Procedure for Submission of Medical Reimbursement Claims (MRCs) by Pensioners (P) Beneficiaries in CGHS

Procedure for Submission of Medical Reimbursement Claims (MRCs) by Pensioners (P) Beneficiaries in CGHS: MoHFW OM dated 28.06.2024

Z15025/19/2024/DIR/CGHS
(Comp No. 8281286)
I/3687353/2024
भारत सरकार
स्वास्थ्य और परिवार कल्याण मंत्रालय
रामकृष्‍ण पुरम, नई दिल्ली

दिनांकित / – 28.06.2024

कार्यालय ज्ञापन / OFFICE MEMORANDUM

Subject: Procedure for Submission of Medical Reimbursement Claims (MRCs) by Pensioners (P) Beneficiaries in CGHS

1.The procedure to be followed by CGHS for submission of MRC by pensioner CGHS beneficiaries shall be as follows:

1. Submission of MRC: The beneficiary will submit the MRC in the prescribed format (Form MRC (P), Annexure A) with all relevant supporting vouchers/documents in original, to the CMO-I/C of the relevant CGHS Wellness Centre. The CGHS Wellness Centre shall verify and ensure, before accepting the claim papers, that all relevant documents are enclosed as per the prescribed checklist (Annexure B) and issue a dated acknowledgement to the claimant in token of receipt of the MRC by CGHS. MRC Claim ID shall be generated by the Wellness Centre which shall be made available through SMS.
2. Forwarding MRC Papers: The CGHS Wellness Centre shall forward the MRC papers online after scrutiny to the concerned Office of Additional Director (AD) CGHS for further processing for reimbursement of claims. The physical papers shall be sent to the office of the AD within one/two days of receipt of the claim papers.
3. Handling Deficiencies: If there are any deficiencies/gaps found in MRC documents/papers, the CMO l/c shall retain the papers and communicate the list of deficiencies/observations to the beneficiary through SMS. If the deficiency is found at the level of O/o AD, they shall retain the papers and communicate the list of deficiencies/observations to the CMO-I/C to remove the shortcomings through email.
4. Informing the Beneficiary of deficiency in the claim: The CMO-I/C shall contact the beneficiary concerned and inform them about the shortcomings in the MRC papers and request them to submit the requisite information/documents. The CMO I/C shall not return the MRC in original unless it is rejected in total.
5. Processing the MRCS: The MRCS shall be scrutinized and processed by the Office of AD as per the extant policy and instructions for issued from time to time about the CGHS rates and admissibility of claims of under CGHS. f. Informing the Beneficiary of approved claim amount: When a bill is sent to the PAO, the details pertaining to the claimant will be entered through computer and the claimant shall be informed of the same along with the amount admissible and details of disallowances indicating the specific reasons/grounds for deductions.
6. Payment Processing: The amount found admissible as per the CGHS guidelines shall be passed for payment and forwarded online to the PAO for making payment. The original documents should also be forwarded simultaneously to the PAO for making payment of the admissible amount to the claimant.

2.Tracking of Status of MRC: The Status of MRC can be viewed online based on the Claim ID generated at the time of submission via the CGHS Web portal (www.cghs.nic.in) or through my CGHS Mobile app (available on Android and iOS devices). The Standard Operating Procedure is enclosed (Annexure 3).

This issue is with the approval of competent Authority

Encl: As Above To,

Signed by Dr Satheesh Y H
Date 28.06.2024 15:15:32
(Dr Y.H. Satheesh)
Director (CGHS)