DR.NTR VAIDYASEVA TRUST: Subject: Dr.NTRVST- Medical reimbursement– Scrutiny of medical reimbursement bills of State Govt. Employees and Pensioners by Dr.NTR Vaidyaseva Trust- Guidelines – Communicated- Reg. Ref: G.O.Ms.No. 6, HM & FW Dept., dated 11.01.2017.
It is to inform that the Government, vide reference cited, has authorised the CEO, Dr.NTR Vaidyaseva Trust to scrutinise the medical reimbursement bills of State Govt. employees and pensioners duly following the existing APIMA Rules, 1972. Subsequent to the above orders, the Trust has received all pending medical reimbursement (nearly 5000) bills from DME and the Trust is under the process of developing the online module for scrutiny of medical reimbursement bills including submission of bills. In this regard, Trust hereby issues the following guidelines (Annexure enclosed) in respect of submission of bills, package rates and other issues with reference to the existing GOs and APIMA rules, 1972. It is therefore, all the beneficiaries entitled for medical reimbursement are requested to follow the guidelines while submission of the bills to Dr.NTR Vaidyaseva Trust.
In pursuance of the Government orders issued vide G.O.Ms.No.6, HM & FW Dept., dated 11.01.2017, a total of 4674 pending medical reimbursement bills were received from DME. According to the above G.O., the scrutiny of medical reimbursement bills to be done by Dr.NTR Vaidyaseva Trust as per the existing APIMA Rules, 1972.
Employees and Pensioners Medical Reimbursement Guidelines:
Guidelines are issued in relation to medical reimbursement of employees and pensioners:
The following guidelines are issued in relation to medical reimbursement of employees and pensioners of Govt. of Andhra Pradesh.
1) Documents required for submission of medical reimbursement bills:
i. Forwarding Letter from concerned HoD.
ii. Application Requisition of individual with date.
iii. Check list duly attested by the Forwarding Officer.
iv. Appendix-II duly signed by the Employee/Pensioner and attested by the Forwarding Officer.
v. Non-Drawal Certificate in Prescribed proforma
vi. Dependent Certificate as required in prescribed proforma with Forwarding Officer signature.
vii. P.P.O.(Pension Payment Order) copy in case of pensioner/ family pensioner attested by the Forwarding Authority.
viii. In case of accident cases and treatment taken in un-recognized hospitals under emergency, FIR should be submitted.
ix. For every follow up treatment for post operative cases and who requires lifelong treatments, revalidation of prescription once in six months from special government doctor preferably and attested by Forwarding Officer.
x. Legal Heir Certificate should be submitted in case of death of the Teachers / Pensioners / Dependents duly attested by the Forwarding Authority.
xi. Emergency Certificate / O.P in original duly signed and stamped by the treating doctor attested by Forwarding Officer.
xiii. Essentiality Certificate in original duly signed and stamped by the treating doctor attested by Forwarding Officer.
xiv. Genuineness certificate issued by the treating hospital.
xiv. Discharge Summary / Discharge Memo.(OP card in respect of OP treatment) in original duly signed and stamped by the treating Doctor attested by Forwarding Officer.
xv. Abstract of Bills (All original Medical Bills should be signed with stamp by the treating
Doctor) attested by Forwarding Officer.
xvi. Detailed proposal along with justification /need in case of claims where relaxation of rules is involved.
xvii. The DDOs shall submit the countersigned bills along with template prescribed by the
Trust in the online application of medical reimbursement.
Note:
i. All the documents should be submitted in original. The concerned Forwarding Authorities/ Drawing and Disbursement Officers are personally held responsible for fake and fabricated bills and misappropriation of public funds.
ii. The details of the sender / HoD concerned like full postal address including pin code and mobile contact number should be furnished on the front side of the envelope.
iii. All the applicants are informed that the online module for scrutiny of medical reimbursement bills will be deployed shortly by Dr.NTR Vaidyaseva Trust. In this regard, it is to inform that the submission of bills in the form of physical records will not be considered as and when online process is enabled. The date of online deployment will be informed in due course.
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2) Package rates:
Vide G.O.Ms.No.74, HM & FW Dept., dated 15.03.2005, the rates prescribed in the CGHS Package by Govt. of India, Ministry of Health & Family Welfare Affairs, New Delhi for Central Government Health Scheme, Hyderabad are adopted in the State for the purpose of reimbursement of medical expenditure incurred by the State Government employees both in service/ retired and their dependents; family pensioners. M.L.As and their family members and all other eligible categories who are entitled for free medical treatment as mentioned in Andhra Pradesh Integrated Medical Attendance Rules, 1972, when the treatment was taken in the private hospitals recognised by the State Government within the State or outside the state.
If any rates which are not covered in the said procedure, the scrutinising authority is empowered to take final decision in the matter basing on the disease/ nature of disease, necessity of treatment /medicine.
3) Quick disposal of claims on priority basis:
i. Quick disposal of medical reimbursement bills will be undertaken in respect of Judges, IAS officers, IPS officers, MLA, Ex-MLA, MPs, Ex-MPs, Ministers, Ex-Ministers.
ii. Full reimbursement shall be considered for Judges and Cabinet Ministers.
4) Non scrutiny of the bills scrutinized by the SVIMS and NIMS:
The medical reimbursement bills of the patients who availed treatment in SVIMS and NIMS already scrutinized by the respective institutions, shall not be scrutinized by the Trust provided a separate scrutiny certificate issued by the concerned institutions is attached.
5) Ceiling limit on the packages:
i. Surgical packages: For all surgical packages, the package rate is limited to the maximum of
Rs.2.00 lakhs.
In case of non-availability of surgical packages or with infection / complications such as
Diabetes Mellitus, Hypertension or multiple procedures, the maximum limit is Rs.1.00 lakh. ii. Medical packages:- The upper ceiling limit for all medical procedures is Rs.1.00 lakh only.
6) Special packages:
i. The procedures under the following categories are considered for a maximum ceiling limit of
Rs.2.00 lakhs.
a. Cardiac procedures
b. Post-Op Neuro surgical procedures
c. Cancer (Chemo, Radio and Surgical)
ii. In case of transplantations, Rs.2.00 lakhs package which includes both donor and recipient.
iii. Dialysis under OP:- Maximum limit of Rs.1.00 lakh will be considered for Haemodialysis depending upon the number of cycles.
iv. OPD treatment for Diabetes by the private hospitals is not considered.
v. For any Laparoscopic procedures, 3 days of hospital stay is admissible and additional stay can be considered with admissible hospital stay of Rs.1500/- per day (room rent) along with additional investigation charges and pharmacy bill.
vi. The upper ceiling limit of package will be Rs.4.00 lakhs for Judges, MLAs, Ex-MLAs, MPs, Ex- MPs, Ministers.
7) Deductions:
i. 15% of the claim will be deducted in case the submission of bill by the applicant is more than
6 months. If the delay is due to administrative lapses, they will be considered as certified by the competent authority.
ii. 10% of the claim will be deducted if the treatment availed in the non-empanelled hospitals. iii. Food bills, Beverages, Administrative charges, Cosmetics, Excess Room Rents, Medical
record charges, Attendant’s room rent, Utilities, Excess charges are non-admissible.
Dr.NTR Vaidyaseva Trust guidelines for Medical Reimbursement Bills Scrutiny 2017
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