed of options, chooses a more expensive implant/device than the one
covered under CGHS rates (i.e., beyond the ceiling limit), the beneficiary will bear
the difference in cost – such difference is not reimbursable by CGHS. In all cases
where a higher-cost implant is used, the HCO must obtain written informed
consent from the beneficiary (or their relative) acknowledging the choice and
additional cost. The HCO must not compel or unduly influence a patient to choose
a costlier implant. If the implant used is unlisted, then the hospital can bill as
per actual purchase price as mentioned in the GST purchase invoice from the
external vendor.
5.1.13 Provision of Medicines & Consumables: The HCO shall not ask a
CGHS beneficiary (or their attendants) to procure medicines, surgical supplies,
or consumables from outside during the course of inpatient treatment or
approved outpatient treatment. All essential medicines and consumables
required for treatment (including during outpatient procedures like dressings,
POP casting, etc.) must be provided by the HCO from its in-house
pharmacy/stock and are considered part of the package or procedure rates as
per CGHS. Only items that are specifically listed as “non-admissible” under CGHS
(Annexure A.I, Table 5) or any permissible differential cost for implants (as
mentioned above) can be charged to the patient. If an HCO is found to have
directed patients to purchase admissible items from outside, or charged
separately for items that are part of package, CGHS will recover the cost of such
items from the HCO’s pending bills (and refund to the beneficiary if the beneficiary
paid), and such an incident may invite further action (including suspension or
removal from the CGHS panel).
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5.1.14 Provision of consumables and drugs costing above Rs 5000/-:
Subject to the provisions of Clause 5.1.11 & 5.1.12 above, all consumables and
drugs(excluding restricted medicines category) costing above Rs 5000/- shall be
charged/claimed as per actual purchase cost, as mentioned in the GST purchase
invoice from the external vendor. The HCO must enclose the GST purchase
invoice from the external vendor for drugs. In case of consumables, a certificate
from the treating doctor must be enclosed, certifying that:
a. Consumables used are single-use disposables
b. Consumables already used for any other patient have not been reused.
c. These consumables shall be disposed off and shall not be reused in any
other patient.
5.1.15 The hospital will issue discharge medications for up to 7 days, and the
bill towards the same will be enclosed along with the credit bill to be submitted
to the Bill clearing agency, subject to the following conditions
1) Only the essential medicines in generic form for continuity of treatment
will be issued by the hospital on request of the beneficiary.
2) No nutritional supplements, tonics, cough syrups, vitamins, or
injections will be issued by the hospitals.
3) No non-drug items/equipment/appliances will be issued.
4) The total cost of such medicines issued by the hospital must not exceed
Rs 2000/- in any case.
5) In case of beneficiaries where the treatment has been provided on a
cash basis, the amount may be collected towards the discharge
medications as mentioned above. The beneficiary shall be eligible to
claim the said amount from his/her department.
5.1.16 No Advance Payment & No Additional Charges:
a. The empanelled Health Care Organisation (HCO) shall not demand any
advance payment or security deposit from CGHS beneficiaries who are
eligible for a credit facility, as defined under Clause 11 of this
Agreement, at the time of admission or during the course of treatment.
b. The HCO shall not levy any separate registration fee, file charge, or
documentation charge on CGHS beneficiaries. Such beneficiaries shall
be deemed registered by virtue of the empanelment agreement with
CGHS.
c. The HCO shall not levy any additional fees for the issuance of Discharge
summaries, Investigation reports, image prints, Diagnostic films or CDs
etc. These documents are considered an integral part of patient care,
and their issuance is included within the CGHS-approved package, ward
charges or investigations rates.
Any violation of the above sub-clauses shall constitute a material breach of
the empanelment terms and may invite penal action, including deduction,
claim rejection, suspension, or de-empanelment as per CGHS policy.
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5.1.17 Reuse of Disposables Prohibited: The HCO shall use new, sterile
disposable items (such as catheters, guidewires, etc.) for each CGHS beneficiary
as required and shall not reuse any disposable medical item that is meant for
single use. Reusing single-use items not only violates medical protocols, but any
such practice, if noted, will be considered a serious breach of the Agreement (Ref:
Annexure A.III and Clause 14 of MoA).
5.1.18 Confidentiality and Dignity: The HCO shall maintain confidentiality
of all patient information and records as per law. It shall treat CGHS beneficiaries
with dignity and ensure a patient-friendly environment. Any form of
discrimination or substandard care toward CGHS beneficiaries compared to other
patients is strictly forbidden.
5.1.19 e‑Medical / e‑Ayush Visa Compliance: Every HCO empanelled under
CGHS shall, as a condition precedent for continued empanelment,
(a) register on the Government of India’s IVFRT (Immigration, Visa, Foreigners
Registration & Tracking) portal
at http://indianfrro.gov.in/frro/medicalvaluetravel
(b) generate and issue all medical‑treatment invitation letters for foreign nationals
exclusively through this portal, ensuring the correctness of every data field so
that Indian Missions and FRRO/FRO offices can verify the invitation online before
granting an e‑Medical or e‑Ayush Visa, and
(c) comply in full with the Standard Operating Procedure set out in
Ministry of Home Affairs Letter No. 25022/46/2022‑F.I dated 14 June 2024; any
failure to register or to follow the IVFRT workflow shall constitute a material
breach of this MOA, attracting penalties.
The above obligations are in addition to any other duties and responsibilities
specified elsewhere in this Agreement. Any breach of the foregoing obligations by the
HCO shall constitute a material breach of this Agreement, making the HCO liable to
penal action, including possible de-empanelment.
Clause 6:
Rights of CGHS Beneficiaries and Grievance Redressal
6.1 Non-Discrimination & Priority: The HCO shall not discriminate
against CGHS beneficiaries in any manner. CGHS beneficiaries are entitled to
the same quality and priority of medical care as any other patient of the HCO.
In fact, being under a government scheme, they should be accorded priority
attention. Under no circumstances shall a CGHS beneficiary be denied
consultation or treatment by any doctor (including specialists or super
specialists, whether full-time or visiting) at the HCO on the grounds of being
a CGHS patient. All facilities available at the HCO that are medically indicated
for the patient must be made accessible to the CGHS beneficiary at CGHS
rates. The hospital shall ensure that its doctors and staff maintain courteous
behaviour towards CGHS beneficiaries and address all queries related to the
treatment or investigations advised.
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6.2 Access to All Facilities: The beneficiary has the right to access all
facilities (including outsourced facilities). It is the responsibility of the HCO to
ensure that all available facilities are offered to beneficiaries at CGHS rates,
in accordance with the terms of empanelment.
