Standard Guidelines for Claim Processing (SGCP) under Ayushman CAFF Scheme

Standard Guidelines for Claim Processing (SGCP) under Ayushman CAFF Scheme.

existing Standard Treatment Guidelines (STG) dated 06.03.2023/;

2. These guidelines will be effective from 15.06.2024 onwards.

3. NHA, CAPFs, O/o Pr. CCA (Home) & O/o ADG (Medical) are requested to widely disseminate these guidelines among hospitals, CAPF person net, CPDs/SAs/DMs/DDOs/PAOs.

4. The bills uploaded on NHA IT portal prior to 15.06.2024 will be processed as per the standard treatment guideline (STG) dated 06.03.2023.

5. NHA is requested to upload these guidelines on Ayushman CAPF Portal.

STANDARD GUIDELINES FOR CLAIM PROCESSING UNDER AYUSHMAN CAPF SCHEME

A. Each Unit/ Office will detail 02x Master trainers so that Jawans could upload their claims correctly with the help of the master trainers.

B. For the persons, proceeding on superannuation/deputation a period of 06 months viewing rights to be allowed for view their claim status.

C. FOR OPD CLAIMS (BILLS RAISED BY INDIVIDUAL/HOSPiTAU

1. Referral is mandatory for all including dependents, except age > 75 years for treatment on OPD basis. Proper referral slip from CAPF/ Govt. Doctor is required in case of treatment in CGHS approved hospitals. The referral will be mandatory for all serving personnel whether on duty or leave etc. and should be referred by any CAPF/Govt. Hospital. There should be no overwriting/cutting on referral slip. Referral should be given on OPD slip with date and will have following components: -

a. Primary diagnosis and clinical examination findings.

b. Purpose of referral (what all services to be provided to patient) - type of specialty, consultation required and/or name of procedure/ investigations required.

c. Date of referral (valid for 01 month or 03 visits/maximum 03 different specialties are allowed in same referral). For the treatment of cancer and chronic cases (name of diseases is mentioned as per MHA letter number E-3648533/MHA/P-II//23/828 dated 26/10/2023), the referral will be valid for 03 months. Sign and stamp of the referring government doctor/CAPF doctor (the stamp of hospital is also acceptable) is required.

d. Referral can be made by doctors of Army Medical Corps (AMC) also.

e. The person having a valid referral from CAPF/Govt. Doctor will be eligible for treatment/investigation from any CGHS hospital empanelled under Ayushman CAPF scheme across India.

f. Stamp on the computer generated CGHS referral slip is not required.

2. CEX and CPD will cross check/match the demography of patient and invoice in all documents with the data available on the portal. Uploading of Ayushman CAPF Card is mandatory. All medical documents to, bo uploaded should be scanned from original copy.  For dependants (except for eligible dependent parents) above 25  years of age, a fresh dependents certificate, issued by respective Units/office will be uploaded along with Ayushman CAPF card. The reasons for continuing as dependant should be dearly certified. Also, a check in statement will be introduced for all reimbursements, that “in case in future, it is found that the patient who underwent treatment was not a bonafide dependant, the serving personnel will be liable for disciplinary action.”

3. Once patient is referred for OPD treatment beneficiary can buy medicines from any registered pharmacy. Non-availability certificate is not required for medicines purchased from outside. However, the drug license number and GST number should be mentioned on the invoice bill issued by concerned pharmacy. If MRP of the medicine is mentioned in the invoice, then it will be ensured that approved

amount is not more than MRP. Medicine/investigation/consultation charges/bills should be within the period of referral i.e., 30 days for all cases except Cancer and chronic cases which is valid for 90 days. No signature and stamp on the invoices are required if it is a computer-generated bill.

4. If the specialist (treating doctor) of CGHS approved hospital advises some other nInvestigations/diagnostic procedure, then another referral is not required.

5. For specified physiotherapy procedures, beneficiary can undergo physiotherapy without new referral for 30 days from the date of prescription /start of treatment. Beyond that new referral is required.

