MRC Procedure and Forms.pdf
Z15025/19/2024/DIR/CGHS
Z15025/19/2024/DIR/CGHS (Comp No. 8281286) 1/3687353/2024
भारत सरकार
स्वास्थ्य और परिवार कल्याण मंत्रालय
रामकृ 4ण पुरम, नई दिल्ली
दिनांकित/-28.06.2024
कार्यालय ज्ञापन / OFFICE MEMORANDUM
Subject: Procedure for Submission of Medical Reimbursement Claims (MRCs)
by Pensioners (P) Beneficiaries in CGHS
1. The procedure to be followed by CGHS for submission of MRC by pensioner
CGHS beneficiaries shall be as follows:
a. Submission of MRC: The beneficiary will submit the MRC in the prescribed format (Form MRC (P), Annexure A) with all relevant supporting vouchers/documents in original, to the CMO-I/C of the relevant CGHS Wellness Centre. The CGHS Wellness Centre shall verify and ensure, before accepting the claim papers, that all relevant documents are enclosed as per the prescribed checklist (Annexure B) and issue a dated acknowledgement to the claimant in token of receipt of the MRC by CGHS. MRC Claim ID shall be generated by the Wellness Centre which shall be made available through SMS.
b. Forwarding MRC Papers: The CGHS Wellness Centre shall forward the MRC papers online after scrutiny to the concerned Office of Additional Director (AD) CGHS for further processing for reimbursement of claims. The physical papers shall be sent to the office of the AD within one/two days of receipt of the claim papers.
c. Handling Deficiencies: If there are any deficiencies/gaps found in MRC documents/papers, the CMO l/c shall retain the papers and communicate the list of deficiencies/observations to the beneficiary through SMS. If the deficiency is found at the level of O/o AD, they shall retain the papers and communicate the list of deficiencies/observations to the CMO-I/C to remove the shortcomings through email.
d. Informing the Beneficiary of deficiency in the claim: The CMO-I/C shall contact the beneficiary concerned and inform them about the shortcomings in the MRC papers and request them to submit the requisite information/documents. The CMO I/C shall not return the MRC in original unless it is rejected in total.
e. Processing the MRCS: The MRCS shall be scrutinized and processed by the Office of AD as per the extant policy and instructions for issued from time to time about the CGHS rates and admissibility of claims of under CGHS. f. Informing the Beneficiary of approved claim amount: When a bill is sent to the PAO, the details pertaining to the claimant will be entered through computer and the claimant shall be informed of the same along with the amount admissible and details of disallowances indicating the specific reasons/grounds for deductions.
g. Payment Processing: The amount found admissible as per the CGHS
guidelines shall be passed for payment and forwarded online to the PAO for making payment. The original documents should also be forwarded simultaneously to the PAO for making payment of the admissible amount to the claimant.
2. Tracking of Status of MRC: The Status of MRC can be viewed online based on the Claim ID generated at the time of submission via the CGHS Web portal
1/3687353/2024
Z15025/19/2024/DIR/CGHS
(www.cghs.nic.in) or through my CGHS Mobile app (available on Android and iOS devices). The Standard Operating Procedure is enclosed (Annexure 3).
This issue is with the approval of competent Authority
Encl: As Above To,
Signed by
Dr Satheesh Y H
Date: 28190-satfleesh);
28-96-2024 15:51:32
Director (CGHS) Tel No. 011-26872280
1. Addl. Director, CGHS(HQ)/ Addl. DDG (CGHS)/ Addl. Directors, CGHS of Cities/
Zone.
2. All CGHS Wellness Centres through concerned AD, CGHS
3. LACS/ZACs through Addl. Directors, CGHS
4. MCTC, CGHS with the directions to upload the document on CGHS Website
5. All Pensioner Associations
6. DDG, NIC Health, MoHFW
7. Sh. Jitendra Singh, CDAC, Noida
Copy of Information to:
1. PPS to Secretary (H&FW), MOHFW
2. PSO/Senior PPS/PPS/PS to Secretary (Personnel), DoPT, MOPPG&P
3. PSO/Senior PPS/PPS/PS to Secretary (DARPG & DOPPW), MOPPG&P 4. Senior PPS to AS & DG CGHS
5. PPS to JS (MOHFW), CGHS
(Dr. Y. H. Satheesh) Director (CGHS)
Tel No. 011-26872280
FORM - MRC (P) (For pensioner beneficiaries)
CENTRAL GOVERNMENT HEALTH SCHEME
MEDICAL REIMBURSEMENT CLAIM FORM
(To be filled by the Principal Card holder/Claimant in BLOCK LETTERS)
1. (a) Name of the Principal CGHS Card Holder
1/3687353/2024
Z15025/19/2024/DIR/CGHS
(b) CGHS Ben ID No.