6.3 Grievance Redressal Mechanism: The HCO shall establish an internal
Grievance Redressal Mechanism specifically for CGHS beneficiaries. An officer
of the rank of Medical Superintendent or equivalent of the HCO shall be
designated as the Grievance Redressal Officer for CGHS patients. Any
complaint or grievance from a CGHS beneficiary must be addressed promptly
by the HCO. The Grievance Officer shall ensure that all grievances are resolved
within 2 (two) working days of being reported. A monthly report of grievances
received from CGHS beneficiaries, and the resolution provided, shall be
compiled by the Grievance Officer, and a copy of this report shall be sent to
the Head/Administrator of the HCO and to the Additional Director, CGHS of
the city for review. Repeated or serious complaints may invite scrutiny by
CGHS (Ref: Annexure A.III and Clause 14 of MoA).
6.4 Appointment of Nodal Officers: The HCO shall also appoint 2 Nodal
Officers for day-to-day liaison with CGHS (one of the Nodal Officers should
also preferably be of senior rank, such as Deputy MS or similar, who is well
versed with CGHS rules). The nodal officers shall be responsible for
streamlining of treatment of beneficiaries, like providing clarification,
assistance in getting appointments, etc. The contact details (name,
designation, phone/mobile number, and email) of the Grievance Officer and
the Nodal Officer(s) shall be prominently displayed in the hospital, especially
at the reception/admission counter and the billing desk for CGHS patients.
6.5 Accessibility to all services to all eligible beneficiaries irrespective
of city.
a) As per prevailing government policy, a CGHS card is valid across India for
availing CGHS services. Accordingly, any CGHS beneficiary (or their
dependent), irrespective of their city of registration, is entitled to receive
treatment at CGHS rates at any empanelled Health Care Organisation (HCO),
provided they hold a valid CGHS card.
b) Additionally, Central Government employees and their dependents and
those belonging to Central Autonomous Bodies and Public Sector
Undertakings (PSUs) and who are holding a valid CGHS card, are also eligible
to receive treatment at CGHS-approved rates on production of a valid Identity
card
6.6 Consequence of Denial: Refusal to provide treatment to a bona fide
beneficiary (especially in emergency, or denial of cashless service to those
entitled) without valid grounds would be considered a serious violation (Ref:
Annexure A.III and Clause 14 of MoA). If the HCO refuses treatment or does
not honour the CGHS card in any legitimate case, CGHS reserves the right to
immediately suspend or cancel the empanelment of the HCO. The HCO will
also be liable to reimburse any expenses incurred by the beneficiary due to
such refusal, and further actions as per this Agreement may be taken.
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Clause 7:
Referral Procedure, Authorisations and Admissions
7.1 Authorisations shall be issued by CGHS (for CGHS beneficiaries, including
Pensioners serving employee and their dependent beneficiaries.) The permissions
issued by any Government specialist of any Government Hospital and HOO/HOD of
respective employee dependent beneficiary are equally valid and shall be honoured
by all HCO throughout India.
7.1.1 OPD Consultation and Treatment: Primary referral for consultation to a
specialist/ super specialist at empanelled HCO is also valid for 5 more
consultations, provided they are availed within 3 months. These consultations
could be with the same speciality or cross consultations. However, these should
be based on clinical need, and HCO shall upload consultation notes justifying
need for follow-up or opinion of other specialists, along with other relevant
documents including geotagged photo and undertaking by the beneficiary. Each
outpatient consultation is valid for 7 days, before which another
consultation in the same speciality is not permitted. Additionally, no further
endorsement from CGHS shall be required for undergoing routine listed
investigations and minor procedures, not requiring admission in the hospital, as
advised by the specialist, within the validity period of 3 months from the date of
issue of the initial referral. The follow-up tests and consultations to be performed
in the same hospital. However, Referral/endorsement from CGHS shall be
required for special investigations like Dental procedures, Physiotherapy, OCT
eye scan, CT scan, MRI Scan, PET Scan, and any other investigation costing over
Rs. 3.000/-, and the referral will be valid for 3 months
7.1.2 Indoor treatment - An Authorization Letter/Referral/Permission is required
from CGHS or concerned Head of office (HOO)/Head of Department (HOD) for any
elective hospitalization, surgery or procedure that necessitates admission
(including day-care admissions), as well as for any listed outpatient
procedures/investigations that are beyond the scope of direct referral (e.g.,
CT/MRI scans as noted). Admission should be done only after such permission
is granted, except in case of a medical emergency.
7.1.3 The Special and High end procedures (like Transplant surgeries,
Intravascular lithotripsy (IVL), Trans-catheter Aortic Valve Implantation (TAVI),
Deep Brain Stimulation (DBS) implantation etc), unlisted treatments, implants,
investigations, Restricted Drugs, shall require prior approval of CGHS (in respect
of Pensioner beneficiaries) and by the Head of Office or the Head of Department
in case of Serving employee beneficiaries; except in case of justified medical
emergency. In respect of unlisted investigations/implants/treatments, the HCO
must provide an estimate to the beneficiary to obtain a specific approval for the
same from the competent authority. Such a permission is also required in
specialised procedures
7.1.4 The approval for the procedure shall be granted by the Competent Authority
only after due examination of its essentiality and the associated cost. The
authority may examine and compare with the estimate received from other HCOs.
Upon issuance, such approval shall be binding on the empanelled Health Care
Organisation (HCO), which shall be obligated to perform the procedure within the
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approved cost and shall not collect any amount from beneficiaries over and above
the approved cost.
7.1.5 Relaxation for beneficiaries above 70 years – The patients above 70 years
(limit defined are eligible to avail direct consultation without prior permission
from CGHS. If the treating physician advises any treatment or investigations
during such consultation, the same may be availed without any endorsement or
permission from CGHS. However, OTP based authentication, submission of
geotagged photos, Aadhar authentication, biometric authentication etc shall be
followed as per the prevalent CGHS orders. Those eligible for credit shall be given
credit. Those not eligible for credit shall pay and get reimbursement from the
concerned authorities. The HCO shall obtain an undertaking (Annexure A.VI) and
attach a geotagged photo along with all relevant documents. All enclosed
documents shall justify each consultation, investigation performed, and
treatment given. (Pensioners' beneficiaries shall get cashless treatment, and
serving dependent beneficiaries will make payment and get reimbursement from
the parent department)
7.2 Emergency Treatment (No Prior Referral Required):
In emergencies, no prior CGHS referral or permission is needed for a CGHS
beneficiary to receive treatment at the HCO. The HCO is mandated not to refuse
admission or demand any advance payment from a CGHS beneficiary (whether
serving or pensioner holding a CGHS card) in an emergency. The guiding principle is
to save life first, paperwork later.
