REIMBURSEMENT ON EMERGENCY ADMISSION IN NON-EMPANELLED HOSPITAL

 STEP BY STEP PROCEDURE

REIMBURSEMENT ON EMERGENCY ADMISSION IN

NON-EMPANELLED HOSPITAL

(As per present provision.  Update will be intimated if any in this website) www.exservicemanindia.info

Authority Reference:

i) Central Organization ECHS Delhi letter B/49778/AG/ECHS/Claim/Policy dated 30 Aug 2017

ii) SOP Treatment Management in ECHS dated 28 Sep 2018

iii) If there are any policy changes issued after this date, relevant changes shall be followed by you

iv) FAQ at https://echs.gov.in/img/Policy/2FAQ%20Medical.PDF

v) Flow Chart at https://echs.gov.in/img/chart/8.html

1. What is an Emergency for admission in an Non Emapanelled Hospital Emergency in ECHS is defined as Life Threatening Conditions.(a Medical Condition), If a Patient gets admitted in an Non Empanelled Hospital due to an Emergency condition, the following important guidelines be followed. Emergency conditions are as below (refer above mentioned SOP document for details)

 Acute cardiac emergencies

 Acute respiratory emergencies

 Neurological emergencies

 Acute visual loss

 Acute pain abdomen

 Acute Renal Failure

 Acute obstetrics and gynecological emergencies.

 Acute kidney failure, dialysis for kidney in chronic kidney diseases

 Acute endocrine emergencies like Diabetic ketoacidosis

 Life threatening injuries including road traffic accidents, Head injuries, Multiple injuries, Crash injuries and thermal injuries.

 Burn injuries

 Acute limb ischemia

 Medical and surgical shocks

 Heat strokes and cold injuries of life threatening in nature.

 Acute poisoning & snake bite.

 Any severe infection leading to life threatening conditions

 Any other condition in which delay could result in loss of life or limb

2. Actions “Patient Admission to Discharge”

a) On admission, it is the responsibility of the Patient or Next Of Kin any representative to intimate the Parent PC or Nearest PC within 48 Hours about the admission including the Hospital Name & Hospital Address

b) The Patient or Next Of Kin (NOK) or any representative to collect Emergency Certificate from the Hospital and hand over to the Parent PC within 48 Hours of admission. (Email a copy of Emergency Certificate to the Parent PC if the patient is far from the Parent PC)

c) On Discharge, Patient or Next Of Kin or any representative should

          (i)      Obtain Discharge Summary

          (ii)     The Discharge summary must include Date of Admission & Date of           Discharge date correctly with details of disease & treatment provided

          (iii)    All Lab Reports

          (iv)    Other Treatment related Documents,

(iv)      Images & Reports.

d) Obtain Bills Summary & itemized bill, for which payment has been made by the Patient

e) In case the ECHS beneficiary has died in Hospital, obtain a Death Certificate

3. Reimbursement Steps

a) The Claim Must be made within 90 Days from Date Of Discharge.

(Note :- Between 91 to 180 days from Date of Discharge waiver from RC is to be obtained. Beyond 180 days, waiver from Central Organisation ECHS to be obtained)

b) Prepare a covering letter with a brief of the emergency condition, and the need to get admitted in a Non Empanelled Hospital due to the Emergency in Nature Illness and any other information that is important.

c) Clearly indicate the documents that are being submitted with the covering letter, your full Name, address, Email ID and Mobile Number for communication

d)      Submit following documents

          a. Original Documents received from the Hospital as below

                   1. Emergency Report or Emergency Information Report (EIR)

                   2. Discharge Summary

                   3. Lab and all Reports

                   4. All Bills (Summary and Individual Item Bills)

                   5. Any other document you received from Hospital

          b. Original Contingent Bill duly filled and signed

c. Copy of the following documents

          i)       ECHS Smart Card

          ii)      Bank Cancelled Cheque (preferably same bank where ECHS          Beneficiary is drawing Pension)

          iii).    Death Certificate in case the patient has died in the hospital. The reimbursement claim can be initiated by the Legal Heirs

 

4.       IMPORTANT NOTES

          i)       The ECHS Beneficiary shall affix signature along with Mobile Number in         all Original Documents being submitted to claim Reimbursement

          ii)      A full set of the Copy of the Claim shall be retained by the ECHS Beneficiary

          iii)     If ECHS Beneficiary has a Health Insurance Policy and due to emergency           received treatment in a non-empanelled private hospital, the beneficiary is       allowed to claim the medical expenses from both sources, provided that the        reimbursement from such sources should not exceed the total expenditure           incurred by the ECHS beneficiary on the treatment. The beneficiary should first    claim the expenditure from the Insurance Agency and after settling the amount,       the beneficiary should put up to the ECHS for claiming the residual amount.

 

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