ECHS ADVISORY ON PAYABLE / NON-PAYABLE ITEMS FOR SETTLEMENT OF CLAIMS

ECHS ADVISORY ON PAYABLE / NON-PAYABLE ITEMS FOR SETTLEMENT OF CLAIMS

Tele: 011-25683476 Ml 36833
Email: jdmed.navy@echs.cov.in
BY REGD POST / SDS
Central Organisation ECHS
Adjutant General’s Branch
Integrated HQ of MoD(Army)
Thimayya Marg,
Near Gopinath Circle
Delhi Cantt – 110 010

B/49778/AG/ECHS/Claim/Advisory                                          04 Oct 2022

IHQ of MoD (Navy)/Dir ECHS (N)

Air HQ (SP), Dte of AV, Subroto Park HQ Coast Guard

HQ Southern Command (A/ECHS) HQ
Easthern Command (A/ECHS)
HQ Western Command (A/ECHS)
HQ Northern Command (A/ECHS)
HQ Central Command (A/ECHS)
HQ South Western Command (A/ECHS)
HQ Andaman & Nicobar Command (A/ECHS)
HQs Training Command AF, Bangalore
All Regional Centres ECHS

ADVISORY ON PAYABLE / NON-PAYABLE ITEMS FOR SETTLEMENT OF CLAIMS

  1. Refer to Para 17 (e) & 44 (j) of SOP on Treatment Management.
  2. There have been many complaints in the past from the environment regarding the cashless claim settlement process as per ECHS policy. Both the ESM clientele and empaneled HCOs repeatedly approach various echelons of the ECHS organization requesting for full reimbursement of their claims.
  3. The package rates for procedures/investigations and cost of implants are published as per compendium of CGHS rates amended from time to time. These city wise rates are taken into consideration while processing CGHS/ECHS claims. Similarly, the policy for items which are payable/not payable for CGHS beneficiaries is also applicable equally for ECHS beneficiaries.
  4. There is no standard list published by CGHS for payable/non payable consumable items and the CGHS earlier considered these as per the merits of the case. Post convergence of Central Government schemes like ESI, CAPF and CGHS on NHA IT platform, there is a standard list promulgated by NHA for processing all hospital and indls reimbursement claims. This list as obtained from NHA is being promulgated through this letter to bring parity and objectivity in processing of claims at all echelons; BPA, RCs and Central Org.
  5. The payable / non-payable template has items summarized under the following heads: –
  6. Administration or non-medical charges (23 Items)                    Appx ‘A’
  7. External durable devices (25 Items)                                         Appx ‘B’
Item specifically excluded in the policies (14 Items)Elements of Room charge (12 Items)Items payable if supported by a prescription (17 Items)Items which from part of hospital services where separate Consumables are not payable (21 Items)Appx ‘C’ Appx Appx `E’
Appx ‘F’
  • Toiletries I cosmetics / personal comfort or convenience  –   Appx `G’
    Items (58 Items).
  • Others (24 Items)  –   Appx ‘H’
  • (j)   Part of Hospital own costs and not payable (03 Items)     –       Appx
  • Cardiology related consumbles.    Queries have also been received from some
    RCs regarding admissibility of Cardiology related consumables like catheters, guidewires sheaths and microcatheters. Modern recanalization systems / devices like IVL and suture mediated closure systems like Proglide etc will require approval from Sr Adv Cardiology / CI specialist with rational justification for use. Other consumables like Guide wires, sheaths, simple wires or catheters are to be construed as part of the package and are not to be billed separately.
  • Investigations billed/claimed separately.    As per SOP, all investigations are
    part of the package rate, therefore even if they are done prior to admission separately, they will not be paid. Billing it separately is tantamount to splitting of bills, hence will not be permitted.
  • Antibiotics.      All NABH accredited hospitals have a written antibiotic policy. RCs
    may ask for the same and accordingly process the bill if indiscriminate injudicious use of antibodies is suspected. CO, ECHS has formulated a standard antibiotic policy in consultation with o/o DGMS. The same may be referred to review antibiotic use.
  • Reimbursement of expenses incurred by beneficiaries as IPD case during Hospital admission.     It is also clarified that expenses incurred on medicines, consumables sundry equipment and accessories which are purchased from outside based on specific authorization of treating doctor / staff of concerned hospital will be reimbursable only if they are falling under the list of payable items. In case, the empanelled hospital has asked an ECHS beneficiary for purchase of such payable items over and above the package rates reimbursement will be made to the beneficiary and the amount shall be recovered from the pending bill of the hospital. (Ref Para 2 of OM Govt of India MoHFW F.No 2-1/2012/CGHSNC/CGHS(P) dated 01 Aug 2013). For such reimbursement cases, the date of purchase of such items should match with the in-patient stay at the hospital.
  1. SEMOs are requested to advise Sr Adv / spls to diligently scrutinize the justification
    on Appx A for unlisted procedures / implants / investigation raised by empanelled hospitals.
  2. All RCs are requested to ensure that the contents of attached enclosures be
    disseminated to all Empaneled hospitals in their AoR for strict compliance.