7.3 Procedure for Treatment When Required Specialty Not Available at HCO:
If a CGHS beneficiary is admitted to the HCO and, during the course of treatment, it
is found that the patient requires a medical/surgical speciality or service that is not
available at the HCO (for example, a super-speciality procedure that the hospital is
not equipped to handle):
7.3.1 In case of an emergency requiring immediate intervention, the HCO shall do
everything necessary to stabilise the patient. If the patient’s condition permits
and requires further treatment that the HCO cannot provide, the HCO shall
arrange to safely transport the patient to the nearest empanelled hospital where
the required speciality is available. All the protocols applicable to the transfer of
an emergency patient shall be followed in order to ensure the health of the
beneficiary is not compromised
7.3.2 If the need for a speciality service is non-emergent (elective) and the HCO lacks
that service, the HCO shall not admit the CGHS beneficiary for that elective
treatment. The patient should be advised to obtain a referral from a wellness
centre that has the required facility. (In other words, the HCO should not “hold”
a patient when it knows it cannot provide the definitive treatment needed, as this
could cause delay in care.)
In all cases, patient safety and continuity of care are paramount. The HCO is
expected to facilitate the best possible outcome for the beneficiary within the CGHS
framework.
Clause 8:
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Reporting, Monitoring, and Information Obligations
The HCO agrees to the following reporting and cooperation requirements, to enable
CGHS to monitor services and ensure smooth operation of the empanelment:
8.1 Notification of Changes in Infrastructure or Location: The HCO
shall immediately notify the Additional Director, CGHS (of the concerned city)
in writing of any significant change in its infrastructure, capabilities, or staff
dealing with CGHS that formed part of the empanelment credentials. This
includes but is not limited to any major reduction in beds, closure of any
important department or facility, shifting of premises to a new location,
change in management or ownership that might affect services, or any
downgrading of facility. The Empanelment is specific to a location and facility.
Hence, in case of shifting premises, the empanelment at the old location shall
be deemed suspended from the date of closure, and the new facility (even if
under the same name/management) shall require a fresh inspection for
accreditation by accrediting bodies and approval by CGHS (with payment of
any prescribed inspection fee) before empanelment can continue at the new
site. Failure to inform of changes can lead to withdrawal of empanelment.
8.2 Monthly/Annual Patient Data Reporting: The HCO shall maintain
records of CGHS beneficiary visits and treatments and submit periodic reports
to CGHS. Specifically, a Daily intimation of any emergency CGHS admissions
and of CGHS beneficiaries above 70 years treated (as inpatient or day-care)
should be furnished to CGHS (through email or portal as instructed). Monthly
reports must be submitted to the Additional Director, CGHS (city………..)
summarising: the number of CGHS referrals received, the number of CGHS
beneficiaries (serving and pensioner) who visited the HCO for OPD or admitted
as IPD in that month, the number of CGHS bills/claims submitted (with total
value), instances where admission could not be provided due to lack of
available beds and the payments received against previous claims. The format
for the monthly report may be prescribed by CGHS. Additionally, the HCO
shall submit an Annual Report each year (for the period April–March, unless
specified otherwise) in the format provided in Annexure A.II. The Annual
Report includes details about the HCO’s empanelment status (e.g., any change
in accreditation status, validity of Performance Bank Guarantee, etc.),
aggregated statistics of CGHS patients handled, and a summary of any
complaints and actions taken. The Annual Report must be submitted to the
Additional Director, CGHS – [Name of City] by a specified date after the end of
each financial year, along with a copy of the HCO’s annual audit report if
required.
8.3 Electronic Medical Records (EMR/EHR): The HCO shall implement
Electronic Medical Records / Electronic Health Records systems conforming
to the standards & guidelines approved by the Ministry of Health & Family
Welfare. The HCO shall disclose the availability and operational status of its
Electronic Health Records (EHR) / Electronic Medical Records (EMR) system
at the time of submitting the empanelment application. EHR/EMR shall be in
place before applying for empanelment if not already in place. The HCO should
work towards integration of such systems with CGHS/ABDM digital
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frameworks so that patient records can be shared securely for continuity of
care and audits.
8.4 Meetings and Coordination: The HCO’s authorised signatory or a
designated senior representative shall attend periodic meetings convened by
CGHS authorities. CGHS may call meetings such as Local Advisory
Committee (LAC) meetings, Zonal Advisory Committee (ZAC) meetings, or
“CGHS Panchayat” meetings with empanelled hospitals to discuss and
address issues related to beneficiary treatment, to streamline procedures, and
to resolve grievances. It is mandatory for the HCO to participate in such
interactions and implement any decisions or guidelines that emerge from
these forums.
8.5 Inspections and Audits: The HCO agrees to cooperate with any
inspections conducted by officials of CGHS, Ministry of Health & FW, or the
Directorate General of Health Services (DGHS), or by the Bill Clearing Agency
(BCA) acting on behalf of CGHS. Authorised representatives (including the
Additional Director or his/her representatives, CMO In-charge of CGHS
Wellness Centres, members of Empanelment Committees, or designated
Medical Audit Teams ) may visit the HCO with or without prior notice to assess
the facilities, check beneficiary treatment records, or investigate complaints.
The HCO shall extend full access to patient records, including financial
records like purchase invoices (pertaining to CGHS cases) and allow
inspection of the premises and services. The HCO’s management and staff are
expected to be courteous and forthcoming during such inspections. Any
information or clarification sought by CGHS or the NHA (e.g., in response to a
query about a particular claim or a general inquiry) should be promptly
provided by the HCO. The HCO shall also respond in writing to any show
cause notices or explanation calls from CGHS within the stipulated time
frame.
8.6 Cooperation in Public Health Emergencies: In the event of any
natural disaster, epidemic/outbreak, or public health emergency, the HCO
shall fully cooperate with government authorities. Upon request of the
Ministry of Health & FW, DGHS, or CGHS officials, the HCO should make
available its resources (beds, manpower, etc.) to aid in management of the
situation, and share necessary information (such as cases treated, disease
surveillance data) as part of the public health response. Such cooperation may
include admitting patients from a disaster or epidemic under CGHS terms or
otherwise, as mutually agreed with health authorities. The HCO shall not
unreasonably refuse any reasonable request of the government in such
situations, recognising the larger public interest.
8.7 Training for CGHS Staff (On Request): The HCO, being a high-quality
healthcare provider, agrees that upon request by CGHS, it may facilitate
training sessions or workshops for CGHS medical/paramedical staff or
officials. This could be in the nature of clinical training, orientation to new
medical technologies, or hospital management practices, etc. Such requests
will be reasonable and occasional, and the HCO’s cooperation will further
strengthen the CGHS system. (Any such training extended will be on mutually
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agreeable terms and not at the HCO’s cost beyond providing access, unless
otherwise specified.)
8.8 All adverse events, including serious drug/vaccine reactions (death,
life-threatening condition, hospitalisation, disability, congenital anomaly, or
requiring intervention), shall be mandatorily reported by healthcare
professionals/HCOs. Serious adverse events shall be reported through the
prescribed notification form at http://www.ipc.gov.in. This obligation applies
to drugs supplied by CGHS as well as by the empanelled hospital.