The CGHS/AB-PMJAY rates will be applicable for physiotherapy. 

6. As per letter no. Min of Health OM No. Z. 13015/11/80-CGHS (P) dated 17/06/1982, Cost of all medicines are reimbursable fully except preparation classified as food, tonics, vitamin, disinfectant, toilet preparation etc. The list of inadmissible items is given in CS (MA) rules. The surgical sundries, disposable like cotton, syringes, needles, catheters, tubes etc. are reimbursable in full when it is certified that these are essential as part of the treatment. The term surgical sundries include those surgical subsidiaries as are used in surgical and other operations and which cannot be reused.

7. Prescription slip/ investigation report/Pharmacy bill/Laboratory bills (where ever applicable) is mandatory. 

8. In case of extra amount claimed by individual instead of querying / rejecting the claims, Claims can be retrenched by CPD as per CGHS rate/package rate and the claims can be processed further.

9. CGHS package rate/investigation rate should be thoroughly checked by CPD.

10. In case of treatment advised by treating doctor on both side of the prescription slip, the sign and stamp of the treating doctor at the end of the prescription slip will suffice.

D. FOR IPD CLAIMS (BILLS RAISED BY THE HOSPITAL!

11. (a) Referral for dependents and age > 75 yrs is not mandatory in PMJAY hospital for IPD admission only.

(b). Referral for age >75 years is not mandatory for taking treatmentin CGHS hospitals.

 

12. Emergency certificate with justification for IPD/ Day care admission be issued by treating doctor with signed and stamped. The date in emergency certificate should be at time of admission.

13. In case of new born baby up to the age of 06 months, treatment will be in the name of mother and her Ayushman CAPF card and claim should be processed further accordingly. The Ayushman CAPF card is mandatory after 06 months of age.

14. The patient undertaking treatment has the right to know the amount of bill raised by the hospital on his treatment. Therefore, a copy of invoice/bills must be provided to the patient/attendant along with discharge summary and their signature must be obtained on the copy of consolidated bill held by the hospital as a token of having received the invoice bill.

15. The consolidated invoice bills, its breakup bills and discharge summary must be duly signed and stamped from the hospital concerned authority. However, all Computer-generated bills/invoices will be accepted with digital signature/ manual signature with stamp of the hospital concern authority.

16. Break-up bills/ invoice should be restricted as per CGHS rate /PMJAY Rates, to be thoroughly checked by CPD and appropriate deduction to be done at CPD level. The day wise break-up bills and consolidated bills with discharge summary should be signed and stamped by concerned hospital authority.

17. CPD to check scanned copy of Ayushman CAPF card which should be clearly visible and readable (both black & white and coloured copy are acceptable).

18. For wards (except parents) above 25 years of age, a fresh dependents certificate, issued by respective Units/ office will be uploaded along with Ayushman CAPF card. The reasons for continuing as dependant should be clearly certified. Also, a check in statement will be introduced for all reimbursements, that “in case in Mura, it is found that the patient who underwent treatment was not 

a bonafids dependant, the serving personnel will be liable for disciplinary action.” The treating Hospital will demand for the fresh dependant certificate and attach a copy in cases of wards above 25 years of age (except parents).

19. Where package rate of CGHS / PM JAY for any particular transaction exist, then only package rate will be applicable.

20. CGHS package rate are applicable in CGHS empanelled hospitals, and these are already integrated in New TMS portal. NHA approved rates implemented by the particular state are applicable In PM-JAY empanelled hospitals and these are also integrated in One TMS portal.

21. NABH/NABL copy with validity date is mandatorily to be provided by the NABH/NABL certified hospital.

22. Surgical procedures as per CGHS rates (AIIMS Rates may be considered If CGHS rates are not available) are applicable. The wrapper of imf)lant/stent or pouch/sticker/barcode should be uploaded mandatorily along with the claim. The wrapper indicating the Batch number in chemotherapy drugs to be uploaded by hospital.

