F. No. G. 28011/1/2010-CGHS-II (Pt.)
OFFICE MEMORANDUM
Subject: Revised Timelines for submission of Hospital bills by Health Care Organizations under CGHS and processing on NHA Portal.
With reference to the above subject the undersigned is directed to convey the approval of competent Authority for issue of revised Timelines and guidelines for submission bills pertaining to CGHS Pensioner beneficiaries by Health Care Organizations empanelled under CGHS and their processing on NHA Portal as per the details given under:
A : Revised Timelines to be followed by HCOs, CGHS and NHA with respect of claim submission on TMS:
Registration on Beneficiary Identification System (BIS) - 02 days (48 Hours from actual admission)
Intimation by Health Care Organization (HCO) - 02 days (48 hours from registration)
Query by PPD (Pre Auth-Processing Doctor) regarding intimation by HCO - 03 hours of intimation by PPD (auto approved if no query within 03 hours
Response by HCO to query raised by PPD. - 02 days (48 hours from query)
Discharge and claim initiation by HCO. - 15 days (Including holidays) from actual date of discharge or last date of completion of OPD procedure as per the duration mentioned in the referral slip or permission letter issued by CGHS/Govt specialist.
Query reply by HCO in the post claim submission period. -
Normally 15 days. If no reply is received from HCO even after a period of 90 days from date of query, the bill will be settled/rejected on the basis of available documents. NHA shall ensure that bills are sent to the Sanctioning Authorities for processing
B: Condonation of delay in submission of hospital bills online by the empanelled HCOs:
i. Delay between 16-45 days:
Additional Directors of the concerned City / HQ is delegated the power for condonation of delay of 16-45 days in submission of bills by the HCOs between (all days including holidays) from the date of discharge/ last date of completion of OPD procedure, as per the duration mentioned in the referral slip or permission letter issued by CGHS/ govt. specialist.
NHA shall create access to the TMS module for all Additional Directors to enable them to examine all rejected claims.
ii. Delay of more than 45 days in claim submission:
Director CGHS. is delegated the power for consideration of condonation of delay of more than 45 days, in submission of bills by the HCOs (all days including holidays), from the date of discharge/ last date of completion of OPD procedure, as per the duration mentioned in the referral slip or permission letter issued by CGHS/ govt. specialist.
NHA shall create access to the TMS module for the Director, CGHS for this purpose.
C. Measures to strengthen the Claim settlement system:
- The Sanctioning Authorities will scrutinize 1% Bills with a value of between Rs. 500/ – Rs. 10,000/-
- The Sanctioning Authorities will scrutinize all Bills/claims costing above Rs. 10,000/-.
- A checklist of documents is to be enclosed by HCOs and scrutinized by CEXs and CPDs while processing bills. The documents should be readily available on NHA portal for reference and ease of bill processing.
- It will be made mandatory to record the reasons for returning of claim/rejection of claim / deduction made by CPD, SA, NO, DDO, along with the case ID.
- The system should ensure a proper channel for the return of claims to the concerned SA/CPD with provision for correction by the official, if required.
- Initial training to CPDs and CEXs is to be imparted by CGHS. Later, a few among the CPDs are to be identified as master trainers for CPDs and CEXs who can train all fresh recruits (CPDs/CEXs) in NHA.
- A system of Grievance Redressal mechanism with escalation matrix will be created for the on NHA the portal.
- Provision is to be created by the NHA on the TMS to enable HCOs to track their claims and raise their grievances.
- NHA will assign an Officer for each City/region. An updated list of contact persons with contact details and defined roles in NHA shall be available on NHA portal.
- The option of assigning user ID to HCOs is to be given to Zonal Additional Directors in the HEM portal. This will enable faster creation of user ID for the newly empaneled HCOs.
- The NABH/NABL certificate uploaded on the HEM portal is to be visible on the TMS to expedite billing according to the eligibility of the HCO.
- A system generated trigger is to be created on the TMS to send e-mail to the HCOs and the Zonal AD thirty days (30 days) before expiry of the PBG to enable the stake holders to undertake corrective steps.
- Provision is to be made by the NHA which allows the HCOs to fetch complete TDS details in Excel/XML format for uploading on the CGHS website.
D) For streamlining HCO bills related to AYUSH treatment, separate guidelines shall be issued.
E) One-time Condonation of Delay in submission of hospital bills by HCOs after 1st September 2023, which were rejected on this account, shall be allowed for resubmission of bills on TMS portal from 16th May 2024 to 31st May 2024. This information may appear as a pop-up message on TMS portal, whenever the HCO logs in to the TMS account.
F. The revised ‘Timelines’ shall be displayed as a ticker on the TMS every time the HCO accesses the TMS and shall also be visible on the CGHS website to facilitate all the newly empanelled HCOs under the continuous empanelment scheme.
Signed by
Dr Satheesh YH
Date: 26-04-2024 10:50:35
Director, CGHS
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