Procedure to process of Medical Reimbursement Claim – Check List for Processing Medical Advance

By SPEED POST

F.No.D-12015/06/2020-Ad.IX
Government of India
Ministry of Finance
Department of Revenue
Central Board of Direct Taxes
*****

Room No.10, 5th Floor,
Jeevan Vihar Building,
Parliament Street, New Delhi – 110001

Dated : 28.10.2020

To

All Principal Chief Commissioner of Income Tax
All Director General of Income Tax (Inv.)

Sub : Streamlining of procedure to process of medical reimbursement claim.

Sir/Madam,   It has been observed that the medical reimbursement claims are being received in the Board, are incomplete and not subjected to any initial check. As a result a lot of time is spent on further communications resulting in delay in settlement of the claim.

2. It has therefore been decided that in future all medical claim are to be submitted to the Board on the basis of the attached Check List with proper referencing of the documents with page number and Annexure.

3. Offices of the Pr. CCIT and DGIT (lnv.) are requested for wide circulation of this advisory amongst the all subordinate offices under their control.

Yours Faithfully

Biswajit Guha
Under Secretary to the Govt. of India
Telefax: 011-23741823

Copy to : IFU/DT for information

---

CHECK LIST FOR PROCESSING MEDICAL CLAIM

Name & Designation of the Claimant:——————————-

Office where working:——————————————

Name of Patient & relationship with claimant:————————————-

S.No.	Detail about the claim	Remark	Page No.I Annexure
1	Whether the patient is a CGHS beneficiary availing benefits under the Scheme. If, so whether a copy of the CGHS Card is enclosed.	Yes/No
2	In case of non-CGHS beneficiary, whether an AMA was appointed, and if so, whether the Appointment Order of AMA is enclosed.	Yes/No
3	Whether Medical Claim Form (duly filled in) has been submitted	Yes/No
4	Whether the claim was submitted within the stipulated period of three months from the date of discharge from the hospital.	Yes/No
5	If delayed, whether reasons for delay beyond 3 months was intimated.
6	Name of Hospital from where the treatment was taken/is being taken.
7	Whether the treatment was obtained from a Government Hospital or CGHS empanelled Private Hospital.	Government Hospital/ CGHS Empanelled Hospital/Non- empanelled hospital
8	In case of CGHS empanelled hospital, whether a copy of the Order/OM is enclosed.	Yes/No
9	Whether the case was referred by CGHS Doctor/AMA. If so, whether a copy of the ‘Referral slip’ is enclosed.	Yes/No
10	In case of treatment was obtained from a Private hospital under emergency, whether Emergency Certificate is enclosed in original.	Yes/No
11	Whether the permission was taken from the concerned office. If so, whether a copy of ‘Permission letter’ is enclosed.	Prior permission or Ex-facto permission
12	Disease(s) being treated
13	Whether the claim for reimbursement has been approved by the H.O.D.	Yes/No

14	Details of payments made by the employee.
15	Whether the treatment was obtained on credit basis. If so, whether a copy of the permission given by his/her office.	Yes/No
16	Whether ‘prescription slips’ of ‘day-to-day report’ of the treating doctor/hospital are enclosed.	Yes/No
17	Whether the Medical Bills of the Hospital are enclosed in original and certified.	Yes/No
18	Total amount of bills given by the Hospital
19	Whether the Discharged Summary has been enclosed in original.	Yes/No
20	Whether a table indicating each item of expenditure charged by the hospital vis-a-vis actual admissible amount as per CGHS rate/CS(MA) Rules, duly authenticated by the HoD concerned has been forwarded with the claim.	Yes/No
21	Amount admissible for reimbursement as per CGHS/CS(MA) Rates.	Rs.
22	A copy of CGHS rate list highlighting the treatment procedures done in the hospital.	Yes/No
23	Outer Pouch of the Stents used for the patients in the hospital is/are enclosed in original.	Yes/No/N.A.
24	A copy of Death Certificate was furnished (in case of death).	Yes/No/N.A.
25	Affidavit on Stamp paper was submitted by the Claimant (in case of death)	Yes/No/N.A.
26	Whether any medical advance was sanction. If so, the amount sanctioned and a copy of the Sanction Order to be enclosed.	Yes/No
27	Net amount to be sanctioned (after adjustment of Medical Advance, if sanctioned)	Rs.
28	Whether a self explanatory letter from the beneficiary if treatment taken in emergency has been enclosed.	Yes/No

