Q47. How would I know to which hospital I should go after taking a referral from ECHS polyclinic?
Ans. The status of hospitals (Emp) may be taken from OIC ECHS PC/ ECHS website. In case of any inconvenience or ambiguity, OIC ECHS may be contacted on his official mobile/ landline number for guidance.
Q48. What should I, as an ECHS beneficiary do, if the empanelled hospital asks to deposit cash for admission?
Ans. The Empanelled hospital has to provide cashless treatment as per ECHS policy/ guidelines. In case of such an issue, the ECHS beneficiary should contact the OIC of nearest polyclinic or Director of Regional Centre and inform them. They will assist you to obtain cashless treatment.
Q49. What is the validity of a referral form for an ECHS beneficiary in cardiac, Oncology and Nephrology cases?
Ans. The referral given by the ECHS polyclinic for Consultation, Investigation and treatment is valid for six months vide SOP on Treatment Management dated 28 Sep 2018.
Q50. What will be the provision for treatment/ hospitalisation in emergencies? |
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Ans. (a) | ESM normally has three options:- (i) Report to nearest service hospital for treatment. (ii) Report to nearest empanelled hospital. Hosp will raise an Emergency Report (ER). (iii) Report to nearest non-empaneled hospital. ESM/his representative will have to pay the charges to the non-empaneled hospital initially. |
(b) | In case where emergency treatment is availed at Non-Empaneled Hosp, it will be the patients’ responsibility to inform his parent / nearest Polyclinic within 48 hrs of where he / she is admitted. The bills for treatment taken in non-empaneled hospitals will be submitted in original to the parent Polyclinic for processing. |
Note:- The onus of informing the ECHS Polyclinic will be that of the patient if admitted in a Non-Empanelled Hosp. Also the onus of proving the emergency will be that of the ESM patient. (Submission of personal application, emergency certificate from treating hospital along with discharge summary and hospitalization treatment record at ECHS PC will be the responsibility of the ECHS beneficiary). |
Q51. What procedure needs to be followed during an emergency treatment at the empanelled hospital?
Ans. (a) Report to a service hospital/ empanelled facility.
- Prove identity through ECHS Smart Card/ Temporary Slip.
- The empaneled hospital will inform ECHS polyclinic at the earliest (but not later than 48 hrs) with the details of ECHS membership, Service No, Rank & Name of the ECHS member, Diagnosis, Date and time of admission, Hospital to which admitted.
- OIC polyclinic will make arrangements for verification of the facts.
Q52. What is the procedure for an emergency treatment at a non empanelled hospital?
Ans. (a) Inform nearest ECHS polyclinic or parent polyclinic within 48 hours.The ECHS polyclinic will generate an EIR.
- Bills will be cleared by the beneficiary.
- Member submits bills along with summary of the case to the concerned polyclinic within 90 Days from the date of discharge from hospital for
- Sanction of reimbursement will be accorded by CFA depending upon the amount. They will be reimbursed according to CGHS rates only
Q53. Hospital had applied for empanelment with ECHS and submitted its application to Regional Centre ECHS. Why is the empanelment process is not concluded?
Ans. After the hospital has applied for ECHS empanelment at RC ECHS, the application undergoes scrutiny at RC level and is further processed with Central Org ECHS. If the hospital is Non-NABH, the CO ECHS facilitates QCI inspection. The hospital will have to apply for QCI inspection directly with the required fees. With the QCI report the application is forwarded to the office of Central Org ECHS. If there are no observations, the application is tabled in the Screening Committee Meeting (SCM) and subsequently goes to MoD (Do ESW) for the promulgation orders in the form of Government Letter Note (GL Note). On issue of GL Note, the same is intimated to hospital and RC. On completion of signing of MoA between hospital and RC, the empanelment of hospital with ECHS is initiated and is valid for a period of two years. Subsequently, the MoA is renewed as necessitated.
Q54. Does a hospital which is NABH accredited, has the same empanelment process as laid down for non-NABH hospital?
Ans. Hospital which is NABH accredited, submits application to RC ECHS which is subsequently processed to Central Org ECHS. If the documents are in order, the ibid application is tabled in SCM without going to QCI. Subsequently the documents are sent to MoD (Do ESW) for issue of GL note and signing of MoA between hospital and RC ECHS, thereafter. On signing of MoA, hospital is entitled to NABH rates till the validity of scope of NABH certification as mentioned in the certificate. A non NABH hospital will have to apply for and get their facility accredited by QCI before their application is placed in the SCM.
Q55. A hospital which is NABH accredited, does the Lab services also get NABL rates?
Ans. Lab services covered through NABL accreditation scope will only qualify for NABL rates. The hospital with NABH accreditation must apply separately for NABL accreditation of lab facilities for allowing NABL rates.
