AWARENESS FOR ECHS MEMBERS : PATIENTS SEEKING TREATMENT IN EMPANELLED HOSPITALS

Dear Veteran Brothers
Kindly Note...
AWARENESS FOR ECHS MEMBERS : PATIENTS SEEKING TREATMENT IN
EMPANELLED HOSPITALS

1. You always need a referral to visit empanelled hospital.
2. Referral cannot be demanded by the patient.  Treating Medical Officer at the polyclinic will decide the requirement.
3. ECHS beneficiary can select any empanelled hospital under the Regional Centre for his treatment.
4. All empanelled hospitals may not have every specialized facility, hence ESM must have the information from the notice board/enquiry of the Polyclinic.
5. In case ECHS Beneficiary wants to utilize any emp hosp outside RC, he/she will have to take referral to the nearest PC of that hosp who in turn will issue referral.  Such referral should have signature of the patient to facilitate verification.  Referrals to review within 30 days can be given directly by the local PC.
6. Two referrals cannot be generated to a patient on a single day for the same cause.
7. Issuing of multiple referrals for the same patient for the same treatment(OPD & IPD) for a particular duration is not permitted.  For example, if a patient is referred on 01 Dec 18 for OP treatment under cardiology, then the same patient cannot be issued with another referral for OP treatment under Cardiology before 30 Dec 18.
8. Normally, prior to any kind of surgery, pre-operation evaluation will be required.  For this a separate referral is required.  Another referral will be required for the surgery procedure.
9. If you have an emergency, you can get admitted in an empanelled hospital without referral.  The by stander must submit/show ECHS card, self attestation form(for children), and other relevant document at the ECHS counter.  If you are not in a position to prove yourself that you are an ECHS member, you are liable to pay.
10. On arrival at the empanelled hospital, please report to the ECHS centre there before and after the treatment.  At the ECHS counter of the hospital, the patient will be given a file allotting a registration number and will be guided to the concerned specialist.
11. There is no special priority for ESM at these hospitals unlike you get in the polyclinic.  So please do not demand for it, maintain your calm and wait for your turn, unless you have a special problem.
12. Once the consultation is over, report back to the ECHS counter with the file and clear your doubts if any.
13. If the specialist recommends any tests/consultation/surgery/other procedures, get the same written in the additional services form and bring to the Polyclinic for further referral.  Referral can only be issued based on treating doctor’s remarks.
14. Review also to be done in the same manner.
15. Same referral can be used more than once depending upon the number of sessions given.
16. Validity of referral is one month.  For chemotherapy/dialysis patients it may be up to six months with more number of sessions.  Dental up to 60 days.
17.  You have to take fresh referrals for every procedure/new treatment/review.
18. You can only visit the doctor whose specialty is mentioned in the referral.
19. No referral for lab/diagnostic facilities which are available in Polyclinic.
20. If a particular test/procedure is not written in the referral you may get a modification to the referral for which you/your bystander have to visit the Polyclinic again.
21. Always carry your old medical records and ECHS card in original to the hospital.
22. If you are bed ridden/too old/weak to travel to the Polyclinic, your by stander may get the referral for you after due justification (proxy referral).
23. There are certain items like surgical consumables, dressing materials, adult diapers and other non-medical items which do not come under ECHS package hence you have to make payment for them.
24. Hospitals are charging cost of Ryle’s Tube feed from patients admitted in ICU.  Exact orders on the subject are not clear.
25. On the Table Decisions.  There are times while a surgery is in progress, doctor may feel the requirement of a procedure which is not included in the package or not a listed procedure.  In such conditions you/your bystander may have to make payment which may or may not be reimbursed depending upon passing/not passing the bill by BPA.
26. If a particular test is not available in the empanelled hospital, same will be organized by them from outside and ECHS will be billed as per CGHS rates.  Patient need not pay for the same. However, practically this is not happening.
27. For cataract surgery with IOL, special lens may be offered at an additional cost.  Same is the case with stents during Angioplasty and dental crown (metal only authorized).
28. Entitlement of Accommodation at Empanelled Hospital.
29.    (a )   Officers                                           -  Private(AC single room)(Rs. 3000/-per day).
   (b)    JCOs and their equivalents in
                         Navy, AF,CG(*including
                         Hon Nb Sub, MACP Nb Sub         -  Semi private (room where 2 to 6 patients 
                         and Hon Lt/Capt).                              are  accommodated)(Rs. 2000/-per day).
