Ayushman CAPF
Frequently Asked Questions
Contents
Acronyms .........................................................................................................................................2
Ayushman CAPF ...............................................................................................................................3
Coverage ..........................................................................................................................................3
Ayushman CAPF Card .......................................................................................................................4
Beneficiary Verification ....................................................................................................................5
Treatment under the scheme............................................................................................................5
Referral ............................................................................................................................................8
Discharge .......................................................................................................................................10
Grievance related ...........................................................................................................................10
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Acronyms
AB-PMJAY Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana
API Application Program Interface
BIS Beneficiary Identification System
CEX Claim Executive
CGHS Central Government Health Scheme
CPD Claim Processing Doctor
e-KYC Electronic Know Your Customer
HCO Health Care Organization
ISA Implementing Support Agency
IP Inpatient
IT Information Technology
MEDCO Medical Coordinator
NHA National Health Authority
OP Outpatient
OPD Outpatient Department
PMAM Pradhan Mantri Ayushman Mitra
PPD Preauthorization Panel Doctor
TMS Transactions Management System
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Ayushman CAPF
1. What is Ayushman CAPF?
Ayushman CAPF is a joint initiative of the Ministry of Home Affairs (MHA) and the National Health
Authority (NHA) for providing cashless healthcare services to the serving CAPF personnel from all seven
forces and their dependents. In January 2024, NDRF was also included in this scheme.
This scheme is being implemented on National Health Authority’s IT platform. Under the scheme,
cashless healthcare services can be availed in all HCOs empaneled with NHA across India.
2. When was the Ayushman CAPF launched?
Ayushman CAPF was launched by Hon’ble Home Minister on 23rd January 2021 in Assam.
Coverage
3. Who can get benefits of this scheme?
All the serving personnel from eight forces, viz. Assam Rifles, Border Security Force (BSF), Sashastra
Seema Bal (SSB), Central Reserve Police Force (CRPF), Central Industrial Security Force (CISF), National
Security Guard (NSG), Indo-Tibetan Border Police (ITBP) and their dependents are entitled to avail
cashless healthcare services in HCOs empaneled with NHA. In January 2024, NDRF was also included in
this scheme. So, serving personnel of NDRF and their dependents are also entitled to all benefits of the
scheme.
4. What is the geographical coverage currently?
The scheme has been rolled out across the country in CGHS empaneled private hospitals which have
signed MoU with NHA, and all the public and private hospitals empaneled under AB PM-JAY scheme.
5. What services are covered under Ayushman CAPF scheme?
The following services are covered under Ayushman CAPF scheme as per the HCO type.
# HCO Type Referral Services Mode Guidelines
required? (As available) / rates
1 MHA and CAPF owned No OPD / IPD Free services -
facilities Other, if any Self-paid (later claim CGHS
‘Reimbursement’)
2 Public HCOs^ No OPD / Free services / Self- CGHS
Diagnostic paid (later claim
‘Reimbursement’)
IPD Cashless AB PM-
JAY
3 Private HCOs empanelled Yes* OPD/IPD/ Cashless CGHS
under CGHS Diagnostics
4 Private hospitals empanelled Yes*# IPD services Cashless AB PM-
under AB PM-JAY scheme in General JAY
Ward only
4 Private HCOs NOT Yes All Self-paid (later claim CGHS
empanelled under CGHS or ‘Reimbursement’)
under AB PM-JAY
(Only in Emergency Cases)
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^All are empaneled under AB PM-JAY
*In Emergency cases, referral is NOT mandatory for taking treatment in private HCOs (empaneled or non-
empaneled)
#As per MHA’s guidelines issued on 06.03.2023, referral is not required for dependents in AB PM-JAY empaneled
hospitals
Ayushman CAPF Card
6. Where can a beneficiary get the Ayushman CAPF card from?
Respective Force HQs is the custodian of its beneficiary database. Aadhaar number of each beneficiary
must be available in the database maintained by respective Force HQs.
For receiving the Ayushman CAPF card, each beneficiary needs to undergo the process of eKYC
verification which can be done either of the following ways.
a. Through the designated PMAM at unit or at any empaneled hospital
b. On Ayushman mobile app of NHA, undergo self eKYC using the Aadhaar details.
