CHECKLIST

Checklist for Sanctioning Authority regarding settlement of claim under the
West Bengal Health Scheme, 2008:-

[Put tick (√) mark]

1. Whether the following information has been furnished in the Sanctioning G.O.?
(i) Name of the employee/ pensioner with Identification No.: Yes/ No
(ii) Name of the patient with Identification No. : Yes/ No
(iii) Name of the Hospital/ Nursing Home with Code No. : Yes/ No
(iv) Disease name : Yes/ No
(v) Period of treatment : Yes/ No
(vi) If treatment done on Package, Procedure name with Code No. : Yes/ No
(vii) Treatment done under O.P.D. or Indoor or both : Yes/ No
(viii) Head of Account has been mentioned properly : Yes/ No
(ix) Adjustment of advance taken with details : Yes/ No
2. Whether the following papers/ information has been checked?
(i) Photo Copy of the Health Scheme Identity Card : Yes/ No
(ii) Photo Copy of the Temporary Family Permit if Identity Card not issued : Yes/ No
(iii) Temporary Family Permit was valid at the time of treatment : Yes/ No
(iv) Information furnished to the office within three days of admission for Indoor treatment : Yes/ No
(v) Permission of the West Bengal Health Scheme Authority obtained for Human Organ Transplantation/ implantation of Dual-Chamber Pacemaker/ more than one Drug Eluting Stent/ more than two Stents or AICD, CRT, Deep Brain Stimulator, Intrathecal Pump/ Digital Hearing Aid, etc. : Yes/ No
(vi) Permission of the West Bengal Health Scheme Authority taken for treatment in Speciality Hospital outside the State : Yes/ No
(vii) Disease for O.P.D. treatment claim is a listed One under Clause-7 of the Health Scheme
(viii) Indoor related O.P.D. treatment and not covered under Clause-7(2) of the Scheme whether the O.P.D. treatment was done within 30 days prior to admission or 30 days of discharge : Yes/ No
(ix) Claim has been preferred within three months vide Memo No. 2618-F (MED), dt. 05-04-2011 : Yes/ No
(x) If not preferred within the stipulated period whether delay has been condoned by the Finance Department : Yes/ No
(xi) All procedures/ investigations/ implants have been checked against the Code Nos. and approved rates : Yes/ No
3. Medical treatment done in non-empanelled Private Hospital/ Nursing Home [vide Para-23 of the Memo No. 797-F (MED), dt. 31-03-2011] Whether-
(i) Name of the Pvt. Hospital/ Nursing Home with address and Clinical Establishment Licence No. has been furnished? : Yes/ No
(ii) No. of beds available in the Hospital/ Nursing Home as per CE Licence has been furnished? : Yes/ No
(iii) Admissibility has been checked as per approved Rate List? : Yes/ No
4. Sanction of advance- whether
(i) Estimate has been taken from recognised hospital? : Yes/ No
(ii) Code No. of the Surgical Package has been mentioned? : Yes/ No
(iii) Estimate has been furnished as per approved rates? : Yes/ No
(iv) Code Nos. of major investigations in case of non-package treatment have been mentioned? : Yes/ No
(v) Detailed bill for services already given by hospital has been furnished for sanction of further advance? : Yes/ No