FAQs/Check List - Medical Claims

Out Patient Claim

  1. Sanction of the CFA.
  2. Contingent Bill, duly counter signed by the competent authority.
  3. MRC(S) Form duly filled and countersigned.
  4. Photocopy of self attested CGHS/Govt. Hospital's referral slip of investigations/consultation of specialist. (Investigations to be carried out within 30 days of the doctor's advice).
  5. If claim includes consultation charges, self attested copies of the prescriptions.
  6. Photocopy of self attested CGHS card of the employer and the patient.
  7. Detailed Bill and receipt issued by the CGHS empanelled Diagnostic Centre/Hospital, in original.
  8. Photocopies of self attested of self attested investigation reports.

In Patient Treatment in CGHS Empanelled Hospital

  1. Sanction of the CFA.
  2. Contingent Bill, duly counter signed by the competent authority.
  3. MRC(S) Form duly filled in and countersigned.
  4. Photocopy of self attested CGHS/Govt. Hospital's referral slip in which the admission was mentioned.
  5. In case of admission without the advice of CGHS/Govt. Doctor, in emergency:
    1. Individual application explaining the conditions of emergency.
    2. Emergency Certificate issued by the Hospital.
    3. Copy of e-mail intimation sent to the Nodal Officer, CGHS by the hospital, (as per MoH & FW OM No. S. 11011/13/2003 CGHS Desk II dt. 16.12.2003).
  6. Photocopy of CGHS card of the employer and the patient.
  7. Detailed Bill and receipt issued by the CGHS empanelled Hospital, in original.
  8. Discharge Summary, in original.
  9. Original or photocopies of self attested investigation reports.
  10. Pouches of costly Medicines(Rs.1,000/- above) used in the treatment.
  11. Invoice of implants such as stents, rods etc., if used as part of the treatment.

In Patient Treatment in non CGHS empanelled Hospital, in Emergency

  1. Sanction of the CFA.
  2. Contingent Bill, duly counter signed by the competent authority.
  3. MRC(S) Form duly filled in and countersigned.
  4. In case of admission without the advice of CGHS/Govt. Doctor:
    1. Individual application explaining the conditions of emergency.
    2. Emergency Certificate issued by the Hospital
    3. Essentiality Certificate issued by the treating doctor.
  5. Photocopy of self attested CGHS card of the employer and the patient.
  6. Detailed Bill and receipt issued by the Hospital, in original.
  7. Discharge Summary, in original.
  8. Original investigation reports or self attested copies.
  9. Invoice of implants such as stents, rods etc., if used as part of the treatment.

General Points to be observed while submitting the Medical Claims

  1. All columns of MRC(S) are filled in and signed by the applicant and countersigned by the competent authority.
  2. CGHS advice for consultation of a specialist at empanelled hospital is valid for 3 times within 30 days.
  3. CGHS doctor's advice for treatment is valid for 3 months.
  4. CGHS advice for investigations is valid for 30 days.
  5. Claim of reimbursement of medical expenses of is to be submitted separately for each period of treatment.
  6. Medicines purchased as part of out-patient treatment, unless advised by the CGHS, are not reimbursable.
  7. Claim is to be submitted within 6 months of the treatment. In case of delay, Time Bar Sanction of Head of the Department or of the authority to whom the powers are delegated is to be submitted (Authority MoH and FW OM No. S.14025/19/2015-MS dt. 27/5/2015 No. S.14025/8/99-MS dt. 25/5/1999.
  8. CGHS doctor's advice for consultation of a specialist at empanelled hospital is only for consultation. If the specialist advices any laboratory investigations, beneficiary has to report back to the CGHS dispensary where the doctor would endorse the listed investigations. However, investigation required urgently as medical emergency, may be carried out directly and a certificate of the specialist regarding emergency is to be submitted along with the claim. (Authority MH & FW OM No. Z/15015/117/2017/DIR/CGHS/EHS dt. 15/01/2018 and Z/15025/117/2017/ DIR/CGHS/EHS dt. 10/10/2018).
  9. Please ensure that the ward mentioned in the CGHS card is correct entitlement of the employee. (General Ward - Pay up to Rs.47,600/-, Semi Private Ward - Rs.47,601/- to Rs.63,100/- Private Ward - above Rs.63,101/-).
  10. In case of emergency, as far as possible CGHS beneficiary has to get admitted in CGHS empanelled hospital, which provides treatment at CGHS rates. In case of other hospitals, the claim would be restricted as per the rates.
  11. If Nursing charges are claimed, justification of the treatment is to be furnished. (Authority: MoH & FW OM No. S.14025/8/2010-MS dt. 18/01/2011).
  12. Photocopies of claim papers and affidavit on stamp paper, in case original papers have been lost.
  13. In case death of the card holder, Affidavit in the prescribed format is to be submitted along with the claim.