Post successful completion of eKYC and approval of card by the L2 approver (nominated officer of the
respective force), the beneficiary can either download the card through the mobile app or the PMAM
can provide the print-out of beneficiary’s Ayushman CAPF card after downloading it from the system.
The print-out of the verified card is sufficient to take cashless services at the empaneled hospitals.
7. How a beneficiary, who has lost plastic Ayushman CAPF card, can get the card?
Ayushman CAPF plastic cards were issued by Ministry of Home Affairs during the initial days of the
scheme launch in 2021. Since 2022, the practice of issuing plastic cards has been stopped. As mentioned
above, the print-out of the verified card is sufficient to take cashless services at the empaneled hospitals.
Beneficiaries who have lost the plastic card are advised to get the printout of their approved Ayushman
CAPF card through either of the way mentioned above.
8. What should the beneficiary do if the details on the Ayushman CAPF plastic card / print out, such as
name, date of birth, incorrect relation with dependent, etc. are wrong?
Forces are the custodian of their respective beneficiary’s data and its correctness. No change in the data
is made at NHA level. Also, NHA IT platform do not allow any change in beneficiary data. So, to correct
the details, beneficiary needs to contact designated official of the respective force.
9. From where a beneficiary can access the list of empaneled hospitals?
List of PM-JAY empaneled hospitals is available on PMJAY portal and can be accessed at
https://hospitals.pmjay.gov.in/Search/empnlWorkFlow.htm?actionFlag=ViewRegisteredHosptlsNew
10. What should a beneficiary do if hospital denies treatment?
It is advised to connect with the respective nodal officer nominated in the respective state / respective
liasioning officers nominated at the force headquarters in case an empaneled hospital denies treatment.
11. Does the beneficiary need a new Ayushman CAPF card if the force or state is changed?
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Ayushman CAPF card is not state specific, so it remains same even if personnel get transferred to other
state. For deputation scenario, there is card portability feature to ensure continuity of same Ayushman
CAPF card for the beneficiary.
12. What is the process for adding a newborn baby or a newly wedded spouse in the beneficiary
database?
Each force HQs is the custodian of its beneficiary database. No change in the data is made at NHA level.
For any addition / updation of the family member, serving personnel is advised to reach out to the
designated officer of the respective Force HQs.
13. How can medical treatment be provided to a newborn baby?
In case of newborn baby up to the age of 06 months, treatment will be in the name of mother and her
Ayushman CAPF card and claim should be processed further accordingly. The Ayushman CAPF card is
mandatory after 06 months of age.
Beneficiary Verification
14. Where can Ayushman CAPF beneficiaries complete their verification process?
The Ayushman CAPF beneficiaries can complete their verification process through Aadhaar number in
either of the below two ways-
a. PMAM designated in units of the forces or at any HCO empaneled with NHA can perform the
beneficiary identification and verification process.
b. The force personnel can themselves verify Aadhaar details through the Ayushman mobile app.
Please note, Aadhaar number is mandatory for activating Ayushman CAPF ID. Additionally, the live
photograph of the beneficiary also needs to be captured for activating the CAPF ID.
15. What document would be required for Beneficiary Verification?
Individual verification is done using the Aadhaar of the beneficiary. For family level verification,
beneficiary either can provide service certificate or dependent card issued by the respective force.
*For wards (except parents) above 25 years of age, a fresh dependents certificate, issued by respective
Units/office will be uploaded along with Ayushman CAPF card. The reasons for continuing as dependent
should be clearly certified. The treating hospital will demand for the fresh dependent certificate and
attach a copy in cases of wards above 25 years of age (except parents).
*As per MHA’s guidelines issued on 03.06.2024.
16. Who will be completing the beneficiary verification process on the BIS portal?
The Pradhan Mantri Arogya Mitra (PMAM) will be operating the BIS portal using the registered mobile
number. The PMAM maybe a front desk executive/HCO receptionist, the existing PMAM in the HCO or
the nominated personnel by the force in a unit.
Treatment under the scheme
17. What documents are required to avail cashless healthcare services in empaneled HCOs?
Beneficiaries need referral from any CAPF hospital / Government (Centre or state) hospital and an active
Ayushman CAPF card to avail cashless healthcare services in empaneled HCOs.
