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.
