Guidelines to improve the Medical facilities for the ESI Beneficiaries-reg.(English)

File No.: U-16012/117/2025-SST Dated:16.09.2025 To, Regional Directors/SMO-All States Medical Superintendents-All ESIC Hospitals Deans-All ESI PGIMSR’s & Medical Colleges Subject: Guidelines to improve the Medical facilities for the ESI Beneficiaries-reg. Madam/Sir, With reference to subject cited above, Competent Authority has given following directions to improve the services- 1. All concerned RDs and MS are directed to ensure that all the Clauses of ESIC Referral Policy 2023 and its amendments are incorporated in the RFP & Agreement For example “If there is no CGHS prescribed ceiling rate for any implant, reimbursement should be limited to 60% of the MRP including GST, and HCOs cannot charge more than that amount from ESIC & its beneficiaries. The pouches/stickers etc. attached should be duly verified by the treating doctor, and the specifications should match with those mentioned in discharge slip and original receipt/invoice or an attested photocopy of receipt/invoice in case of bulk purchase, to be submitted with the claim.” 2. Strictly adhere to CGHS package referral where disease /diagnosis specific packages are there , open billing packages like ( Consultation 2, Ventilator Charges 512 etc.) to be avoided . Justification is mandatory in P1 form if open billing package. 3. All packages have specific days of admission and in many cases it has been observed that days/stay are extended beyond Package limit, it should be used only in exceptional cases with proper documentation & justification by concerned specialist and same is to be routed through referral committee of ESIC before approval. 4. All Direct admission cases from RD offices should be examined/approved/reject within 24 hrs of admission and there should not be delay of more than 48hrs as the delay causes difficulty in verifying the emergency condition. RD should ensure that proper verification of identity /diagnosis of direct admission cases and are in compliance to extant Referral Policy of ESIC and if needed opinion of nearest ESIC Hospital should be taken for clinical justification for emergency condition. 5. Conversion of secondary medical conditions into Tertiary/Super specialty diagnosis should be avoided unless it is justified. Referral Review committee should periodically review such referral particularly in Surgical /ICU cases, It is observed that General surgery cases are being sent for super specialty departments. (Please Refer to list of Secondary /Tertiary Procedure.) U-16012/117/2025-SST I/3055400/2025 6. MS/Deans of respective referral units may review clinical performance census in view of referred cases of referring Doctors. 7. It is observed that after 4 PM(Mon-Friday)/1PM on Saturday/Sundays & Holidays, due to absence of some basic Patients are being referred forTest/Radiological investigation (Critical laboratory test used in emergency like CBC,HB, KFT,LFT,ABG and electrolyte etc/X-Ray). Efforts should be made for 24*7 operationalization of lab services in the interest of beneficiaries. 8. All emergency referral P1 made after hospital hours (beyond 4PM Monday to Friday/1PM on Saturday and on Sundays/Holidays) must be reviewed on the next working day by the referral review committee, without fail. Delay in submission of P1 for claim ID or extension requests should be reviewed regularly. Proper record with vitals and treatment provided should be readily available in emergency department. 9. Subsequent approvals of additional procedure/items as per referral policy should be examined by the referral committee. All such document should be routed through online UTIITSL example like culture Reports for high cost antibiotics request etc. 10. For referrals related to Chemotherapy: All the medicines names and dosage and cycle should be mentioned in the P1 form. 11. Proforma for extension of stay (copy enclosed) is attached for immediate implementation. All such permission should be routed through UTIITSL portal only ( except in exceptional cases where there is technical glitch or others issues) 12. Random visit of empaneled Hospitals and getting details/Progress of ESIC Patient. 13. Random Calling/Video verification of patient admitted in empaneled Hospital and proper record of the same should be maintained. 14. Ensure that ESIC referral Policy and its amendments are implemented at all levels. 15. Referral ID should be restricted to regular staff only. 16. All the staff posted in SST Cell should be rotated, as per CVC guidelines 17. Display Board -a) Patient can choose their empaneled Hospital" ( if referred) b)" All treatment through ESIC referral in empaneled Hospitals are cashless" in three languages. All information regarding referral/reimbursement should be displayed in prominent places. 18. Strengthening of the in house services should be the goal. 19. Mandatory Rotations of SST I/C , Medical store I/C etc. every 3 years as per CVC guidelines This is issued with approval of Competent Authority. Encl: As above Yours faithfully, (Dr. B C Deka) Dy. Medical Commissioner (SST) Copy to: Website Content Manager, to upload on website U-16012/117/2025-SST I/3055400/2025