Q56. Does hospital which has NABH pre-entry level accreditation qualify as NABH?
Ans. It is only a hospital which has NABH final accreditation that will qualify as NABH and not the hospitals which have been accorded NABH pre-entry level accreditation.
Q57. How does a hospital which is CGHS empanelled gets empanelled with ECHS?
Ans. A hospital which is CGHS empaneled will have to apply to Regional Centre ECHS in the form of usual application alongwith following documents: –
- Valid office memorandum issued by CGHS notifying that the hospital is empaneled with CGHS.
- Copy of MoU signed between CGHS and hospital.
- Copy of QCI inspection report undertaken for the hospital if its nonNABH. Whatever facilities recommended in QCI report will be empaneled with ECHS.
Q58. Does a hospital which is NABH final accredited offer partial facilities?
Ans. As per existing regulations, hospital which is NABH accredited will offer the entire facilities as mentioned in the scope of NABH accreditation. However, if the hospital is desirous of partial services, same will have to be endorsed by the hospital in their application to RC ECHS along with justification for partial services. Such cases will be considered on merit and appropriate decision will be taken at SCM.
Q59. Can the medicine be issued for more than 30 days?
Ans. For patients of chronic diseases medicines can be issued for more than 30 days up to 90 days subject to availability of medicines with OIC PC. For patients traveling to foreign countries the medicines may be issued for 180 days. The OIC PC should be informed well in advance so that medicines be arranged. It is also informed that tickets and valid visa is required to be produced at the time of collection of medicines.
Q60. What is the policy for issue of medicines to patients from PC other than parent PC?
Ans. Patients taking medicines from PC other than parent PC can be issued medicines for a period of fifteen days at a time.
Q61. Can the medicines be purchased from the market and reimbursement claimed?
Ans. Medicine not available with the PC and also ALC can be purchased from the open market and reimbursement claimed provided that the prescription shows the medicine as NA.
Q62. Can I shift my dependency from one PC to another PC?
Ans. There is a provision of shifting dependency from parent PC to another PC once in three months. The transfer can be undertaken online by logging in to the application on the Source Infosys web page.
Q63. Do I have to intimate the polyclinic in case of emergency admission in an Empanelled Hospital?
Ans. The Hospital is supposed to intimate the Polyclinic online. You may however confirm / cross check the intimation by contacting the polyclinic on telephone or personally.
Q64. Can I opt for higher value implants than the CGHS prescribed ceiling rates in empanelled hospitals?
Ans. Yes, ECHS beneficiaries are allowed to get costlier IOL (Intra Ocular Lens)/ coronary stents/ equipment after paying for the differences in cost over and above the laid down ceiling rates. An undertaking certificate to this effect duly signed by the ECHS beneficiaries will be attached with the claim.
Q65. If my claim in non-empanelled hospital is not reimbursed in full, then can I appeal to a higher authority for full re-imbursement?
Ans. All claims, whether in empanelled or non-empanelled hospital are reimbursed as per CGHS/ ECHS rates. In case of any query/ representation, an appeal for supplementary claim can be sent to higher authority through the OIC PC or action to claim reimbursement in excess of laid down rates can be undertaken for consideration by High Powered Committee. Govt of India MoD Letter No 22A(37)/2018/WE/D(Res-I) dated 15 Jan 2019 may be referred. The letter is available in the Compendium of Govt letters on ECHS Website.
Q66. Should one pay for extra items in an empanelled hospital if I am intimated by the hospital that some items are not covered by ECHS?
Ans. There is a standard list of items for payable/ non-payable consumables. Hospitals cannot demand payment for any items whether payable or non-payable.
Q67. Within what period of time one should submit the hard copy of the claim for treatment in a non-empanelled hospital?
Ans. The hard copy should be submitted within 90 days from the date of discharge from the hospital.
Q68. For patients not residing in NCR area, is prior approval required for Hip or Knee replacement cases or in cases of cancer patients requiring treatment or cardiac cases requiring implants?
Ans. TKR and THR are listed procedures and any listed procedures in the CGHS rate list or those whose rates have been promulgated through CGHS letters do not require any permission. Those whose parent Polyclinic is a Military PC will have to be routed through an AFMS hospital . It is not required when the parent polyclinic is non- military and can be directly referred to an empaneled hospital.
Q69. What is the validity period for a routine referral?
Ans. For a routine referral the validity period is one month. However, for Cancer cases requiring Chemotherapy/ Radiotherapy, Maintenance Haemodialysis, Diabetes, Hypertension and cardiac patient, it is valid for 180 days (six months). The referral letter should clearly mention the validity period.
Q70. Who is responsible for taking prior permission for unlisted implants/ procedures/ tests?