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18. How can a beneficiary get help in an HCO for Ayushman CAPF scheme?
Beneficiary needs to meet the Pradhan Mantri Arogya Mitra (PMAM) at the empaneled private HCO.
PMAM will help beneficiary with all the queries like beneficiary verification, registration, hospitalization
etc. The key responsibilities of the PMAM are as follows:
a) Operating the Beneficiary Identification System (BIS) to identify and verify the beneficiaries
entitled under Ayushman CAPF
b) Guiding the beneficiary about the overall benefits under Ayushman CAPF and providing
information about receiving prompt treatment at HCO
19. Who is MEDCO? What is the role of MEDCO?
MEDCO is the medical coordinator at the HCO, designated to look after clinical activities related to CAPF
beneficiary. Her/his role is to diagnose and block the right Health Benefit Package / procedure, raising
intimation, enhancement, discharging the patients and then submission of claim on NHA’s TMS portal.
All these activities are done by MEDCO in coordination with treating doctor.
20. Will all the beneficiaries need pre-authorization of a doctor for availing cashless healthcare services
in HCO onboarded on NHA platform?
MEDCO, after registering the patient in TMS, raises the intimation on the portal to Pre-auth Panel Doctor
(PPD) for seeking approval on initiating the treatment. OPD, emergency, and patients aged more than 75
years, get auto-approval to avoid any delay in the treatment. For all IPD patients, Pre-auth Panel Doctor
(PPD) scrutinize and process each case of intimation.
21. How can beneficiary avail the medical treatment under Ayushman CAPF?
a) For the self-paid services at CAPF or the government owned facilities (diagnostics, implants,
medicines etc.), the CAPF serving personnel may submit a reimbursement request using CAPF
Reimbursement Module. CAPF serving personnel can raise reimbursement claim of the expenses
incurred for availing healthcare services for self and dependents. Please note that the
reimbursement, when approved, will be paid as per CGHS rates.
b) CAPF or the government owned facilities may refer the beneficiary to the CGHS and /or PM-JAY
empaneled private HCO. In this case, the beneficiary may avail cashless medical treatment by
registering at the HCO after providing referral and a print-out of activated Ayushman CAPF card.
c) In case of an emergency, the beneficiary may avail self-paid services at non-empaneled HCO and
submit a reimbursement request using CAPF Reimbursement Module. Reimbursement, when
approved, will be paid as per CGHS rates and guidelines. The beneficiary has to provide certificate
from hospital about the NABH certification to get reimbursement at NABH rates of CGHS. If the
certificate of NABH accreditation is not provided, then the reimbursement claim will be paid as per
non-NABH rates of CGHS.
22. What is the process for availing cashless healthcare services at HCOs onboarded on NHA IT platform?
Beneficiary must visit the nearby CAPF Hospital/ Government Hospital for receiving medical care.
Government doctor may decide to refer the patient to any empaneled HCO for further medical care.
Each beneficiary visiting HCOs onboarded on NHA IT platform should carry referral and activated
Ayushman card for availing cashless healthcare services.
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At HCO, beneficiary needs to meet the MEDCO who will then register the verified beneficiary on the
Transaction Management System (TMS) of NHA for delivery of cashless healthcare services. In CGHS
empaneled hospitals, in case IPD services are to be provided, beneficiary will be admitted as per the ward
entitlement.
23. What is the ward entitlement criteria for CAPF beneficiaries?
Ward entitlement in CGHS empaneled hospitals is as per the basic monthly pay in the 7th CPC. This is
given below.
SN Ward Entitlement Corresponding Basic pay drawn by the officer in 7th CPC per month
1 General Ward Up to Rs. 36,500
2 Semi-private Ward Rs. 36,501 to Rs 50,500
3 Private Ward Rs. 50,500 above
24. Is there any limit for availing treatment under this scheme?
There is no cap on the cost of medical services for CAPF beneficiaries.