(c) CGHS Wellness Center to which the card is attached :
(d) Validity of CGHS Card
(e) Ward Entitlement - Pvt./Semi-Pvt./General
:
(1)
Full Address
(g) Mobile telephone No. and e-mail address, if any
2. (a) Patient's Name
(b) Patient's CGHS Ben ID No.
(c) Relationship with the Principal CGHS card holder
:
3.
Category of pensioner beneficiary - please specify :
(Central Govt. Pensioner/Pensioner of Autonomous/Statutory body/Ex- MP/ Ex-Governor/ Former
Judge of Supreme Court/ Former Judge of High Court/Freedom Fighter/Legal Heir/Others)
4.
Name & address of the hospital / diagnostic center /
imaging center where treatment is taken or tests done:
5.
Whether the hospital/diagnostic/imaging center is empanelled under CGHS
Yes/No
6.
Treatment for which reimbursement claimed
(a) OPD/Test & investigations
:
(b) Indoor Treatment
:
7.
Whether credit facility was availed. If not,
reasons thereof (clarification may be attached)
8.
Whether treatment was taken in emergency
Yes/No
9.
Whether prior permission was taken for the treatment:
Yes/No
10.
Whether subscribing to any health/medical insurance :
Yes/No
scheme, If yes, amount claimed/received
:
11.
Total amount claimed
(a) OPD Treatment
:
(b) Indoor Treatment
(c) Tests/Investigation
:
12.
Name of the Bank...
SB A/c No.:
Branch MICR Code:
IFSC Code............
*********
DECLARATION
I hereby declare that the statements made in the application are true to the best of my knowledge and belief and the person for whom medical expenses were incurred is wholly dependent on me. I am a CGHS beneficiary and the CGHS card was valid at the time of treatment. I agree for the reimbursement as is admissible under the rules.
Date:......
Place:
Signature of the Principal CGHS card holder / Claimant
1/3687353/2024
Z15025/19/2024/DIR/CGHS
1.
2.
3.
Documents to be attached
Photo copy of the CGHS card of the principal card holder along with the patient's CGHS Card.
Copy of permission letter, if any.
Emergency certificate (original), in case of emergency.
4.
Copy of the discharge summary.
5.
Ambulance Certificate (original), if any.
6.
Original bills /cash memo / vouchers etc. for the reimbursement amount claimed.
IMPORTANT
Kindly ensure to provide the following information / documents, wherever applicable:
a) Obtain Break up of Investigations from the hospital/diagnostic center/imaging center (details and rates of individual tests and the exact number of tests, X-ray films, etc.,) as the reimbursable amount is calculated as per approved rates per test.
b) In case of loss of original papers, Affidavits as per Annexure I to be submitted. All photocopies of the bills to be
attested by the treating doctor/specialist.
c) In case of death of the card holder, Affidavit as per Annexure II to be filled and attached to claim
reimbursement,
c) In case of implants, Invoice No. along with sticker with serial number of the implant to be attached.
d) In case of Coronary Stents, outer pouch of stents is to be enclosed.
e) In case of replacement of pacemaker / ICD etc., copy of the warranty certificate of earlier pacemaker /ICD may
be enclosed.
Note: Misuse of CGHS facilities is a criminal offence. Penal action including cancellation of CGHS card may be taken
in case of willful suppression of facts or submission of false claims / statements.
1/3687353/2024
Z15025/19/2024/DIR/CGHS
Annexure-I
Draft for Affidavit for Duplicate Claim Papers/bills on stamp Paper
I, ......
son/ wife / daughter of..............
and resident of
.have lost / misplaced the original paper or
the same are not traceable. I hereby give an undertaking that I have not received any payment against the original bills/claim papers from any source and that if the original papers are traced, I shall not stake claim against original bills in future and that in the event, I receive any cheque against the original bills in future, I shall return the same to competent authority.