Ans. The onus lies on the empanelled hospital to take prior permission for unlisted implants/ procedures/ tests. The permission for unlisted procedures can be obtained online by the empaneled hospital. The beneficiary or his NOK do not have to obtain such permissions themselves. The hospitals are not supposed to ask the beneficiaries or their NOK to obtain permissions.
Q71. Can an ECHS beneficiary who have subscribed for Mediclaim policy from an insurance agency, be permitted to claim reimbursement from both the sources, i.e from the insurance agency as well from ECHS?
Ans. The beneficiary is allowed to claim the medical expenses from both sources, provided that the reimbursement from such sources should not exceed the total expenditure incurred by the ECHS beneficiary on the treatment. The beneficiary should first claim the expenditure from the Insurance Agency and after settling the amount, the beneficiary should put up to the ECHS for claiming the residual amount.
Q72. Do I require prior permission for liver transplant?
Ans. Yes. Prior permission for liver transplant from CO ECHS is required .The application or permission will routed through parent Polyclinic and RC who will forward it to CO ECHS.As per the letter permission will be given by MD ECHS after consultation with Gastro surgeon.
Q73. Can I take treatment from Government hospitals without referral from ECHS Polyclinic? What will be the reimbursement amount?
Ans. Yes, you can take treatment from Government hospitals for OPD & inpatient treatment without any referral except in cases of organ transplant, hip and knee replacement, cancer treatment and in cases of neurosurgery and cardiac surgery, referral from Polyclinic is required.The claim will be reimbursed at CGHS/ ECHS rates.
Q74. Can ECHS beneficiary draw monetary advance from ECHS for taking treatment?
Ans. A beneficiary can take advance from ECHS for undertaking treatment in Govt hospital/ Hospital of National Repute limited to 80% of the likely expenditure incurred through respective RC. The amount will be paid to the treating hospital directly. The balance amount can be claimed by the beneficiary after treatment.The veteran will have to get an estimate from the Government Hospital and fwd an application through the RC for approval of MD ECHS.
Q75. Is reimbursement in full possible in cases availing treatment in Govt Hospitals?
Ans. Reimbursement is carried out in full except for the room rent and the cost of implants if exceeding the ceiling rates. Room rent and cost of implants will be paid as per CGHS/ ECHS rates. In case the room rent/ or the cost of implants is more than the ceiling CGHS/ ECHS rates then the ECHS beneficiary will have to pay the difference from his own resources.
Q76. What types of medicines/ items are not supplied under ECHS?
Ans. Only generic medicines will be demanded as stipulated in GoI, MoD letter No
S-11025/45/10/MH-I dt 26 may 2010 and letter No S-11011/16/2012-CGHS(P) dt 08 Apr 2015.Food supplements, cosmetics and ayurvedic preparations will not be demanded. Vitamins, Minerals and anti-oxidants will be restricted to prevalent PVMS/CGHS formulary only contained vide CGHS office memorandum No393/2003-04/CGHS/MSD/RS dt 23 Jul 2009. Dangerous medicines, to be administered under supervision of Doctor/ Nurse care, are not supplied to veteran from polyclinics.
Q77. What are the guidelines for vaccines under ECHS?
Ans. Vaccines in general are inadmissible except Hepatitis B, Influenza, Leprovac vaccines for high-risk individual if recommended by concerned specialist of empanelled hospital with justification and countersigned by service specialist of concerned speciality.
Q78. Is there any provision for issue of medicines by empanelled hospitals at the time of discharge?
Ans. Seven days medicines (costing not more than Rs 2000/-) is given by Empanelled hospital after discharge. All medicines after this will be provided by the polyclinics.
Q79. Is the prescription of specialists of empanelled hospitals valid in the ECHS PC?
Ans. Yes, all the prescriptions of Specialists of empaneled hospitals are valid in ECHS PC. It is reiterated only generic medicines will be issued from the polyclinics.
Q80. What are the guidelines for Specialist Consultation from ECHS empanelled hospitals?
Ans. Referral from ECHS PC is mandatory for consultation with specialist in any empaneled hospital. Beneficiaries 75 years and above can consult specialists without referral in any empaneled hospital.
Q81. What is the procedure for undergoing treatment/ investigations recommended by Specialist at private empanelled hospital, after referral by ECHS PC?
Ans. ECHS beneficiary will report back to Medical Officer ECHS PC for further referral for the Investigation/ procedures/ test as recommended the specialist of empanelled hospital and to validate the recommendation of Specialist if required. For veterans above the age of 75 years they can get all listed procedures. They will require permission for unlisted procedures.
Q82. Is re-registration required if a beneficiary visit Polyclinic to just collect indented medicines?
Ans. Yes.
Q83. Is it mandatory for the Diagnostic Labs to stamp the date and the number of tests performed on original prescription slip?
Ans. Yes.
