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Wednesday, November 2, 2011

REVISION OF CEILING RATES AND GUIDELINES FOR CGHS BENEFICIARIES

F No Misc.1002/2006/CGHS(R&H)/ CGHS(P)
Government of India
Ministry of Health & Family Welfare
Department of Health& Family Welfare

Maulana Azad Road, Nirman Bhawan
New Delhi 110 108 dated the 31 October 2011.

OFFICE MEMORANDUM

Subject: Revision of Ceiling Rates and guidelines for various Coronary /Vascular                          Stents for CGHSICS (MA) beneficiaries.

            In supersession of the Office Memorandum of even No dated 12.09.2007 of the Ministry of Health & Family Welfare for the revised rates and guidelines for Coronary / Vascular Stents for reimbursement of CGHSICS(MA) beneficiaries, all DCGI approved Coronary / Vascular Stents are approved for reimbursement to CGHSICS(MA) beneficiaries as per the ceiling rates mentioned below

1. DRUG ELUTING CORONARY STENTS-

i. All DCGI and FDA approved Drug Eluting Stents – Rs. 65,000/-
ii. Ail DCGI and CE approved Drug Eluting Stents - Rs. 50000/-
iii All DCGI approved Drug Eluting Stents - – Rs 40000/-

2 BARE METAL CORONARY STENTS

i) STAINLESS STEEL STENTS – Rs.12000/-
ii) COBALT STENTS – Rs.20,000/.

a) All DCGI and FDA approved
b) Ail DCGI and CE approved – Rs. 18,000/-
c) All DCGI approved – Rs. 15,000/-

iii) COATED I OTHER STENTS – Rs. 25,000/-

3. BARE METAL VASCULAR (NON CORONARY ) STENTS

i) STAINLESS STEEL STENTS – Rs 20000/-
ii) COBALT STENTS – Rs 22,000/-
iii) NITINOL / OTHER STENTS – Rs 25,000!-

            Reimbursement to beneficiaries /empanelled hospitals shall be limited to ceiling rates or as per actuals, whichever is lower.

2.         Coronary Stents shall be permitted on the advice of Govt. Specialist, of which not more than two shall be of Drug Eluding Stents. Permission shall be granted as per the laid down procedure. If more than two drug eluding stents are implanted in an empanelled hospital and no written informed consent was obtained from the beneficiary that he / she would bear the difference in cost between the DES and Bare Metal Stent, arid the hospital has charged this amount from the beneficiary, the additional amount shall be deducted from the pending bills of hospitals and shall be paid to the beneficiary

3.         It is essential for the empanelled hospitals to quote the Batch number when a coronary/vascular stent of any type is implanted in the case of a CGHS/CS (MA) beneficiary and also enclose a copy of the relevant invoices pertaining to the procurement of the stents by the hospitals. In addition to this, the outer pouch of the Stent packet along with the sticker on it on which details of the stent are printed shall also be enclosed with the medical bill for claiming reimbursement from the Govt. In case of treatment from a private non-empanelled hospital, where the treatment was taken in an emergency, it is the responsibility of the beneficiary to obtain the batch number, invoice and outer pouches of the stent(s) before the submission of the medical claim to CGHSI concerned department, as the case may be.

4. The empanelled hospital shall submit a self certified undertaking that the hospital has not charged the CGHS / CS(MA) beneficiary more than the rate at which the stent has been procured by the hospital and in case of any detection and establishment that the hospital has overcharged the hospital shall be removed from the list of hospitals empanelled under CGHS without any further notice.

5.         UTI-TSL, while processing the hospital bills of coronary I vascular stents shall ensure that the hospitals have enclosed copies of the relevant invoices pertaining to the procurement of the stents by the hospitals and the outer pouch of the Stent packet along with the sticker on it on which details of the stent are printed and that the prescribed rates and the guidelines have been followed, before making provisional payments to the hospitals

6.         The revised rates and guidelines shall come into force from the date of issue and shall be in force for a period of one year or tilt they are revised, whichever may be earlier.

7.         This issues with the concurrence of Finance Division vide Dy. No 2979 dated 20.10.2011 of the office of AS&FA Min. of H&FW

(JAI PRAKASH)
UNDER SECRETARY TO
GOVERNMENT OF INDIA

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