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Draft Policy IP Medical Reimbursement As Per CGHS Rates

The document outlines the medical reimbursement policy for indoor treatment of entitled beneficiaries at private hospitals in emergency situations. It details: 1) Reimbursement will be based on CGHS package rates, with deductions for rooms and additions for certain items. 2) Where no package rate exists, reimbursement will be based on itemized CGHS rates for stay, visits, medicines, investigations and certain procedures. 3) Additional reimbursement may be provided for dialysis, minor procedures, burn injuries, and ambulance charges in some cases. 4) Cancer treatment reimbursement varies based on hospital. 5) Other illnesses and treatments like IVF may be reimbursed based on CGHS

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251 views2 pages

Draft Policy IP Medical Reimbursement As Per CGHS Rates

The document outlines the medical reimbursement policy for indoor treatment of entitled beneficiaries at private hospitals in emergency situations. It details: 1) Reimbursement will be based on CGHS package rates, with deductions for rooms and additions for certain items. 2) Where no package rate exists, reimbursement will be based on itemized CGHS rates for stay, visits, medicines, investigations and certain procedures. 3) Additional reimbursement may be provided for dialysis, minor procedures, burn injuries, and ambulance charges in some cases. 4) Cancer treatment reimbursement varies based on hospital. 5) Other illnesses and treatments like IVF may be reimbursed based on CGHS

Uploaded by

Hghbsjsn
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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IP Medical Reimbursement as per CGHS Rates ( Draft Policy )

Medical reimbursement of expenses done by IP towards emergency indoor treatment for types of
diseases included in the list of 27 diseases at nearest private hospital in emergency situations for
entitled beneficiary.

To simplify the reimbursement procedure and bring uniformity and transparency in disposal of
claims following method is beind adapted at MHESIS.

1. As per CGHS Package Rates ( Non NABH )wherever CGHS package rates are available :

( CGHS Package Rate - 10 % ) + ( Stay Charges as per CGHS rates ) + ( Medicines 100 % ) + (
Investigations charges as per CGHS rates ) + ( Implants charges 85% / Stents charges as per ceiling
rates ) + ( Oxygen Charges, Blood Products charges, Physiotherapy charges as per CGHS rates )

Package rates includes : Surgery / Procedure charges, Surgeon charges, Assistant Surgeon charges,
Anaesthetist charges, Operation Theatre charges, RMO charges, Doctor visit charges, Nursing
charges. Package rates are for semi-private rooms since IP's are entitled for treatment at general
ward 10% amount is to be deducted from package rates.

Stay charges includes : Ventilator / Monitor / Syringe pump charges, Consumables, Disposables, Diet
related charges, Registration charges, any Miscelleneous charges.

Medicine charges includes only medicine items.

Investigation charges includes all investigations Pathology, Biochemistry, Microbiology, Radiology.

2. Item wise charges wherever CGHS Package rates are not available :

( Stay Charges as per CGHS rates ) + ( Doctor Visit Charges ) + ( Medicines 100 % ) + ( Investigations
charges as per CGHS rates ) + ( Implants charges 85% / Stents charges as per ceiling rates ) + (
Oxygen Charges, Blood Products charges, Physiotherapy charges as per CGHS rates )

Stay charges includes : Ventilator / Monitor / Syringe pump charges, Consumables, Disposables, Diet
related charges, Registration charges, any Miscelleneous charges.

Doctor Visit Charges includes maximum 2 doctors 2 visits per day charges as per CGHS rates.

Medicine charges includes only medicine items.

Investigation charges includes all investigations Pathology, Biochemistry, Microbiology, Radiology.

3. Following items are considered additional to above mentioned as per CGHS rates :

A. Dialysis charges.

B. Minor procedures like lumbar puncture, pleural / ascitic fluid tapping, plaster charges, Endoscopic
procedure charges, etc.

C. Patients with Burn injury : dressing charges, minor procedure charges.

D. Ambulance charges: provided certificate from concerned MS / AMO mentioning non availabilty of
an ambulance.
4. Treatment of cancer related illnesses :

Treatment availed at TATA Hospital in ' C ' category or Government recognised cancer hospitals can
be sanctioned as 100%.

Treatment availed at TATA Hospital in other than ' C ' category or private hospitals can be sanctioned
as per CGHS rates.

5. Treatment for illnesses not included in 26 emergency diseases list at private hospitals :

If such treatment was not available at MHESIS / Government / Municipal Corporation / Tie Up
hospitals at that period ( provided certificate from concerned MS/AMO ) can be considered as per
CGHS rates at the sole discretion of concerned Medical Reimbursement Committee.

6. Treatment related to IVF, COVID can be sanctioned as per CGHS rates.

7. Extra expenses borne by IP while taking treatment at Tie-Up hospital can be sanctioned as per
CGHS rates after confirming that Tie-Up hospital has not claimed the same to ESIC.

8. Any amount towards GST, other taxes, etc is not allowed.

9. Concessions / discounts given by treating hospitals, funds received from charitable trusts /
company, amount received from any other insurance company to be deducted from Demand
Amount and Sanctioned Amount both.

10. Mumbai CGHS rates are applicable to AMO Mumbai, MGM Hospital Parel, MHESIS Hospitals
Mulund, Worli, kandivali, Thane, Vashi, Ulhasnagar.

Pune CGHS rates are applicable to AMO Pune, MHESIS Hospitals Pune, Solapur, Aurangabad, Nashik.

Nagpur CGHS rates are applicable to AMO Nagpur, MHESIS Hospital Nagpur.

Sr No Item Mumbai (Rs) Pune , Nagpur (Rs)


1 Stay Charges Ward /day 1000 1000
2 Stay Charges ICU / day 3230 1750
3 Indoor Consultation / visit 90 135
4 OPD Consultation / visit 255 270

11. Visit to CGHS websites regularly and keep yourself updated with circulars.

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