Q84. Is treatment taken in an emergency at non empanelled private hospital reimbursable? If yes what is the procedure?
Ans. Reimbursement is made at CGHS rates in case the treatment taken in an emergency from private non-empanelled hospitals. The reimbursement shall be restricted to CGHS package rate or actual expenditure whichever is less.
Q85. What are the guidelines for consideration of reimbursement over and above the approved CGHS rates?
Ans. Individual reimbursement is done as per applicable CGHS rates. Certain cases of individual reimbursement for IPD where full reimbursement (100%) are permitted provided they meet the criteria for taking up the cases with High Power Committee at MoD as per Govt of India MoD Letter No 22A(37)/2018/WE/D(Res-I) dated 15 Jan 2019. The letter is available in the Compendium of Govt letters on ECHS Website.
Q86. Is there a provision for collection of medicines from the ECHS PC by an authorized person?
Ans. Yes. ECHS beneficiary can authorize a representative, who should have the identification card as well as the authorization certificate to collect medicines from ECHS PC on the basis of valid prescription.
Q87. What are the guidelines for settlement of medical claim?
Ans. For individual reimbursement cases for treatment done at non-empaneled hosp, the bills are cleared on CGHS/ Govt/ AIIMS rates as applicable on the basis of merit (Acute emergency/ sanctions of MD CO ECHS) and for empanelled hospital bills are first scrutinized by BPA and once authorized by BPA the claims are further scrutinized by medical approvers of ECHS.
Q88. What should I do in case of overcharging by the empanelled pvt hosps?
Ans. Empanelled hospitals have signed MoU and cannot charge an ECHS beneficiary. The treatment is given cashless. However, in some cases where the individual demands a treatment for his own comforts, the hospitals take an undertaking signed from beneficiary so that beneficiary does not ask for any reimbursement later.
Q89. Where should I complain for the medical negligence at empanelled hospitals?
Ans. The beneficiary can approach OIC ECHS PC with proof of medical negligence. In addition, the beneficiary may take recourse to other methods of lodging complaints such as registering complaint with Medical Council of India or with Police.
Q90. What is the procedure for reimbursement of medical claim in ECHS? |
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Ans. (a) | Empanelled Hospital. (i) Hosp uploads the bill within seven days of date of discharge. (ii) Verified by BPA and validated by Regional Centre ECHS/ COECHS. (iii) Then claim is finally & settled at CGHS rate. |
(b) | Non-Empanelled Hospital. (i) Proof of emergency/ emergency admission notified to OIC ECHS PC by beneficiary within 48hrs. (ii) Documents should be submitted after discharge at ECHS PC along with (ECHS card copy, personal application, bill summary, emergency certificate) within 90 days of discharge. (iii) Case is verified/ justified and recommended by RC ECHS/ CO ECHS depending on bill claimed and processing time claim is finally approved by concerned CFA and then settled. Bills are cleared at CGHS rates. |
Q91. My spouse was a ECHS card holder. He/ She was sick and died while in a non-empanelled hospital. How do I get medical reimbursemen |
Ans. (a) Proof of emergency/ emergency admission notified to OIC ECHS PC by beneficiary within 48hrs.
- Documents should be submitted after discharge at ECHS PC along with (ECHS card copy, personal application, bill summary, emergency certificate).
- Case is verified/ justified and recommended by RC ECHS/ CO ECHS depending on bill claim and processing time. Bills are cleared at CGHS rates
Q92. My original claim papers having bills, receipts of hospital treatment are lost. Can I claim on duplicate papers?
Ans. Yes. The claim should be supported with a letter from hospital where treatment was taken and all documents to be given to OIC ECHS PC alongwith affidavit for loss of original documents.
Q93. I went to Hyderabad on personal visit and sustained fracture of leg bone. I received treatment from a private non-empanelled hospital. Will I get reimbursement?
Ans. Yes, in case of emergency treatment, the bills are reimbursable at CGHS rates after submitting the required documents and informing the polyclinic within the given time.
Q94. What are the guidelines for IVF?
Ans. IVF treatment is approved under ECHS. The policy letter can be accessed on ECHS website.
Q95. Are Ambulance charges reimbursable?
Ans. Yes, Ambulance charges are reimbursable within the city, if there is a certificate from treating doctor that conveyance by any other mode would definitely endanger patient’s life or would grossly aggravate his/her condition.
Q96. Is it necessary that the ECHS PC specialist should specify the name of the empanelled hospital for the purpose of referral?
Ans. No.
Q97. What are the ceiling rates for reimbursement of expenses on purchase of Hearing Aids?
Ans. The revised ceiling rates fixed for various types of hearing aid (for one ear) are as per CGHS rate:-
- Body worn/Pocket type 3000.
- Digital BTE 15000.
- Digital ITC/CTC 20000.