Verified by Notary Public
Deponent
1/3687353/2024
Z15025/19/2024/DIR/CGHS
1/3687353/2024
Annexure - I|
Draft for Affidavit on Stamp Paper for claiming medical reimbursement IN CASE OF DEATH of a CGHS Card Holder
.husband/ wife / son / daughter of Late........
I,............
resident of
mother Late Shri/ Smt..
Death Certificate is enclosed).
*********
.... and
hereby submit the medical
reimbursement claim papers pertaining to treatment of my husband wife / father/
........who has expired on
(copy of
Late Shri/Smt............
has left behind the following other legal heirs,
none of whom have any objection if the entire reimbursable amount is paid to me.
No Objection Certificate signed by other legal heirs on Stamp paper is enclosed.
Deponent
Attested by Notary Public
Draft for No Objection Certificate on Stamp Paper.
Z15025/19/2024/DIR/CGHS
We (i)
S/o D/o Late Shri..
S/o D/o Late Shri........
(ii)
(--)
(--)
(--)
S/o D/o Late Shri...................
being the legal heirs of Late Shri/Smt...
entire amount reimbursable
.have no objection if the
pertaining to the treatment of late Shri / Smt
is paid to Shri / Smt
(i) (Signature)
(ii) (Signature)
Name:
Name
(iii) (Signature) Name:
Address:
Address:
Address
(iv)..........
(v)..........
(vi)..........
Verified by Notary Public
Checklist for Reimbursement of Claims
Claim Submission
1. The claim is to be submitted to the concerned department by serving employees
and to the CMO I/C of the CGHS wellness Centre (where the CGHS card is registered) by the pensioner beneficiary within 6 months of discharge from the hospital. Alternatively, the claim may be submitted to the Wellness center of city where the beneficiary is taking treatment.
2. In case of delay in submission of claim beyond 6 months, the reasons justifying the
delay must be stated by the beneficiary in a forwarding letter
3. In case of treatment in emergency in non-empanelled hospital/expenditure incurred
for treatment in empanelled hospital, Medical Reimbursement Claim (MRC) will have to be submitted by the beneficiary for reimbursement of expenses incurred. 4. Please note that it is the responsibility of the claimant to provide all the required
documents
5. No payment can be made against Provisional or Running or Intermediate or Interim bills. No payment can be made against photocopies of the bills. No outpatient (OP) medicines can be reimbursed, and they shall be collected from WC. No costs
1/3687353/2024
Z15025/19/2024/DIR/CGHS
towards Implants or Stents or Costly medicines can be considered without invoice. 6. Non-medical expenses are not covered under CGHS and hence expenditure
incurred in this regard are not admissible as per CGHS Guidelines.
7. Reimbursement may be subjected to examination of the case by technical
committee.
Acknowledgement and following up of the claim submitted by pensioner beneficiaries and serving CGHS employees:
1. On verification as per check list if the claim is found to be complete with all
documents, then an acknowledgement will be generated with a claim number in the computer module of the wellness Centre.
CHECK LIST FOR MRC
Please enclose Self attested Documents in the sequence given below for every claim along with page numbering
1. Self-explanatory letter -duly signed by main card holder
-forwarded by CMO I/C
-with detailed sequence and justification of the claim and reason for going to a non-empanelled hospital
-In case of delay in submission of more than 90 days from date of discharge/treatment, the reason for delay to be mentioned clearly with
request for condonation of delay.
-If claimant is not in a position to sign then Right thumb impression in case of females and left thumb impression in case of males may be put in place of signature. If medically unfit to sign, then a certificate from
physician regarding the disability is to be enclosed.
2. Photo Copy of Card of the claimant and the patient duly verified by CMO I/C 3. Medical Reimbursement Claim Form (MRC (S) for serving and MRC (P) for
pensioner) available on cghs.gov.in under the link: downloads) duly signed by main card
holder/claimant in case of death of card holder
Page 1 of 5
(Please mention email id and mobile no.)
2. The status of the claim can be viewed in the CGHS computer module using the
claim number. SMS will also be sent to beneficiaries at each stage of MRC processing.
3. Particulars of the claims which are more than one month old are now displayed on
the CGHS website.