8.9 HCOs, Medical practitioners and diagnostic laboratories shall
mandatorily notify the local health authorities of all cases of notifiable
diseases, as required under law.
By complying with the above, the HCO will enable CGHS to ensure the scheme runs
smoothly for beneficiaries and that the HCO itself stays aligned with CGHS
requirements.
Clause 9: Display of Information and Nodal Contact Points
For the transparency and convenience of CGHS beneficiaries, the HCO shall
prominently display certain information and provide trained staff for handling CGHS
cases, as detailed below:
9.1 Empanelment Signage: The HCO shall display at prominent places
(e.g., at the main reception, billing counters, and emergency entrance) a notice
stating that “This Hospital/Centre is Empanelled under CGHS for [CGHS
City]” for the information of beneficiaries. However, the HCO shall not misuse
or exaggerate this empanelment for undue commercial gain. The CGHS name
or the fact of empanelment must not be used in any advertisements aimed at
promoting the HCO’s business beyond a simple statement of fact. Specifically,
the HCO must avoid projecting CGHS/Ministry of Health & Family Welfare or
the Government of India’s name in any manner that suggests endorsement of
the hospital over others in the market.
9.2 Nodal Officer Contact Details: As required in Clause 6.4, the HCO
must display the contact details of its CGHS Nodal Officers and Grievance
Redressal Officer. This information (name, designation, location of office
within hospital, direct phone/mobile, and email) should be clearly visible at
the CGHS helpdesk or reception. The Nodal Officers should be easily
accessible to CGHS beneficiaries and CGHS authorities, and at least one
Nodal Officer of sufficiently senior rank (e.g., Medical Superintendent or
Deputy MS) should be available to intervene in case of any issues (especially
for grievance resolution). The HCO should also provide CGHS authorities with
up-to-date contact numbers (including after-hours emergency contact) for a
managerial point-of-contact (such as a Manager on Duty or Credit Cell in
charge) who can coordinate admissions or resolve issues on a 24x7 basis,
especially for emergency admissions on credit. A comprehensive list updated
from time to time of Nodal Officers and Grievance Redressal Officers for each
empanelled HCO shall be prominently displayed on the CGHS and MoHFW
websites, along with their contact details.
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9.3 List of Eligible Beneficiaries for Credit: The HCO shall clearly display
the list of categories of CGHS beneficiaries who are eligible for credit (cashless)
treatment. For instance, a board can enumerate: “CGHS Pensioners (Green
Card), Serving employees of CGHS/MoHFW (Blue strip card), Ex-Members of
Parliament, Freedom Fighters, etc., are eligible for cashless treatment – please
produce a valid CGHS card.” In case of emergency, the serving employees
holding CGHS card (Blue strip) are also eligible for the cashless facility.
However, they are to submit a letter from their department indicating
beneficiary entitlement and authority designation and the address where the
claim must be submitted by HCO for receiving payment before the discharge.
Further details in Table 3 below:
Category of CGHS Beneficiary
Eligibility for
Credit/ Cashless Treatment
Bill Submission and Payment Process
Payment authority
Pensioners holding CGHS Card with green strip, Ex Members of Parliament, Freedom Fighters
Sitting Members of Parliament holding CGHS Card with Red Strip
Yes Credit Bills to be submitted to
National Health
Authority portal
(NHA) online.
Yes HCO shall submit directly to the
concerned
Parliamentary
Secretariat (Lok
Sabha/Rajya
Sabha), New Delhi;
the HCO shall
retain a copy for a
minimum of five
years.
CGHS
through NHA
Lok Sabha /Rajya
Sabha
Secretaria t, New
Delhi.
| Serving CGHS/DGHS/Ministry of H&FW Employees and their dependents holding CGHS Card with Blue Strip | Yes | Physical bills in duplicate shall be submitted to the Office of the Additional Director of the concerned CGHS city where treatment is undertaken in respect of Serving CGHS employees and to the concerned | HOD/HO O of Concerne d Departme nt |
|---|
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Category of CGHS
Beneficiary
Serving Employees and their dependents of all other Departments (other than CGHS/DGHS/Ministry of H&FW) holding CGHS Card with Blue Strip
Eligibility for
Credit/
Cashless Treatment
Credit to be given in
emergenc y cases. Obtain
*letter
from the HOO/HOD of the
Beneficiar y
departme nt.
Bill Submission and Payment
Process
Department in respect of
DGHS/Ministry of H&FW Employees
Physical bill in duplicate to be submitted to the Office of the
beneficiary as mentioned in the letter given by the HOO/HOD of the concerned
department.
Payment authority
HOD/HO O of
Concerne d
Departme nt
Pensioners of Autonomous bodies holding CGHS Card with Yellow Strip
No Treatment shall be provided on a
payment basis as
per the CGHS
Rates.
Beneficiaries shall
seek
reimbursement
from their
department
HOD/HO O of
Concerne d
Departme nt
| Pensioners of Air India (Orange Strip) | Yes. | To be submitted to Bill Clearing Agency as decided by concerned authorities. | Air India Assets Holding Limited (AIAHL) |
|---|
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Category of CGHS Beneficiary
Eligibility for
Credit/ Cashless Treatment
Bill Submission and Payment Process
Payment authority
| Currently the BCA is UTIITSL |
|---|
*The letter shall certify the entitlement of beneficiary or dependent of beneficiary along with details of submission of bill and payment process
9.4 Bed availability status: The availability status of beds in different wards (General, Semi-private, Private) and ICU should be updated and displayed daily in real time wherever possible so that CGHS beneficiaries are aware of bed availability, and to ensure transparency in admission category. The CGHS Beneficiaries have the right to occupy all available vacant beds, and HCO should not restrict the allotment of beds by fixing some percentage of beds to CGHS patients. In the event of bed unavailability, the HCO shall provide a written notice to the CGHS beneficiary, duly signed and stamped by the designated Nodal Officer.
9.5 Helpdesk and Staff Orientation: A dedicated CGHS help desk or counter with trained personnel shall be setup to streamline the treatment of CGHS patients. This counter would assist beneficiaries in filling forms, explain entitlements, and coordinate paperwork like credit bills and discharge documentation. The HCO shall ensure that its staff handling CGHS beneficiaries (front desk, billing, admission, medical records, etc.) are well
trained in CGHS procedures and guidelines. It is the prime responsibility of the HCO to keep copies of key CGHS policy documents, rate lists, and latest CGHS circulars at the counters dealing with CGHS patients apart from keeping the concerned staff trained. These should serve as references for staff and also for beneficiaries who may have queries. Periodic internal training should be conducted so that staff are updated on any changes (for example, a change in rules about referrals or an update in rates).
By adhering to the above, the HCO will facilitate CGHS beneficiaries in availing services with minimal hassle and ensure clarity in the hospital’s dealings with them.
