DIMAPUR, JUL 8 (NPN): Nagaland Health Protection Society (NHPS) has clarified the provisions of the Chief Minister Health Insurance Scheme (Employees & Pensioners) [CMHIS (EP)] following a grievance raised by a beneficiary over charges incurred during prolonged Neonatal Intensive Care Unit (NICU) treatment at an empanelled hospital.
In a statement, chief executive officer NHPS Thavaseelan K said the beneficiary had raised concern over an additional bill of Rs. 5,15,704, while only Rs. 1,63,975 was processed and settled under the scheme as the eligible claim amount.
Responding to the matter, NHPS said it had taken up the issue with the concerned empanelled hospital and reiterated the provisions under the scheme. It said that NICU bed charges were covered in accordance with approved package rates. The scheme also provides coverage for paediatric care for newborns, wherever applicable, besides separate add-on packages for oxygen, laboratory and diagnostic investigations.
NHPS said medicines were reimbursable through the open billing mechanism, with claims settled as per National Pharmaceutical Pricing Authority (NPPA) ceiling or the actual cost of the drugs. It further clarified that consultation charges were included within the approved package rates and were not payable separately, except in approved cross-consultation cases where add-on provisions were specifically provided under the scheme guidelines.
NHPS emphasised that all applicable package provisions, claims settlement and approval processes available under CMHIS must be fully explored and appropriately utilised before concluding that any expenditure was not covered under the scheme.
It also reiterated that no additional amount should be recovered from beneficiaries except for non-payable items under IRDAI guidelines, such as diapers and toiletries, or where beneficiaries voluntarily opted for higher room entitlement or higher-value implants beyond the scheme entitlement. In all other circumstances, it said, the scheme mandates cashless treatment and recovery of outstanding amount from beneficiaries was not permissible.
NHPS further reminded the hospital that, under the Memorandum of Understanding signed during empanelment, it had agreed to provide cashless treatment to all eligible AB PM-JAY/CMHIS beneficiaries strictly in accordance with approved package rates and scheme guidelines.
Accordingly, NHPS advised the hospital to process the claim strictly in accordance with the applicable CMHIS package provisions and scheme guidelines and refrain from recovering any amount from the beneficiary except in circumstances expressly permitted under the scheme.
NHPS said it remained committed to safeguarding the interests of beneficiaries and ensuring that all empanelled healthcare providers adhered to the scheme guidelines. It also urged beneficiaries and empanelled hospitals to contact NHPS at the earliest in case of any concern to facilitate timely resolution.
AB PM-JAY and CMHIS beneficiaries may contact the NHPS toll-free helpline at 1800-202-3380 through call or WhatsApp for assistance or to register grievances.