---

CHECK LIST FOR PROCESSING MEDICAL ADVANCE

Name & Designation of the Claimant:

Office where working:

Name of Patient & relationship with claimant:

S.No.	Detail about the claim	Remark	Page No.
1	Whether the patient is a CGHS beneficiary availing benefits under the Scheme. If, so whether a copy of the CGHS Card is enclosed .	Yes/No
2	In case of non-CGHS beneficiary, whether an AMA was appointed, and if so, whether the Appointment Order of AMA is enclosed.	Yes/No
3	Name of Hospital from where the treatment is being taken/proposed to be taken.
4	Whether it is a Govt. Hospital or CGHS empanelled private hospital or Non-CGHS empanelled hospital
5	In case of CGHS empanelled hospital, whether a copy of the OM of its empanelment is enclosed .	Yes/No
6	Whether the case was referred by CGHS Doctor/AMA. If so, whether a copy of the ‘Referral Slip’ is enclosed.	Yes/No
7	Whether credit facility is extended to the patient.	Yes/No
8	Whether approval of H.O.D. was obtained.	Yes/No
9	Estimated cost for the treatment given by the hospital.	Rs.
10	Whether the admissible amount has been restricted as per CGHS rates I CS(MA) Rules I Govt. hospital rates.	Yes/No
11	Amount of Advance admissible for sanction	Rs.

Proforma for item-wise expenditure charged by the hospital vis-a-vis actual admissible amount as per CGHS rate/ CS(MA) Rules, duly authenticated by the HoD concerned

Name & Designation of the Claimant:

Office where working:

Name of Patient & relationship with claimant:

Name of the Hospital and address;

Duration of the Treatment:

SI. No.	Items	Amount Charged	Amount admissible as per CGHS rate/ CS(MA) Rules	Remarks
1)	Bed Charges			Annexure- 1
2)	ICU Charges			Annexure -2
3)	Doctors’ Visit			Annexure-3
4)	Medicines			Annexure-4
5)	Lab/Test Charges			Annexure-5
6)
7)
8)
9)
10)

Checked and verified by:

Signature with stamp

Certified and authenticated by HoD

 

Signature with stamp

---

Annexure

Proforma for Item-wise details

Name of item : Medicines

SI. No.	Date	Name of medicines	CGHS Code	Amount Charged	Amount admissible as per CGHS rate/ CS(MA) Rules	Remarks
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)

Source: Click Here to view/download the pdf 

F.No.D-12015/06/2020-Ad.IX

Government of India

Ministry of Finance

Department of Revenue

Central Board of Direct Taxes

*****

Room No.10, 5th Floor,

Jeevan Vihar Building,

Parliament Street, New Delhi – 110001

Dated : 28.10.2020

To

All Principal Chief Commissioner of Income Tax

All Director General of Income Tax (Inv.)

Sub : Streamlining of procedure to process of medical reimbursement claim.

Sir/Madam, It has been observed that the medical reimbursement claims are being received in the Board, are incomplete and not subjected to any initial check. As a result a lot of time is spent on further communications resulting in delay in settlement of the claim.

2. It has therefore been decided that in future all medical claim are to be submitted to the Board on the basis of the attached Check List with proper referencing of the documents with page number and Annexure.

3. Offices of the Pr. CCIT and DGIT (lnv.) are requested for wide circulation of this advisory amongst the all subordinate offices under their control.

Yours Faithfully

Biswajit Guha

Under Secretary to the Govt. of India

Telefax: 011-23741823

Copy to : IFU/DT for information

________________________________________

CHECK LIST FOR PROCESSING MEDICAL CLAIM

Name & Designation of the Claimant:——————————-

Office where working:——————————————

Name of Patient & relationship with claimant:————————————-

S.No. Detail about the claim Remark Page No.I Annexure

1 Whether the patient is a CGHS beneficiary availing benefits under the Scheme. If, so whether a copy of the CGHS Card is enclosed. Yes/No

2 In case of non-CGHS beneficiary, whether an AMA was appointed, and if so, whether the Appointment Order of AMA is enclosed. Yes/No

3 Whether Medical Claim Form (duly filled in) has been submitted Yes/No

4 Whether the claim was submitted within the stipulated period of three months from the date of discharge from the hospital. Yes/No

5 If delayed, whether reasons for delay beyond 3 months was intimated.

6 Name of Hospital from where the treatment was taken/is being taken.

7 Whether the treatment was obtained from a Government Hospital or CGHS empanelled Private Hospital. Government Hospital/ CGHS Empanelled Hospital/Non- empanelled hospital