Clause 10:
Entitlement of Wards and Treatment Charges
All treatment provided under this Agreement shall be as per CGHS-approved rates and beneficiaries’ entitlements. The following terms apply to charges and billing for CGHS beneficiaries:
10.1 Ward Entitlement: CGHS beneficiaries are entitled to hospital accommodation (rooms/wards) based on their pay grade/pension. The HCO must provide accommodation according to the beneficiary’s eligible ward category as per CGHS
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norms. The current entitlement criteria (subject to revision by the Government) are
as below:
10.1.1 General Ward – Eligibility: Central Govt. employees with pay up to ₹36,500
(Level 1 to 5, as per 7th CPC) or equivalent pensioners. Definition: A general ward
is typically a hospital room/hall with 4 to 10 beds without an attached bathroom
(common for the ward) and basic amenities. Rate: ₹1,500 per day.
10.1.2 Semi-Private Ward – Eligibility: pay range ₹36,501 to ₹50,500 (Level 6) or
equivalent. Definition: A semi-private ward is a room with 2–3 beds, an attached
toilet facility, air-conditioned, with necessary furnishings. (Usually includes a
nurse-call system, etc.) Rate: ₹3,000 per day.
10.1.3 Private Ward – Eligibility: pay ₹50,501 and above (Level 7 and above) or
equivalent. Definition: A private ward is a single-bed room with an attached toilet,
furnished with a wardrobe, bedside table, attendant’s bed/sofa, etc., and is air
conditioned (with nurse-call system). Rate: ₹4,500 per day.
10.1.4 ICU/ICCU/Neonatal ICU/Paediatric ICU/HDU/Isolation Ward –
Entitlement: These critical care areas, when needed, have the same rate for all
categories of CGHS beneficiaries (no distinction by pay level in ICU charges). The
ICU charge includes monitoring and diet; it excludes ventilator charges
(ventilator, if used, is billed separately as per CGHS rate). ICU Rate: ₹5,400 per
day (for any category of patient).
10.1.5 Day Care (6–8 Hour’s admission) – Sometimes a patient is kept under
observation or short-term treatment in the emergency/observation ward not
requiring overnight admission. For such day-care cases (6–8 hours) across all
categories, a flat day-care charge of ₹1,500 is applicable towards accommodation
charges.
(The above rates are subject to change as per CGHS orders. “Pay” refers to basic pay
of the entitlement rule. The HCO should verify the beneficiary’s entitlement category
from their CGHS card or employment details.)
No beneficiary shall be accommodated in a ward lower than their entitlement. If the
entitled category ward is not available on admission, the HCO must provide a higher
category ward (if available) but charge only the rate of the entitled category. For
example, if a semi-private entitled patient is kept in a private ward due to the non
availability of semi-private, the billing shall still be at semi-private rates. Under no
circumstances should a beneficiary be asked to accept a lower category (e.g., general
ward for someone entitled to semi-private).
10.2 Approved Rates: The empanelled HCO shall charge CGHS beneficiaries strictly
as per the CGHS notified rates applicable at the time of service, subject to the
condition that if the HCO’s own usual rates for a service (charged to general patients)
are lower than the CGHS rate, the lower rate shall be charged. In summary, the
chargeable rate is the CGHS rate or the HCO’s usual rate for public (not covered by
any schemes/insurance), whichever is less.
10.2.1 The CGHS rate list (both General and Cancer rates, as applicable) for
the city and the procedures for which the HCO is empanelled are an integral part
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and are available on the CGHS website (http://cghs.mohfw.gov.in). The HCO
shall give an undertaking that it understands the inclusions and exclusions for
each listed procedure/package in the CGHS rate list. The definitions, inclusions
and exclusions of ward charges, packages, and implant rates are well understood
by them, and they will strictly charge as per CGHS rates and guidelines. It shall
collect money only towards non-admissible items as per the non-admissible list.
The HCO shall not unbundle components of a package and charge them
separately if they are included as part of a package rate. Similarly, items that are
part of ward/day-care charges or part of procedural charges as per CGHS
definitions (e.g., routine nursing care, routine consumables, documentation, etc.)
must not be billed additionally (Annexure A.I provides lists of non-admissible
and already-included items).
10.2.2 The HCO has provided (during application) a schedule of its normal
charges for various procedures and services, and a comparative statement with
CGHS rates. The HCO hereby certifies that CGHS beneficiaries shall not be
charged more than what is charged to its general (non-CGHS) patients for any
given service. The HCO shall furnish an authenticated list of its current prevailing
rates (for major procedures, ward charges, investigations, etc.) for general
patients to CGHS, along with the application. This list will be used by CGHS for
reference to ensure that at no point is CGHS billed at a higher rate than other
patients. In case the HCO revises any of its charges downwards for general
patients (sales/discount etc.), the benefit should also pass to CGHS bills if lower
than CGHS rates.
10.2.3 Revision of Rates: CGHS rates are subject to change via the Ministry’s
orders. The HCO agrees that any revision (increase or decrease) in CGHS rates or
introduction of new rates during the period of empanelment shall be applicable
to this Agreement from the effective date of such order. CGHS will endeavour to
inform empanelled hospitals of such changes, but it is the HCO’s duty to keep
track of official rate revisions. The HCO or CGHS may, if required, append the
updated rate list to this Agreement by mutual signing, but even if not physically
appended, the latest CGHS-notified rates shall override previous ones.
10.3 Billing under Package Rates:
10.3.1 For all procedures for which a CGHS Package Rate has been prescribed,
the Empanelled Health Care Organisation (HCO) shall charge strictly in
accordance with the applicable package rate. The handwritten bills are not
acceptable. The package rate is comprehensive in nature and includes the cost of
all services, consumables, and components as defined under Clause 1 (Definition
of Package Rate) and Annexure A.I (List of Included Items). No additional charges
shall be levied on the beneficiary for any items or services that are part of the
defined package.
10.3.2 The HCO is required to adhere strictly to the scope and definition of the
package, as outlined in the CGHS guidelines. CGHS encourages a single-line
billing format for surgical packages, except in cases where there is documented
medical management of co-morbid conditions or complications that are clearly
unrelated to the primary surgical procedure.
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10.3.3 In cases of conservative management, ward charges, consultations,
blood charges, investigations, and any other similar items, where the individual
components are clearly defined, shall be considered an integral part of the
respective item. If any such component is already included in the charges for that
item, it shall not be billed or recovered separately from the patient. Annexure A.I
provides a List of Non-Admissible Items (which are never reimbursable) and a List
of Items Included in Packages, which clarifies many such components. The HCO
must ensure its billing software or staff do not add these items to CGHS bills. If
any such inadmissible or included item is found billed, CGHS/BCA will disallow
it and may impose a penalty for overcharging.