    (c)  Recruits to Hav and their
                        Equivalents in Navy, AF,CG           -  General ward(Rs. 1000/- per day).    
(* Hon Nb Sub and MACP Nb Sub and their dependents will be entitled to ‘semi private’  accommodation only if they have paid the ECHS contribution(Rs. 67,000/-) as per the revised scale effective from 29 Dec 2017.
30.  Your authorization of accommodation on admission is indicated on your card.
31. Room/Ward charges include charges like Nursing care, Consumables,
             electricity/water charges, Diet etc and not the room alone.
32. When a patient is in ICU, by stander cannot avail the room facilities.  If he/she  
             utilises the facility, payment will have to be made.

33. If you wish to take a higher facility than authorized to you, you may pay the
difference in charges. It is not only the difference of room rent, but you may need to pay a percentage of the procedure, medicine, nursing charges and doctor’s consultation etc additionally.
34. There are few hospitals who, irrespective of your authorization, allot private rooms  
to the patients subject to availability.  The patient should not take this for granted   
when he visits another hospital.
35. Emergency Treatment.  In case of an emergency, treatment can be availed as below:
(a) At any Service Hospital and no further action is required.  
(b) At any empanelled hospital duly producing the ECHS card.  Details of the hospitalization in such cases will be intimated online by the hospital and approval by Polyclinic will also be accorded online.
36. During extreme emergency if there is no ECHS empanelled hospital nearby, you can get admitted in a non-empanelled hospital.  Please note that:
-  Your by stander must obtain an Emergency Admission Report (format in your  
   treatment book) from the hospital and report to the nearest polyclinic within 48  
   hours of the admission.
-  After the discharge, the reimbursement at CGHS rates will be done from the 
   parent polyclinic only.
-  All bills, receipts, investigation reports, discharge summary, x-rays, EIR and any
   other documents will be submitted to the polyclinic for reimbursement.
-  This is to be done within three months from the date of discharge.
37. Some other points with respect to non-empanelled hospital are:
-  Reimbursement is for the expenditure from admission to discharge only.
-  Planned procedures are not reimbursable.
-  Out Patient consultation/medicines purchased during OP   consultation   and treatment cannot be claimed.
38. Treatment at Govt Hospitals/RCC Trivandrum.  All government(central/state/local self govt) hospitals and Regional Cancer Centres are considered to be deemed empanelled.  ECHS beneficiaries shall be eligible to obtain treatment from these hospitals and submit their medical re-imbursement claim to their parent polyclinic.  OPD medicines would be obtained from the ECHS polyclinic and no re-imbursement is permissible.  It would be preferable that they take a referral(manual) for all planned treatment at these hospitals which would ensure that the beneficiary has no difficulty in the reimbursement of the claim.  Re-imbursement of IOL. Knee Joint/Hip/Shoulder Replacement implants, cardiac implants etc will be limited to the ECHS ceiling rates.  In case of expenditure more than ceiling rates and/or ward entitlements, the ECHS beneficiaries will have to pay the difference of the amount from own resources and is not reimbursable.  Prior approval of competent authority will also be required for implants, which are not listed.  
39. Hospital Stay.    One can stay in an empanelled hospital for a maximum of 12 days.  Further stay if required needs approval of OIC Polyclinic up to 30 days, RC up to 60 days and COECHS up to 120 days.
40. If you visit a hospital directly without referral expecting to get admitted but the hospital only keeps you under observation and do not consider it as an emergency, do get a referral from your polyclinic at the earliest else you will have to pay the hospital charges.
41. At times hospitals may ask you for an advance to be deposited if you fail to produce the ECHS card.  Please cooperate with them.  On production of the card at the earliest, same will be returned to you.
42. A self-attested preformat is required for the children above 18 years of age at the hospital along with the referral(sample given in the last page).
43. Patient continuing treatment at an empanelled hospital may require approval for certain additional services which are not listed in the CGHS list.  Such requirements from the hospital are intimated through ‘Appendix A, authorization for additional services’.  This has to be brought to the polyclinic for OIC’s signature and further taken to SEMO/CHAF Bangalore for approval.  Once the approval is obtained, a separate referral is required to be taken from the polyclinic.  Either the patient/bystander can get this sanction from SEMO within a day by taking it by hand or through ECHS by post in about seven to ten days’ time.  If the time is very short and the approval is a must, then SEMO can send the same by email to the hospital followed by the hard copy(ink signed).