4. Mandate for e payment - Any of the following needs to be submitted-
a. Cancelled cheque/photocopy of cheque bearing name of the main card
holder/ claimant in case of death of main card holder OR
b. Copy of pass book showing account number with name of main card holder
1/3687353/2024
Z15025/19/2024/DIR/CGHS
1
2
/claimant in case of death of main card holder OR
c. Mandate form verified from concerned bank, if name of main card
holder/claimant is not present on cheque.
5. Original permission letter/ original emergency certificate.
6. Discharge summary in original/copy
7. Copy of referral from the specialist / advice of the specialist wherever this applies. 8. Final consolidated bill in original.
9. Original or copy of break up of hospital bill (Interim bill is not valid.)
10. Receipts in original of total amount paid to hospital/pharmacy. Please note:
a. Invoice needed in case of implants/devices specifying batch number and
specifications of the device/implant
b. If 'duplicate' receipt is enclosed in place of original, then affidavit regarding lost
receipts needs to be submitted with MRC.
11. List of all receipts/bills enclosed in the medical claim with receipt number/bill
number showing total claimed amount.
12. Duplicate set of whole claim with page numbers.
13. Whether taken any advance or no-please state Yes/NO.
If advance taken, then utilization certificate from hospital that
the advance amount has been utilized
Beneficiaries may please note:
7. Number all pages of your MRC in the sequence given above
*Make 2 photocopies of the original claim
*Retain 1 set with yourself as record and submit the other
set along with the original MRC to the wellness centre
7. if the claim is being returned after clearing any objection then the fresh documents
submitted should be in duplicate
Page 2 of 5
CHECK LIST FOR MRC FOR SPECIAL CASES Please enclose Self attested Documents in the sequence
given below along with page numbering -
If original bill lost (as per Medical Claim Form (S) or (P))
• Affidavitonnon-
•
judicialstamppaperCLEARLY MENTIONINGdetailsofthelostdocumentasperAnnexure Photocopies of all the above claim papers duly verified by treating specialist. For cases where partial credit is given :
Complete final bill of hospital with break up
1/3687353/2024
Z15025/19/2024/DIR/CGHS
3
• Break up bill from the hospital for items for which credit was not given. In case of death of the card holder please note:
a. Death of main card holder (pensioner)-only living spouse is the
eligible claimant irrespective of who has made the payment to the hospital for treatment. (It is advisable to get a family pensioner card issued before the medical claim is put up for reimbursement).
b. Death of family pensioner (spouse)-Any of the living children can claim
reimbursement provided he/she gives an affidavit that he is the legal heir and a separate NOC from other heirs that they have no objection if reimbursement is made to the legal heir (as per Annexure II of MRC Form).
c. Death of pensioner with no living spouse/ death of family pensioner and no
surviving children - a 'succession certificate' issued by the court has to be
produced by whosoever is the claimant (proving that he is the legal heir) along with the proof that payment to the hospital has been made by him.
Documents to be enclosed in Death Cases :
Affidavitonnonjudicialstamppaperbytheclaimant(asperAnnexurellofMRCForm)
NOCfromallthelegalheirsseparatelyforeach individual.
• Death certificate.
Copy of death summary from the hospital.
ID proof of claimant with name of father in cases where both main
card holder and spouse have expired
Succession certificate issued by court wherever required (see above)
4. In cataract surgery with Intra Ocular Lens (IOL) claims (as per OM no. 536/2012/R
& H/CGHS dated 21/08/2014)
O
• Original sticker of IOL with batch number of IOL, duly signed and stamped by the surgeon of private empanelled hospital
Bill of IOL showing type of IOL used and IOL batch no. in case of
surgery in private empanelled hospital
Discharge summary/prescription to mention:
■ typeoflOL(Hydrophobic Foldable/HydrophilicAcrylic/ScleralFixated/PMM/ Type of cataract surgery done
·
Page 3 of 5
5. For Cardiac/vascular stents (as per OM no. 1002/2006/CGHS (R&H)/CGHS(P)
dated 31/10/2011)
Outer pouch of the stent with sticker on it with batch no. and other details. Invoice of the stent from the private empanelled hospital with
1/3687353/2024
Z15025/19/2024/DIR/CGHS
7
8
batch number. and details of stent
Certificate from empanelled hospital that they have not charged the beneficiary more than the rate at which the stent has been procured by the hospital
Angiography report (for opinion of Government specialist)
CD of angiography & PTCA(for opinion of Governement specialist)
6. For Pacemaker, Combo Device, Defibrillator, Rotablator (as per OM no. S-
11011/29/208- CGHS(HEC)/DIR/CGHS dated 6th August 2018)
Sticker of device having batch number
Copy of terms of warranty ECG and Holter report
ECHO cardiography report
In case of replacement, copy of warranty of earlier device to be submitted
Ambulance used (as per OM no. S4924/2010/CGHS (R&H)/CGHS(P) dated 17/1/2011)
Ambulance is allowed only for going to the hospital in
emergency. It is not allowed after discharge.