10.3.4 While submitting the claim, both the non-admissible items for which
HCO has collected the amount and the essential treatment bill, which will be
uploaded to the NHA portal for claiming from CGHS, shall be uploaded as
separate documents. The HCO shall ensure to transparently disclose any amount
collected from the beneficiary, along with a detailed breakup of such amounts,
clearly identifying the non-admissible items or services against which the
collection has been made. Such non-admissible items must be excluded from the
claim submitted to CGHS for reimbursement.
10.3.5 The HCO understands the duration of hospitalisation covered by each
package (as defined in CGHS rate list/tender). If a patient’s hospital stay extends
beyond the specified days in the package due to complications or justified medical
reasons, the HCO can request additional reimbursement as per CGHS rules:
typically limited to ward charges, routine investigations, and two doctor visit
charges per day and cross consultations based on the clinical needs of the patient
for the extended period. Such extensions will be scrutinised; if the extension is
due to hospital-acquired infection, surgical complication, or any fault of the HCO,
no extra charge should accrue to CGHS or the patient. If multiple specialists’
visits were needed beyond the package, justification must be provided in the
claim.
10.3.6 If CGHS has no package rate for a particular surgery/treatment (and it
is not a listed procedure), then billing shall be done item-wise as per CGHS rates
for ward, surgery, investigations, etc., but in aggregate not exceeding the HCO’s
normal package (if the HCO has its own package for it) or reasonable estimate.
Prior permission is required in such cases.
10.4 Same billing practice to be followed for non-credit eligible beneficiaries:
HCO shall apply a similar billing practice of package rates, item-wise billing practice
in case of medical management and shall strictly adhere to the List of Non-Admissible
Items (which are never reimbursable) and the List of Items Included in Packages,
which clarifies many such components (Annexure A.I). All guidelines, like for
implants, high-end specialised procedures, supply of chemotherapy drugs, unlisted
procedures, implants, etc, are applicable on similar lines
10.5 Purchase of Implants from Outside: As stated, the HCO must supply
necessary implants and disposables from its own pharmacy stock. Implants, which
are payable in addition to package rates, are to be provided to the patients. The
hospital shall charge either the actual purchase cost or the CGHS ceiling rate,
whichever is lower. The hospital shall enclose the GST purchase invoice from the
external vendor. No handling charges are allowed. If any bulk purchase was done by
the hospital (covering multiple items or patients), a copy of the bulk invoice with the
particular batch/lot highlighted can be given along with a declaration that the rate
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charged is proportionate and not higher than the pro-rata of the bulk. Additionally,
for implants/prostheses, the surgeon must certify in a letter that the specific implant
(give details: make, model, size, etc.) was used in the patient and is functioning well.
Failure to provide required documentation for such outside purchases may lead to
the disallowance of those charges in claims.
10.6 Action on Overcharging: If an instance comes to light where the HCO has
overcharged a CGHS beneficiary (i.e., charged above CGHS rates or charged patient
for an item that should not have been charged), CGHS shall issue a written warning
to the HCO apart from directing the HCO to refund the excess charged amount to
beneficiaries along with actions as mentioned in Annexure A.III
In summary, the HCO must charge strictly within entitlements and at CGHS
approved rates only. Any deviation not only burdens the beneficiary but also violates
this Agreement, attracting penalties.
Clause 11:
Billing, Claim Submission and Payment Procedure
The process for submission of bills/claims and receiving payments for the treatment
of CGHS beneficiaries is as follows:
11.1 Credit Facility and Categories of Beneficiaries: CGHS distinguishes between
categories of beneficiaries who are eligible for cashless (credit) treatment and those
who are not eligible for credit (must make payment themselves and seek
reimbursement). Central Government pensioners and other specified categories are
treated on credit, whereas serving employees (except defined cases) pay and then
claim reimbursement from their departments, unless an emergency credit procedure
is invoked. The broad categorisation is:
11.1.1 Always Credit (Cashless): Pensioner CGHS card holders (with Green
colour code on card for pensioners), Ex-Members of Parliament, Freedom
Fighters, and certain other entitled categories like former Governors, former Vice
Presidents, etc., are eligible for cashless treatment. These beneficiaries should
not be charged by the hospital at the time of service (except for any non
admissible expenses as per CGHS rules). The claim shall be submitted as per the
laid-down procedure.
11.1.2 Credit for Sitting MPs and CGHS/MoHFW Serving Employees:
Sitting MPs holding a red-stripe CGHS card and serving employees of CGHS,
DGHS, and MoHFW (blue-stripe) with their dependents are eligible for cashless
treatment at the HCO; for claims, if a sitting MP is treated the HCO shall submit
physical bills in duplicate directly to the concerned Parliamentary Secretariat (Lok
Sabha/Rajya Sabha); for serving CGHS employees (blue-stripe) and their
dependents, the HCO shall submit physical bills in duplicate to the AD office of
the concerned CGHS city, while for serving DGHS and MoHFW employees (blue
stripe) and their dependents, the HCO shall submit physical bills in duplicate
directly to the concerned Ministry/Department.
11.1.3 Credit for Air India Beneficiaries: The Air India beneficiaries holding an
orange stripe card are entitled to credit. However, the bills are to be uploaded to
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the respective BCA portal (currently UTI ITSL). The protocol for uploading the bills
is the same as in the case of pensioner beneficiaries to the NHA portal.
11.1.4 Emergencies – Serving Employees of Other Departments: If a
serving employee (holding CGHS card-blue strip) of a ministry (other than Health
Ministry) or their dependent is brought in an emergency and does not have prior
permission for credit, the HCO should still provide treatment without demanding
advance. The HCO should obtain a letter from the patient’s Head of Office as soon
as possible (the patient’s family or department can arrange this, confirming the
person is a central govt employee entitled to CGHS and that bills will be
reimbursed, clearly mentioning the bill submission and paying authority, along
with the timeline for payment of the bill. Considering the emergency situation, a
reasonable time shall be given to the beneficiary or his relatives to submit such a
letter from their office. Under no circumstances, emergency treatment be delayed
or denied for a delay in providing the letter. With such a letter, the HCO can treat
the case as credit. The bill, after treatment, would then be sent to the patient’s
department for direct payment to the HCO. (The specifics are below.) .
11.1.5 No Credit (Pay & Reimburse): Serving employees and their
dependents other than Ministry of Health (Holding blue stripe card), Serving
employees of central Autonomous Bodies/Statutory Bodies, Public sector
undertakings on CGHS (Holding Yellow stripe card), are entitled to receive
treatment on payment at CGHS rates. However, Central Government serving
employees and their dependents holding a blue stripe card are eligible for credit
under emergency.
11.1.6 For clarity, the following outlines the bill submission and payment
authority for major categories:
11.1.7 CGHS Pensioners (Green Card strip), Ex-Governors, Ex-MPs,
Freedom Fighters: Credit. The HCO shall submit these bills online to the NHA.