3.     The list of payable & non-payable is not exhaustive in nature and will be revised from time to time as per extant policies of CGHS / GOI directives in future.

Jt Dir Claim for MD ECHS

Encls: – As above Internal:

Ops & Coord

Med P&FC

C&L Emp S&A please upload on ECHS portal.

Copy to:-

M/s UTI ITSL UTI Bhawan Plot No 3, Sector 11 CBD Belapur, Navi Mumbai Maharashtra – 400614for info and necessary action regarding ECHS related bills.

Appx ‘A’

(Ref to this HQ letter No B/49778/AG/ECHS/Claim/Advisory dt  &Q Oct 2022.

ADMINSTRATIVE OR NON-MEDICAL CHARGES

S NOITEMSSTATUS
I.MORTUARY CHARGESPayable up to 24 hrs, shifting charges not payable
 ADMISSION KITNot Payable
 BIRTH CERTIFICATENot Payable
 BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGESNot Payable
 CERTIFICATE CHARGESNot Payable
 CONVEYANCE CHARGESNot Payable
 COURIER CHARGESNot Payable
 DAILY CHART CHARGESNot Payable
 DIABETIC CHART CHARGESNot Payable
 DISCHARGE PROCEDURE CHARGESNot Payable
 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSESNot Payable
 ENTRANCE PASS / VISITORS PASS CHARGESNot Payable
 FILE OPENING CHARGESNot Payable
 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)Not Payable
 MAINTENANCE CHARGESNot Payable
 MEDICAL CERTIFICATENot Payable
 MEDICAL RECORDSNot Payable
 MEDICINE BOXNot Payable
 MEDICO LEGAL CASE CHARGES (MLC CHARGES)Not Payable
 PATIENT IDENTIFICATION BAND / NAME TAGNot Payable
21:PHOTOCOPIES CHARGESNot Payable
 PREPARATION CHARGESNot Payable
 WASHING CHARGESNot Payable

Appx ‘8’

(Ref to this HO letter No B/49778/AG/ECHS/Claim/Advisory dt o Oct 2022

EXTERNAL DURABLE DEVICES

S NOITEMSSTATUS
I.LUMBOSACRAL BELTry                                                                                                                                                                                                                 ___ Payable for surgery of lumbar spine.
2.NIMBUS BED OR WATER OR AIR BED CHARGESNot payable included in RR
r4ABDOMINAL BINDEREssential and should be paid at least in Post Surgery patients of major Abdominal Surgery Including TAH, LSCS, Incisional Hernia Repair, Exploratory Laparotomy for Intestinal Obstruction. Liver Transplant Etc.
 AMBULANCE COLLARNot Payable
 AMBULANCE EQUIPMENTNot Payable
 ARMSLINGNot Payable
 BIPAP MACHINENot Payable    .
 CERVICAL COLLAR                                                                                        .`Not Payable                             ..
 BEDPANNot Payable
 CPAP/ CAPD EQUIPMENTSDevice not payable
II.DIABETIC FOOT WEARNot Payable
 INFUSION PUMP — COSTDevice not payable
 KNEE BRACES (LONG/ SHORT/ HINGED)Not Payable
 KNEE IMMOBILIZER/SHOULDER IMMOBILIZERNot Payable
 MICROSHEILDNot Payable
 NEBULIZER KITNot Payable
 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL)Not Payable
 PULSEOXYMETER CHARGESDevice not payable
 SPO2 PROBENot Payable
 SPACERNot Payable
 SPIROMETREDevice not payable
 SPLINTNot Payable
 STEAM INHALERNot Payable
 THERMOMETERNot Payable
 WALKING AIDS CHARGESNot Payable

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