""
Certificate from the treating doctor for justification stating the following The ambulance was essential as it was an emergency and any other mode of transport would have aggravated the patients condition or endangered his life. Ambulance has been used within the city limits"
Knee & Hip Implants (as per OM No. Z.15025/74/2017
/DIR/CGHS/EHS dated 26/09/2017): ceiling rates applicable.
-
Cost of knee implant component-wise along with brand name, name of manufacturer
/importer/batch number/specifications and other details, if any to be mentioned in the final bill/invoice
For special Nurse/Aya/attendant- Permitted only Govt. Hospital for in patients or private
9. recognized hospital where treatment has been taken with prior permission.
No reimbursement of domiciliary nurse/aya/attendent (as per OM no. S- 11011/7/88- CGHS (P) dated 3/8/1988)
Certificate from treating doctor that services of special nurse/aya/attendant were essential for recovery/prevention of serious deterioration in the patient
no.
Page 4 of 5
For
Domiciliary Physiotherapy
(as
per
OM
S-11011/24/10
·
2011 / CGHS (P) dated 1/6/2011)
Prescription from PMT specialist/Ortho/Neuro/Neurosurgery/ENT
1/3687353/2024
Z15025/19/2024/DIR/CGHS
specialist for home based rehabilitation programme which should include the following descriptive specifics:
1. The therapy to be used:
a. Electrotherapy;
b. Active Exercise Therapy;
c. ADL Training;
d. Speech Therapy;
e. Gait Training; and
f. Passive Exercises.
2. The technical person required to institute the therapy 3. The frequency of the
therapy required by the patient 4.Duration of the therapy programme Receipt in original for payment made with stamp
and designation of person who has given therapy
In case of locomotor disability, certificate showing >80% disability or 2 Govt. Specialists to certify that patient is totally dependent on care giver.
11. For purchase of medicines for 7 days on day of discharge (OPD MEDICINES ARE NOT REIMBURSABLE unless permitted by CMO I/C in writing) as per OM no. S-11011/09/2014/CGHS(HEC)/CGHS(P) dated 20/6/2014 and OM no. S- 11018/6/95- CGHS(P) dated 24/7/1995
Certificate from Private empanelled hospital that they have
not issued the medicines on the day of discharge.
12. For Insurance cases: beneficiary to first put up claim to insurance company (as
per OM no.S- 11011/4/2003/CGHS(P) dated 19/2/2009)
Certificate from insurance company indicating the
amount for which beneficiary has received credit from them.
Photocopies of all bills and vouchers duly certified with stamp of
insurance company
13. For nebulizer(as per OM no. Misc.11006/2000-JD(R&H)/CGHS(P) dated
11/6/2001
Advise by Government specialist
Undertaking that nebulizer has not been procured at Govt.
expense in the last 5 years and that cost of maintenance will be borne by beneficiary
Receipt of purchase
Hearing Aid reimbursement (as per OM No. S.14025/10/2002/MS dated 26/05/2015
14. and S.11011/37/2019-EHS dated 1st December 2020)
Referral letter from parent Wellness Centre
Copy of prescription of ENT consultant (CGHS/Govt Hospital) with the Audiogram Report duly authenticated by the treating ENT Consultant (CGHS/Govt).
machine
Warranty card photocopy stating model and serial number of the
Bill/Receipt in original for hearing aid bearing details of the hearing aid seller i.e (a) Name (b) Qualification (c) RCI/MCI Registration number
Empty carton of Hearing Aid clearly mentioning name and address of manufacturer, model and serial number of machine (should be the same as that on warranty card and receipt)
1/3687353/2024
Z15025/19/2024/DIR/CGHS
Original Permission Letter to purchase Hearing Aid
1/3687353/2024