The physical original bills and supporting documents must be kept by the HCO
(for at least 5 years) and only furnished to CGHS if asked for an audit. The claims
shall be uploaded to the NHA portal, and CGHS will arrange direct payment to
HCO.
11.1.8 Sitting Members of Parliament (Red Card strip): Credit. The HCO
must submit physical bills (in duplicate) to the Additional Director, CGHS of the
city where treatment took place. The CGHS AD’s office will forward the bills to the
Lok Sabha/Rajya Sabha Secretariat, New Delhi (as applicable) for payment to the
HCO. (The HCO should keep a copy and also retain records for audit.) (Payment
Authority: Parliament Secretariat). Contact details as below
Sr. no.
Name of the nodal Office Address & Telephone no. of the concerned Organisation
| 1 | Deputy Secretary Lok Sabha Secretariat | Room No.138, First Floor, Parliament House Annexe, New Delhi – 110001 Phone no. 011-23035676/ 5151/ 5861 |
|---|
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| 2 | Deputy Secretary Rajya Sabha Secretariat | Room No. 228, Second Floor, Parliament House Annexe, New Delhi 110001 Phone no. 011-23034228 |
|---|
11.1.9 Serving Employees of MoHFW (including CGHS/DGHS) (Blue Card
strip with designation): Credit. For serving CGHS employees (“blue-stripe”) and
their dependents, the HCO shall submit physical bills, in duplicate, to the
Additional Director (CGHS) of the respective city; for serving DGHS/MoHFW
employees (“blue-stripe”) and their dependents, the HCO shall submit physical
bills, in duplicate, directly to the concerned Ministry/Department. (Payment
Authority: Respective Department/Ministry HOD/HOO.)
11.1.10 Serving Employees of other Departments (Blue card) – in Emergency
cases where credit was extended on the basis of dept letter: The HCO must
secure a letter from the patient’s HoD/HoO stating that the patient is entitled
and the department will consider the bills. Then the HCO will submit the
physical bills to that beneficiary’s office/department directly (or via CGHS AD
if instructed, but usually directly since the department pays). The
department’s HoD/HOO will arrange payment to the HCO as per Government
rules. If no such letter is obtained, the HCO might not get paid – so it’s
essential to coordinate on this when patient stabilizes. (Payment Authority:
Beneficiary’s Department/Office.)
11.1.11 Pensioners of Autonomous Bodies (Yellow card for CGHS, if any):
These cases are Non-Credit (as per CGHS instructions). The HCO should
charge them at CGHS rates, and the beneficiary will pay the bill. The
beneficiary then seeks reimbursement from their own organisation as per that
organization’s rules. The HCO’s contract for payment is with the patient in
such cases. (In summary, treat at CGHS rates, but Payment Authority: the
patient (who later claims from their organisation.)
11.1.12 Pensioners of Air India (CGHS cards issued to AI retirees): Special
category – Credit as per the current policy. The HCO will submit claims to the
designated BCA (currently UTIITSL) or as directed; payment will be made by
Air India’s concerned authority via the BCA. (Payment Authority: Concerned
Air India authorities via BCA.)
The HCO is responsible for familiarising itself with these categories. Annexure A.II
(Annual Report format) or CGHS guidelines often list the colour coding on cards for
easy reference. If in doubt, the HCO’s billing department should liaise with the CGHS
Nodal Officer or CGHS Wellness Centre.
11.2 Presentation of Bills/Claims:
11.2.1. For credit bills that the HCO submits (whether to NHA/ BCA or to Govt
offices), each claim must be prepared and submitted in the required format with all
supporting documents. The HCO shall use the electronic billing system/portal
provided by the NHA/BCA for online submission wherever applicable (for CGHS
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pensioner bills, etc.). Even when physical submission is needed (e.g., to a
department), the HCO should maintain a digital record. The HCO shall have
adequate manpower to submit bills, regularly monitor the NHA/BCA portal for claim
status and queries, and respond quickly to avoid loss of legitimate payments.
11.2.2. All bills must be submitted in a timely manner – as per CGHS instructions
(generally within 45 days of discharge for credit bills to NHA, etc., subject to current
guidelines). Delayed submissions beyond 45 days shall be rejected and there is no
scope for delay in condonation under any circumstance. The HCO must also
promptly respond to any queries on bills within stipulated timelines.
The following documents (in chronological order) shall be compiled with each
bill/claim:
a. Copy of the CGHS Card (front and back) of the beneficiary (for reference of
entitlement and identity).
b. Copy of the CGHS Permission/Referral Letter for treatment/procedure,-
In cases of elective treatment of < 70 years beneficiaries and In all cases of
planned unlisted tests/ Procedures /implants and STC drugs
c. Undertaking form (for treatment without referral) – the standard format to
be filled by all beneficiaries availing follow up consultations or investigations
and for beneficiaries above 70 years availing listed procedures /investigation
etc
d. Emergency Certificate (if applicable) – a certificate signed by treating doctor
or hospital stating that the treatment was emergency in nature. It should
include brief details of the emergency and justification for immediate
treatment without prior approval.
e. Detailed Discharge Summary – issued by the hospital for admitted cases, or
detailed treatment summary for OPD cases. This must be legible (in Machine
readable format) and include diagnosis, procedures done, date of admission
& discharge, and treatment given including details of surgery performed. It
should clearly indicate no of ICU or ward stay, justify use of antibiotics or any
other costly drug or consumable, use of ventilator etc It shall justify any
deviation from referral treatment or from preauthorisation. For claim scrutiny,
a machine-readable (typed or electronic) discharge summary is required to be
uploaded into the NHA portal. The treatment given as per discharge summary
shall be in line with billing details. Discrepancies shall be construed as
fraudulent activity (Ref: Annexure A.III and Clause 14 of MoA). All entries
should be in English (or bilingual with English).
f. OT Notes: Separate OT notes are mandatorily to be enclosed in all surgery
cases. The details shall include complete details about surgical procedure,
duration of surgery, type of anaesthesia, implants used etc
g. Hospital Final Bill(s) – The comprehensive bill of the hospital, preferably one
consolidated bill with itemized break-up attached. The charges should be
grouped logically (ward charges, investigations, procedure, pharmacy,
discharge medications etc.) and should align with CGHS package or rates. The
bill must clearly indicate CGHS rates and calculations. If the hospital’s billing
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system generates a single consolidated bill, a break-up in chronological order
of charges or department-wise may be attached. . The bill should be submitted
in an OCR-readable format (machine readable PDF ) .The detailed bill clearly
specifying the items against which amount is collected from beneficiary shall
be enclosed in Machine readable format separately. The HCO shall ensure that
amount collected from beneficiary is deducted from the bill being submitted
to CGHS and any act of claiming such items from CGHS are construed as an
act of fraud (Ref: Annexure A.III and Clause 14 of MoA). The bill towards
Discharge medications as mentioned under Clause 5 shall also be enclosed
separately.
h. Day-to-Day Clinical Notes – legible photocopies of the doctor’s daily progress
notes, nursing notes, drug charts, treatment charts, and operative notes (if
surgery done). These should be arranged in chronological order (from
admission to discharge) and each page should be signed by the treating
medical personnel. These notes are critical for a medical audit to justify the
treatment given.
i. Investigation Reports – copies of all investigation results (laboratory reports,
imaging reports, etc.) that are relevant to the treatment and for which charges
are claimed. Arrange them in chronological order. Each report shall have
unique identifier number which shall be verifiable.
j. Implant details: a letter from the treating doctor indicating detailed
specifications of the implant, like make, type, size, model, and number used.
