Scrutiny of Medical Re-imbursement Claims standard Proforma

GOVERNMENT OF PUNJAB
DEPARTMENT OF HEALTH AND FAMILY WELFARE
(HEALTH V BRANCH)

Subject:-   Scrutiny of Medical Re-imbursement Claims standard Proforma.

All the Financial Commissioners, Principal Secretaries and Administrative Secretaries to Government of Punjab may kindly refer to the subject noted above.

2. In order to scrutinise the medical claims of employees as well as pensioners of Punjab Government a new standard Proforma given overleaf has been approved by the Finance Department. Therefore they are requested to enclose this proforma on the medical claim case to be sent to the Finance Department.

3. This issue with the concurrence of Finance Department conveyed vide their I.D. No. 8/118/96- 5 F.E. II/4166 dated 23-5-96.

Sd/-
Deputy Secretary Health

To

All the Financial Commissioners,
Principal Secretaries and
Administrative Secretaries to the
Government of Punjab.

ID.No.12/54/96-5HB5/12720

Dated, 14-6-1996

Proforma for Submitting Medical Claims :

1. Name of the Employee

(a) Name of Dependent/patient
(if any)
(b) Relationship.

2. Whether claims is for Indoor treatment or
outdoor treatment.

3. Diagnosis (Chronic/Non Chronic)

4. Name of Hospital from where treatment
obtained and (Private/Government)

5. Date of Treatment.

6. Whether permission of the State Government for
treatment outside the State or in a Private
Hospital has been taken according to instructions
dated 13-2-95 of Punjab Government.

7. Total expenditure incurred on treatment.

8. AIIMS/PGI Rate admissible in such cases.

9. Amount payable after deducting
Non-re-imburseable items,
according to check list dated 11-12-95

10. Whether all necessary documents are complete and
attested by the competent Medical Officer and Claim
presented.

Signature of
Administrative Secretary or
Spl. Addl. or Joint Secretary.

CHECK LIST FOR SCRUTINISING THE MEDICAL REIMBURSEMENT BILLS

It may be verified :

1. That the bill is within the limit of Rs. 1200/- Fixed by the Govt./bill is for Chronic disease out side the limit of 1200/-.

2. That the medicine have been purchased within the time limit from the date of prescription of medicine.

3. That the bill has been submitted within six months front the date of completion of treatment. As a proof Diary No. & dale of submission of bill should be given.

4. That the medicine/items are re-imburseable.

5. Re-imburseable items their total and non reimburseable items and their total should be shown separately so that proper checking may lie carried out.

6. That the claim pertains to out door/indoor treatment.

7. That the bill is according to various instructions issued by the Government from time to time.

8. That the Total of the bill is correct.

9. That the claimant is taking fix medical allowance/ not taking fixed medical allowance.

10. That the claimant has taken Rs. / as out door reimbursement in the current Financial year (in case of those taking 1200/- only).

11. That the prescription slip and bills bears the stamp of the Authorized Medical Attendant.

12. That the bill is countersigned by the Head of the office.

13. That the Head of Account is ______ _____  _____   end the funds are available under this Head.

14. The Name of the medicine item should be written in Capital Letters neatly so that the bill could be checked properly.

15. All the Departments should possess all the instructions issued by the Secretary to Govt. Punjab Health and Family Welfare Department, Chandigarh and the concerned dealing Assistants should to through these instructions thoroughly.

16. Certified that all Non-Reimburseable medicines/items have been deducted.

I 7. Certified that the charges for diet at are not included.

18. Certified that the charges for the Heater and A.C. are not included.

19. Certified that no room rent charges have been included (Allowed, only in P.G.h Chandigarh.)

20. Certified that the patient is fully dependent upon me (Affidavit from 1st class Magistrate) as proof be attached.

21. Only employees and retiree stationed at Chandigarh, Mohali and Panchkula can take treatment from P.G.I. without being referred Rest of the employees and retirees will have to get referred from Civil Surgeons of the districts.

22. Certified that under taking regarding accepting of Government rates for taking treatment from pvt. hospital is attached.

24. Certified that the bill is for treatment in private Hospital in the state and has been approved by the District Medical Board.

25. Certified that bill is for treatment in private Hospital out side the State and has been approved by the State Medical Board.

26. Certified that the bill is for the private hospital and has been approved by the Director Health Services, Punjab, Chandigarh.

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