44. Channel of Seeking Prior Approval.
(a) Initiated by empanelled hospital in Appendix A.
(b) Detailed case summary justifying the proposed procedure to be att.
(c) Forward to Polyclinic.
(d) Polyclinic to SEMO.
(e) SEMO returns to PC.**
(f) From PC to hospital along with a referral.
(g) **If above two lakhs & up to four lakhs, SEMO will forward to nearest Service Specialist; Above four lakhs, forward to Senior Advisor/Consultant at Command Hospital and then action as per paras (e) and (f) above.
45. Cases requiring opinion/prior approval of CHAF, Bangalore.  Prior approval on Appendix A is required to be taken from CHAF, Bangalore for the following:
(a) Cardiac Stents (for additional stents in excess of 2 DES+ 1 Bare Metal Stent).
(b) All Cardiac Procedures.
(c) Pacemakers.
(d) Bone Marrow Transplant.
(e) Procedures/Investigations costing more than Rs. 2 lakhs.
46. CHAF does not give approval on certain cases which can be performed at that hospital.  Accordingly the patient can plan to get the procedure/treatment done at CHAF, Bangalore.
47. When you are discharged from an empanelled hospital, you will be issued with 7 days of medicine.  Further medicines will have to be collected from polyclinic.  Only medicines in their generic names will be issued. ECHS members cannot demand specific branded medicines.
48. Medicines prescribed by private doctors/non empanelled hospitals (unless admitted in an emergency) will not be issued from Polyclinic.
49. Any medical expenses incurred at the empanelled hospital by the patient at his
own will cannot be reimbursed.
50. Admission of Patients in Empanelled Hospitals for Radiotherapy.  ECHS patients requiring Radiotherapy treatment are to be referred on OPD basis.  In case admission is required, patient is to be referred only on recommendation by Service Specialist.
51. Treatment in Service Hospitals.  For cardio and TKR/THR cases, patients can be referred to AH(R&R) directly.  Referral should be made to ECHS Cell, Army Hospital(R&R) (ECHS Polyclinic Base Hospital, Delhi Cantt).  Telephonic co-ordination is required prior to dispatch of patient.  For details, contact your polyclinic.
52. Referral to Reputed Hospitals for Planned Treatment.  ECHS members can take referral to reputed private hospitals and Medical Institutes of National Repute for planned procedures on merit of the case. List of such hospitals are available at the polyclinic. Approval for such referrals would be granted on a case to case basis by CO ECHS based on recommendations by the Medical Officer/Specialist at the Polyclinic, OIC Polyclinic and the concerned Regional Centre.  Ex-Post-Facto sanction is not permitted.  There is no provision for waiver to such a sanction.  The cost of treatment would be borne by ECHS member.  Reimbursement would be limited to CGHS approved rates.  TA will not be entitled in such cases.
53. Preventive Tests.   Referrals for preventive tests are not allowed.  Only ailment based treatment/tests will be conducted both at PC/referred facility. 
54. Unauthorised Charging by Hospitals on Major Procedures.  When there is a major procedure (for eg Craniotomy), there may be two or three other associated minor procedures.  In such cases, cost of the major procedure is reimbursed fully but only 50% of the cost of the minor procedures is reimbursed.  This is a policy and hospitals are aware of it.  It does not mean that hospitals can ask for the difference in the amount from the ECHS beneficiary.  Sometimes they force the patients to pay the difference which is not allowed.
55. Presently, online registration is in progress.  All ECHS members have to apply for 64 KB card.  If any false information/malpractice like adding fraudulent dependents been caught, ECHS facilities will be permanently withdrawn from him and his legal dependents.
56. It is the prime responsibility of the ESM to educate his dependents about the rules and regulations, dos and don’ts of ECHS.
57. Always carry copy of your ECHS card in your purse/bag for emergencies.
58. It is a good idea to keep a photo of your ECHS card in your smartphone.  At the same time, all members of your family should know about the location of the documents in your house.

Regards and Jai Hind🙏🇮🇳
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Dear all,
Almost all the important issues and  points have been covered and are more practical provided these instructions are implemented on ground. PCs  give more preference to local orders issued by Stn  HQ which are some times in contravention to Central Org policy and guidelines due to obvious reasons as their appointments are controlled by local authorities  I have gone through all the points and submit the following against certain points -
Point No 2. Referrals.