23. The scanned copy from original medical documents should be uploaded while processing the claim.

24. For any unlisted/unspecified/procedures not covered in any health benefits package, concurrence from Director (Medical) is mandatory. Director (Medical) may further take the advice of any committee/MoH&FW to decide on that. The same may be taken by the Director Medical of the Force on e-file.

25. If the final amount of a claim is much more than the amount of pre- authorization, the pre-authorization amount may be revised/enhanced, as per the procedure, with full justification and before discharge of a patient,

26. Under AB-PMJAY scheme, empanelled hospital provides cashless hospitalization to beneficiary as per NHA approved Health Benefit Package (HBP) which is bundled. HBP is inclusive of all the costs associated with the treatment. Since hospital is paid as per selected HBP which cannot be modified by the hospital, so there is no need to submit the invoice at the time of claim submission.

E. FOR 1PD/DAY CARE CLAIMS (BILLS RAISED BY THE INDIVIDUAL)

27. For reimbursement case: - The Reimbursement will be done at CGHS rate only. ^

a. For empanelled hospital: - reimbursement will be done for all services which are available in empanelled hospital for cashless treatment. CEx and CPD will thoroughly verify the empanelled hospital status.

b. For non-empanelled hospital: - The treatment will be provided only in the case of emergency. The beneficiary has to upload the emergency certificate duly signed and stamped of treating doctor with justifications for the emergency by the treating doctor. Date in emergency certificate should be at the time of admission.

c. Referral is mandatory for all including dependents cases except emergency and age of dependent >  75 years of age.

28. CPD and CEX to check the following:

a. Demographic details of the patient: -

1. Name

2. Gender

3. Age

4. Beneficiary type (Self/dependent) - If dependent then relationship with self.

5. Ward entitlement as per CGHS rule and CS (MA) rule

6. Date of referral and date of treatment

b. Hospital State and NABH status.

c. CPD has to check the status and NHA should update CPD and CEX time to time.

 29. Reimbursement claims related to non-empanelled hospital will be applicable only in emergency. Beneficiary has to provide certificate from hospital about the NABH certification. In such cases reimbursement claim will be paid as per NABH rates of CGHS. if the certificate of NABH accreditation is not provided then reimbursement claim will be paid as per non NABH rate of CGHS.

30. Referral of any doGtor of CAPF/Govt. Hospitals mandatory for admission except in emergency condition as notified in the emergency list as per CGHS/CS (MA) Rules.

31. Emergency certificate should be issued by the treating doctor. The  counter signature of medical superintendent of the treating doctor  is mandatory if the hospital is non-empanelled hospital.

32. For any unlisted/unspecified/procedures not covered in any health benefits package, concurrence from Director (Medical) is mandatory. Director (Medical) may further take the advice of any committee/MoH&FW to decide on that. The same may be taken by the Director Medical of the Force on e-file.

33. Referral of any Govt. Hospital/CAPF doctor or emergency certificate from the treating hospital with clearly defined reason for emergency admission is mandatory.

34. In case of new born baby up to the age of 06 months, treatment will be in the name of mother and claim should be processed further accordingly. The Ayushman card is mandatory after  06months of age.

35. Break-up GST invoice/ bills should be restricted as per CGHS rate to be checked by CPD & CEx and appropriate deduction to be done at the CPD level.

36. Where package rate of CGHS for any particular transaction exists, then only package rate will be applicable.

37. CPD to check scanned copy of Ayushman CAPF card which should be clearly visible and readable (both black & white and coloured copy are acceptable).

38. The relationship of the dependent with the Govt, servant must be clearly mentioned on the Ayushman card. If not then CPD should demand a fresh a dependent certificate from the Govt, servant to be issued by his/her office

39. Break-up bills/ invoice should be restricted as per CGHS rate, to be checked by CPD and appropriate deduction to be done at CPD  level. The day wise break-up bills and consolidated bills should be  signed and stamped by concerned hospital authority.

40. For IVF treatment: - As per latest CS (MA) rule and CGHS guideline.