The Central Government Health Scheme (CGHS) helps more than 50 lakh beneficiaries. It covers healthcare needs. Beneficiaries can get 100% cashless treatment or reimbursements.
This scheme includes the following:
- Central government employees
- Pensioners
- Members of Parliament
- Retired constitutional authorities
CGHS empanelment offers healthcare through CGHS wellness centers and hospitals across India. In several cases, CGHS allows cashless treatment or reimbursement for selected medical services.
But many CGHS beneficiaries can face a problem with approval. The system can either reject the claim or deny the request for cashless treatment.
This situation can stress and disappoint a health seeker. It’s even harder in an emergency. But the reason is not the treatment but some other factors.
Knowing the common reasons for CGHS claim failures can help you avoid them later. Keep reading to learn how to enjoy CGHS and avoid last-minute rejections.
Who is Covered Under CGHS?
Check if you qualify first. Then, worry about claim rejections or approvals. The Central Government Health Scheme gives medical help. It supports many departments. Let’s look at all of them.
- Serving central government employees in ministries, departments, or offices. But they should fall under the CGHS-covered area. The additional benefit is that dependents of CGHS cardholders get coverage too.
- Central government pensioners continue to receive the same CGHS coverage after retirement. The bonus is that even after retirement, their dependents are also covered.
- Employees of certain autonomous bodies can access CGHS scheme benefits. But it depends on whether the body has joined the scheme.
- Members of Parliament (MPs) have CGHS coverage. This includes both current and former MPs, along with their dependents.
- Former presidents, governors, and judges get CGHS healthcare benefits. These benefits are for them, along with their dependents.
- Freedom fighters also receive CGHS benefits in specific situations.
Note: Before benefiting from any CGHS treatment, verify CGHS eligibility beforehand.
Beware of the Common Reasons Why CGHS Claims Get Rejected
Unfortunately, the reason for the CGHS claim rejection is not something huge. It is very small mistakes that lead to the final rejection. Either the problem arises in reimbursement or cashless referral disputes. What are these reasons that we need to take care of? Let’s know them:
1) Reimbursement Claim Rejections
- Bills Higher Than CGHS Package Rates: CGHS has fixed treatment rates. If the hospital or wellness center charges more than the approved rates, CGHS will reject the whole claim. They may also reject the extra amount. (It depends.)
- No Referral from the CGHS Wellness Center: You must get a referral from the chief medical officer (CMO). This is required before you can receive treatment at the CGHS wellness center. Without the referral issue, the claim will not get approved.
- Treatment at a Non-Empaneled Hospital: A CGHS cardholder can only get cashless or reimbursable treatment if the hospital or wellness center is empaneled with CGHS. The authorities may reject the CGHS claim unless a genuine emergency occurred.
- Procedures Not Covered Under CGHS: The CGHS scheme does not cover all treatments. CGHS does not cover some treatments, such as cosmetic and dental treatments. There are some excluded elective surgeries.
- Incomplete Documentation: How can any claim be settled if the documents are incomplete? Impossible! Missing prescriptions, medical reports, discharge summaries, or incorrect hospital bills can lead to claim rejections.
- Improper Billing Format: Billing on plain paper does not count. Bills should be proper. They include hospital letterheads, item-wise charges, and the authorities’ stamps and signatures.
2) Cashless Treatment or Referral Issues
- No Referral from CMO: If the CMO at the CGHS Ayurvedic hospital or wellness center does not approve any treatment, they will not issue a referral. This blocks the cashless treatment procedure.
- Emergency Case Disputes: CGHS allows cashless treatment in cases of life-threatening emergencies. But the authorities reject the claim if the situation is not that serious in the end.
- Second Opinions at Personal Expense: If you pay for second opinions out of your pocket, the system won’t approve your claim.
- Lack of Pre-Authorization for Cashless Treatment: There are some treatments that need CGHS pre-approval. If the hospital doesn’t get authorization first, they deny the cashless benefit. The patient will have to pay out of pocket.
Other Mistakes That Lead to Health Insurance Claim Rejections
Health insurance claim rejections do not happen due to the rules of the CGHS health scheme. Most insurance companies also follow the same principles. Some other reasons for claim refusal are the following:
1) Not Sharing Past Health Issues: Patients with insurance must share their full medical history. You should do this before treatment. Any alteration after the treatment will lead to final claim refusal.
2) Late Notice to Insurance Companies: Insurance providers need hospitals to inform them in advance. At least 24 to 48 hours. As the intimation delays, so does the claim settlement.
3) Policy Lapse Due to Unpaid Premiums: You can file a claim for hospitalization. This is only possible if your policy is active when it occurs.
4) Treatments not covered in the policy do not get coverage. Such claims face rejection.
5) Lack of Medical Necessity: Insurance companies approve treatments after doctors’ justification. Claims get cleared after the treatment appears necessary.
How to Avoid CGHS Claim Rejection
Many CGHS claims get rejected due to small mistakes. Proper planning and knowledge can save you from a failed claim settlement. So, what can you do to avoid this thing at all costs?.
1) Get a referral first. You usually need one from the CGHS Wellness Center (CMO) before seeing a specialist. But you can skip this step if it is a serious medical emergency situation.
2) Check hospital empanelment before admission. Verify if it is among the CGHS-empanelled hospitals.
3) Understand CGHS package rates that follow fixed government rates.
4) Keep all the medical records safe. Maintain a proper file with all original documents, such as:
- Medical bills
- Prescriptions
- Diagnostic reports
- Discharge summary
- Hospital invoices
What to Do if Your CGHS Claim Gets Rejected
Don’t worry if your CGHS cashless treatment doesn’t get approved.
- STEP 1: If you have an unsettled claim, check whether it concerns referral or approval. Then, contact your CGHS Ayurvedic hospital or wellness center’s Chief Medical Officer. Note that if they reject your request, get their reason in writing from them.
- STEP 2: File a complaint with the additional director of CGHS in your city. Explain your case in detail.
- STEP 3: File a complaint on the CPGRAMS portal to escalate the unresolved claim. Send the issue to the Ministry of Health and Family Welfare. Use the CPGRAMS grievance portal.
- STEP 4: Use the Right to Information Act (RTI). If you think you’re eligible for cashless CGHS treatment, check your documents. If everything is correct, file an RTI. You can request the following:
- The rule that rejects your claim
- The officer responsible for the rejection of the claim
These steps and procedures clarify how treatment works under CGHS.
Also Read: https://vrindavanchikitsalayam.com/blog/cghs-ayurvedic-hospital
