Para 2.16.8 — CAM
Original Rule Text
2.16.8 MEDICAL REIMBURSEMENT CLAIMS
The medical reimbursement claims should be checked and regulated as per the provisions under the Medical Attendance Rules, as amended from time to time. The following main checks are to be exercised by PAOs in respect of Medical Reimbursement
The bill for medical reimbursement should be prepared in Form RPR – 23.
Bills1. 2. The amount drawn in the bills must be supported by proper paid receipts and vouchers in all cases, and should be submitted by the Government servant along with essentiality certificates in Form 'A' or 'B'. 3. PAO is to examine as to whether the fees charged by the Authorised Medical Attendant is in accordance with the prescribed rates. 4. Examine that all the sub-vouchers including for tests etc. prescribed by private hospitals are duly countersigned by the Medical Officer in CGHS Centre and by the competent authority accepting the claim of medical reimbursement. Cases where officials undergo treatment in emergency, requisite emergency certificate issued with the approval of HoD are enclosed along with bill. 5. Special care is to be taken in regard to the diet charges (because these are normally included in the hospital bills submitted by the Government servants). 6. Medicine purchased from open market/chemist is not admissible i.e. in case of CGHS beneficiaries as per OM issued by CGHS dated 24.07.1995 &. 18.02.2000. Inadmissible items should not be allowed as per CGHS OM F.No.2-l/2012/CGHS/VC/CGHS(P) dated 01.08.2013. 7. Restricted/approved amount should be attested by DDO through Passed for Payment. 8. Check that if part settlement has been made by medical claim insurance policy, certificate to the effect that total reimbursement amount claimed from both (insurance & CGHS) are not exceeded from actual expenditure is provided with the bill in terms of M/o Health & Family Welfare orders.
9. Check that medical advance, if any, is to be paid in favour of hospital only and not in individual account of employee. 10. Check that copies of CGHS card of the patient, CGHS card of the primary card holder and of CGHS referral slip are available with other supporting medical documents. In case of AMA, referral to be done in empanelled Hospital by an authorized AMA. Check that discharge summary duly signed by treating specialist/CMO etc. is attached with the bill in case of indoor patient. Check that CGHS rate codes are mentioned in bills as per CGHS OM No.Z-15025/117/2017/Dir/CGHS/EHS dated 10.12.2018 as amended and revised from time to time.
What This Means
Medical reimbursement claims must be checked against the Central Services (Medical Attendance) Rules. The bill must be in the prescribed Form RPR-23, supported by paid receipts, vouchers, and essentiality certificates (Form A or B). The PAO verifies whether the treatment was at a recognized hospital, whether the employee or dependent was eligible, whether prior approval (referral) was obtained where required, and whether the rates claimed are within prescribed limits. CGHS and non-CGHS cases have different processing requirements.
This explanation was generated with AI assistance for educational purposes. Always refer to the official gazette notification for authoritative text.
Key Points
- 1Medical reimbursement bills must be in Form RPR-23 with paid receipts and vouchers
- 2Essentiality certificates in Form A or Form B must accompany the claim
- 3Treatment must be at a recognized/empaneled hospital for full reimbursement
- 4Prior referral or approval may be required for certain treatments and hospitals
- 5PAO verifies eligibility, rates, hospital recognition, and compliance with Medical Attendance Rules
Practical Example
A government employee's spouse undergoes knee replacement surgery at a private hospital empaneled under CGHS. The employee submits a medical reimbursement claim of Rs.4 lakh with the hospital bill, discharge summary, essentiality certificate from the treating specialist, and CGHS referral letter. The PAO verifies that the hospital is empaneled, the procedure was covered under CGHS rates, the referral was obtained before admission, and the claimed amount does not exceed the CGHS-prescribed package rate for knee replacement.
This explanation was generated with AI assistance for educational purposes. Always refer to the official gazette notification for authoritative text.
Frequently Asked Questions
What forms are required for medical reimbursement claims?▼
Does the hospital need to be CGHS-empaneled?▼
Can the PAO reject a medical claim?▼
This explanation was generated with AI assistance for educational purposes. Always refer to the official gazette notification for authoritative text.