Yes, The medical officer should be the sole authority to decide referral where as on ground some percentage have been  laid down for referral, and therefore, medical officers can not refer  patients beyond that even in deserving cases.
3. ECHS patient can select hospital.
Yes, it should be. But practically majority of the beneficiaries aren't aware of the quality of hospital and specialists and therefore depends on the medical officer,  may not be in writing but verbally, yes, and is more practical.
4. Yes, but ground situation is different. Many empanelled hospital have got empanelment facilities but on ground it's not existing. And the patient have to shuttle from one or the other hospitals. No check to this regard is carried out by any authority
5  .Out Station Patients to report near by ECHS for getting separate referrals.
Yrs, as per policy. But it is time consuming for the patients coming from out stations far away from PCs.  Sometime they reach late due certain compelling reasons and the PC  is closed. They can't be entertained by the empanelled Hosp ever in bad health conditiond which otherwise may not be emergency. So, the patients should be allowed to go to empanelled Hosp directly and Hosp should be directed to get the new referral or ID generated next day from th delendant PC based on the prescription and recommendation of specialists. This will ease out the problem of out station patients.
7. The patients should  be issued referral for OPD/IPD or as required as medical officer at PCs  can not decide whether admission is required or not. On reporting of the patient in Hosp and when the specialist  decides requirement of  admission which otherwise can not be done on OPD referral. The patient have to go back to parent PC o get amendnent to the referral which may be far away and can not come back same day.Therefore, on line amendment facility to the referral should be introduced based on the recommendation of specialists which can be emailed to the PC.
8. Yes, but on ground PC aren't issuing fresh referral in such cases before 30 days and the patient have to wait for surgery even in urgent cases.
13. Out station patients can not go back to parent PC for getting referral in such cases, it is therefore recommended that either local PC should be authorised to make amendments or on line amendment  facility to the original referral based on recemnendations of specialist be introduced.
14. On ground situation is different. Referral is not being issued by PC . Referral for review or follow up must be issued so that medicines which  may be changed, discontinued or stopped by the  specialists based on medical condition of the patient..
17   Yrs. But not being given which are otherwise required. PCs should be advised to issue .
18.Yes, in certain cases referred specialist desires and advised consultation of other specialist for which referral is not there. In such cases , on line amendment facility to the referral to be introduced based on the findings of specialist which can be emailed or the local PC should amend the original referral for far away patients.
20, Yes, but ground situation is different. OIC PC insist to bring the patient to them.
22. As Ser 20. Even sometimes the patient are taken to PC on stretcher in ambulance as insisted by OIC PC.
26. The empanelled hospital refused that, so  strict instructions are required to be issued.
32. Suitable facilities for stay of by standard or attendant is not available in majority of the hospitals  Instructions should be issued and checked for impmementations.
39. Yes, approval from the local PC is possible beyond 12 days but approval from RC is delayed  even in cases where  referred before completion of 30 days based on the recommendations of specialists. Therefore, either the patients is to be discharged or their relatives have to pay for stay beyond 30 days. So, on line approval system be introduced or RC should give approval before or on the day of completion of 30 days.
40. On reporting of the patient in emergency, which may be for the patient but not otherwise, the hospital must provide medical aid to stabilise the medical condition of the patient and advise to bring referral there after . In no case, treatment should be refused by the hospital.
45.
(a) Getting approval for implants  from MH is cumbersome. The approval is given three days in a week and if happen of holiday on any day or the surgeon is not available,  it is further delayed. The surgery even  in some urgent cases can not be performed without approval for fracture, injury etc. In some cases, the rate quoted by the  Hosp is not accepted and the approval refused , where as, quotations from distributors are attached. Therefore, on line approval facility to be introduced  or distributors for all type of implants be selected and communicated to all the hospitals so that the hospital have no say in prices of implants or either implants to be provided by MH.
(b) it is stated by the hospitals that cost of single chamber pace maker is much more than the authorised rate  by ECHS. So, either the Hosp refused to implant or ask the patient to pay for the differences. It is confirmed that the hospital implant double chamber in place of requirement of single chamber to make up the loss as double chamber as cost is almost the same as authorised.

There are certain other issues too , which will be put up separately.

Regards