The treating doctor shall also certify the satisfactory functioning of the implant
k. Original purchase invoices for Implants/Stents/Grafts/High-Cost
Medicines – If any implants (e.g., stents, orthopaedic implants, intraocular
lens) or expensive external purchase medicines were used and charged
separately, attach the original invoice from the external supplier . Also include
the implant stickers (e.g., for cardiac stents, orthopaedic implants) and any
warranty cards or barcodes in the documents. If bulk purchase copy is used,
highlight the relevant item and ensure it matches the charge. Additionally,
include the surgeon’s certificate regarding the implant as described.
l. Any other relevant documents – Informed consent if any amount is
collected towards implant difference.
m. Verification of IP treatment by beneficiary – The beneficiary shall sign and
mention mobile number on the final bill and shall also indicates if any amount
was collected from patient.
n. Feedback form regarding treatment
o. Detailed break up bill towards amount collected from Beneficiaries
If the claim documents are not in proper order or required documents are missing,
the BCA/CGHS may return the claim unpaid for rectification, causing delay or
denial. The HCO should thus be diligent in claim preparation.
11.3 Digital Submission and Technology and adequate staff for submission of
claim and reconciliation of payments:
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The HCO must have the capability to submit claims electronically via the NHA’s
portal. This includes having a computer with internet, scanner, and the software to
upload bills in prescribed format (OCR / machine readable format PDF/Excel etc.).
The HCO shall mandatorily have facility to submit the documents in Machine
readable format. The HCO is also required to implement features like geotagging and
Aadhaar-enabled biometric verification of patients to ensure the patient’s presence
and identity. The HCO shall integrate such tech processes in their workflow as
directed. They should have adequate staff for the submission of claim and
reconciliation of payments.
11.4 Retention of Records:
The HCO shall maintain the original physical records of all claims for a minimum of
5 (five) years from the date of service. (For claims sent to departments, at least keep
a copy set with acknowledgement.) In case of any audit, vigilance, or investigation by
authorities, the HCO must produce the records even if the hospital has received
payment. Failure to produce supporting records upon request may result in recovery
of the claim amount or other action.
11.5 Payment to Hospital and Bill processing Fees:
For claims processed through the NHA portal (like pensioner claims), the CGHS will
make eligible payments within 90 days of claim submission (provided no exceptional
approval needed), directly into the HCO’s bank account by CGHS. The HCO should
ensure it has given correct bank details to CGHS/NHA. The CGHS is entitled to a
processing fee (and applicable taxes) as notified by CGHS. This fee is deducted at
source from the claim amount. CGHS reserves the right to revise the claim processing
fee rates, and the HCO shall accept the same.
A claim-processing fee of 2% of the claim amount plus applicable taxes if any
shall apply, subject to a minimum of ₹12.50 and a maximum of ₹1,500 per claim
both exclusive of taxes. Payments to the HCO will be made net of this fee (i.e.,
claim amount minus the processing fee). The HCO must account for this deduction
in its books and may not pass this fee on to the patient.
For claims sent to government offices (like serving employees), payments will be made
as per those offices’ procedures (often through cheque or bank transfer) and may not
follow the 90-day norm exactly. The HCO should follow up with the paying authority
if payment is delayed beyond reasonable time.
11.6 Scrutiny by NHA/CGHS/BCA (Claim Audit):
11.6.1. CGHS /BCA will scrutinize each claim against CGHS rules. The HCO should
be aware that the CGHS/BCA will disallow or adjust parts of the claim that are not
as per CGHS entitlements. The checks include, but are not limited to:
a. Verification of Treatment Necessity: Ensuring that the treatment provided
was medically appropriate for the diagnosed condition. Unnecessary
admissions (for minor ailments that could be managed on outpatient basis) or
procedures will be flagged. If a planned procedure was billed under emergency,
that will be checked.
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b. Package conformity: Checking that only permitted procedures were done as
per the referral. If procedures or tests outside the scope of permission were
done, justification is needed; otherwise, those charges may be disallowed.
c. Rates and Package components: Verifying that the rates charged match
CGHS rates and that the package rules are followed (no unbundling of costs).
If the HCO charged for something included in the package/ward charges, that
amount will be deducted.
d. Non admissible items: CGHS shall check if HCO has charged towards any
non-admissible items and shall ensure that components otherwise included
under consultations, ward charges, package charges, blood component
charges, ICU charges are not billed separately.
e. Quantity/Cost reasonability: Checking if the quantity of consumables and
drugs used is reasonable for the case or if it appears inflated. Also verifying
that costly drugs or a high number of disposables were indeed needed as per
case notes.
f. Diagnostic correlation: Ensuring tests conducted were in line with the
diagnosis and treatment plan, preventing billing of unrelated or repetitive tests
without justification.
g. Split Billing: Detecting any attempt to split a procedure into multiple claims
or multiple entries to inflate cost (e.g., billing two separate minor surgeries on
consecutive days which normally would be a single procedure).
The NHA maintains a digital record of claims history to spot patterns of excessive
billing or irregularities.
11.6.2. For any recoveries or deductions beyond 25 percentage of claimed amount
in an in-patient claim including the rejected claims (By SA), HCO shall have an
opportunity to represent or clarify within 15 days of the deduction notification.
Based on the representation, the deduction or rejection shall be reviewed by CGHS.
11.6.3. If the HCO fails to respond /represent within 15 days, it is assumed to have
accepted the deductions, and the claim moves on. No further appeals on those
deductions will be entertained by CGHS afterwards through the NHA process. The
HCO is thus advised to regularly monitor the NHA portal for claim status and queries,
and respond quickly to avoid loss of legitimate payments.
11.6.4. Recovery of Overpayments: If at any time a payment has been made in
excess to the HCO (due to oversight or later found inadmissible), CGHS is authorized
to adjust or recover that amount from future bills of the HCO. The HCO will be
notified of such adjustment.
By adhering to the proper billing process and maintaining transparency, the HCO
will facilitate timely payments and minimize disputes or rejections.
Clause 12:
12.1 Medical Audit and Quality Assurance
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