8 In case of CGHS empanelled hospital, whether a copy of the Order/OM is enclosed. Yes/No

9 Whether the case was referred by CGHS Doctor/AMA. If so, whether a copy of the ‘Referral slip’ is enclosed. Yes/No

10 In case of treatment was obtained from a Private hospital under emergency, whether Emergency Certificate is enclosed in original. Yes/No

11 Whether the permission was taken from the concerned office. If so, whether a copy of ‘Permission letter’ is enclosed. Prior permission or Ex-facto permission

12 Disease(s) being treated

13 Whether the claim for reimbursement has been approved by the H.O.D. Yes/No

14 Details of payments made by the employee.

15 Whether the treatment was obtained on credit basis. If so, whether a copy of the permission given by his/her office. Yes/No

16 Whether ‘prescription slips’ of ‘day-to-day report’ of the treating doctor/hospital are enclosed. Yes/No

17 Whether the Medical Bills of the Hospital are enclosed in original and certified. Yes/No

18 Total amount of bills given by the Hospital

19 Whether the Discharged Summary has been enclosed in original. Yes/No

20 Whether a table indicating each item of expenditure charged by the hospital vis-a-vis actual admissible amount as per CGHS rate/CS(MA) Rules, duly authenticated by the HoD concerned has been forwarded with the claim. Yes/No

21 Amount admissible for reimbursement as per CGHS/CS(MA) Rates. Rs.

22 A copy of CGHS rate list highlighting the treatment procedures done in the hospital. Yes/No

23 Outer Pouch of the Stents used for the patients in the hospital is/are enclosed in original. Yes/No/N.A.

24 A copy of Death Certificate was furnished (in case of death). Yes/No/N.A.

25 Affidavit on Stamp paper was submitted by the Claimant (in case of death) Yes/No/N.A.

26 Whether any medical advance was sanction. If so, the amount sanctioned and a copy of the Sanction Order to be enclosed. Yes/No

27 Net amount to be sanctioned (after adjustment of Medical Advance, if sanctioned) Rs.

28 Whether a self explanatory letter from the beneficiary if treatment taken in emergency has been enclosed. Yes/No

________________________________________

CHECK LIST FOR PROCESSING MEDICAL ADVANCE

Name & Designation of the Claimant:

Office where working:

Name of Patient & relationship with claimant:

S.No. Detail about the claim Remark Page No.

1 Whether the patient is a CGHS beneficiary availing benefits under the Scheme. If, so whether a copy of the CGHS Card is enclosed . Yes/No

2 In case of non-CGHS beneficiary, whether an AMA was appointed, and if so, whether the Appointment Order of AMA is enclosed. Yes/No

3 Name of Hospital from where the treatment is being taken/proposed to be taken.

4 Whether it is a Govt. Hospital or CGHS empanelled private hospital or Non-CGHS empanelled hospital

5 In case of CGHS empanelled hospital, whether a copy of the OM of its empanelment is enclosed . Yes/No

6 Whether the case was referred by CGHS Doctor/AMA. If so, whether a copy of the ‘Referral Slip’ is enclosed. Yes/No

7 Whether credit facility is extended to the patient. Yes/No

8 Whether approval of H.O.D. was obtained. Yes/No

9 Estimated cost for the treatment given by the hospital. Rs.

10 Whether the admissible amount has been restricted as per CGHS rates I CS(MA) Rules I Govt. hospital rates. Yes/No

11 Amount of Advance admissible for sanction Rs.

Proforma for item-wise expenditure charged by the hospital vis-a-vis actual admissible amount as per CGHS rate/ CS(MA) Rules, duly authenticated by the HoD concerned

Name & Designation of the Claimant:

Office where working:

Name of Patient & relationship with claimant:

Name of the Hospital and address;

Duration of the Treatment:

SI. No. Items Amount Charged Amount admissible as per CGHS rate/ CS(MA) Rules Remarks

1) Bed Charges Annexure- 1

2) ICU Charges Annexure -2

3) Doctors’ Visit Annexure-3

4) Medicines Annexure-4

5) Lab/Test Charges Annexure-5

6)

7)

8)

9)

10)

Checked and verified by:

Signature with stamp

Certified and authenticated by HoD

Signature with stamp

________________________________________

Annexure

Proforma for Item-wise details

Name of item : Medicines

SI. No. Date Name of medicines CGHS Code Amount Charged Amount admissible as per CGHS rate/ CS(MA) Rules Remarks

1)

2)

3)

11