25. Can a beneficiary go to a non-empaneled hospital for medical services?
In emergency cases, beneficiary can go to a non-empaneled hospital for treatment. Emergency certificate
should be issued by the treating doctor. *The counter signature of medical superintendent of the treating
doctor is mandatory if the hospital is non-empaneled hospital. Subsequently, CAPF serving personnel can
raise reimbursement claim of the expenses incurred for availing healthcare services for self and
dependents. Reimbursement of expenses will be done as per CGHS rates and guidelines.
*As per MHA’s guidelines issued on 03.06.2024.
26. What is the process for reimbursement for availing emergency treatment at a non-empaneled
hospital?
Beneficiary has to first pay from out-of-pocket for availing the healthcare services. Subsequently, the
serving personnel can submit the reimbursement claim with prescription and other invoices on NHA’s
Reimbursement portal which is accessible at https://tms.pmjay.gov.in/OneTMS/loginnew.htm.
Reimbursement module user manual and video tutorials are available on PMJAY portal and can be
accessed at https://pmjay.gov.in/ayushmancapf/resources. Please note that only serving personnel is
allowed to raise the reimbursement claim on the portal. Family member or dependent cannot raise
reimbursements.
The claim will be scrutinized and processed by ISA and accordingly approved, queried, or rejected. On
approval, it will be paid electronically to serving personnel’s bank account, details of which would be
available in the beneficiary database maintained by respective Force HQs.
27. What if the reimbursement claims are not uploaded within the stipulated time of 180 days on NHA’s
IT platform?
Reimbursement claim is to be raised within 6 months of the treatment date. In case, due to some reason,
serving personnel could not raise the claim within 6 months then personnel have to reach out to the
respective Head of Department (HOD) (IG Frontier/Sector) level and get the condonation letter with
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official sign and stamp. This signed and stamped condonation letter has to be uploaded on the portal
while raising claims of > 6 months.
28. How to fill cost of any procedure, medicine, investigation if the amount is in decimals?
As on date, reimbursement module does not allow to enter cost in decimals. Beneficiary can enter the
amount after rounding down to the specified number of decimal places.
29. What to do if any procedure or medicine or investigation is not found in dropdown list?
In case the medicine is not under ‘Type of Pharmacy’, choose ‘Other’ and add the medicine name. In case
procedure or investigation is not found in the dropdown list, use ‘Other Allied Charges’ to add the
expenses incurred.
Referral
30. What is a referral letter?
The referral letter is a mandatory document issued by the doctors at the government facilities, CAPF
HCOs, and Army Medical Corps (AMC) to the beneficiary for getting cashless healthcare services in
network HCOs empaneled with NHA. This is required to seek planned treatment on outpatient or
inpatient basis. Beneficiary coming with electronic referral from CGHS Wellness Centre cannot avail
cashless treatment under Ayushman CAPF scheme. In case beneficiary wants cashless treatment under
Ayushman scheme, referral can be obtained from unit / referral hospital / CAPF Hospital or Government
(Center or state government) Hospital / doctors of *Army Medical Corps (AMC). The referral will be valid
for one month, until specified by the doctor in the referral, and for three OPD consultations.
Beneficiaries of age 75 years and above can directly avail the cashless services for listed investigations
and procedures at the empaneled HCO without any referral. In case of emergency, referral is not
mandatory for seeking cashless services in empaneled HCOs. However, treating doctor will authenticate
that it was an emergency condition for patient and accordingly hospital must upload an emergency
certificate while raising their claim to NHA.
*As per MHA’s guidelines issued on 03.06.2024, referral can be made by doctors of Army Medical Corps (AMC) also.
31. Does a beneficiary need referral letter for consulting specialist in Govt HCOs?
Beneficiaries can avail OPD consultation from specialists in any Government HCO directly without the
need for any referral.
32. What details would be mentioned in the *referral?
Referral slip from CAPF / Government Hospitals may be accepted by HCOs when referral is given on
letterhead of the hospital with the following components:
a. Primary diagnosis and clinical examination findings
b. Purpose of referral (what all services to be provided to patient) – type of specialty consultation
required and/or name of the procedure/investigation required.
c. Date of referral (valid for 01 month or 03 visits/maximum 03 different specialties are allowed in
the same referral). For the treatment of cancer and chronic cases (name of diseases is
mentioned as per MHA letter number E-3648533/MHA/P-II/23/828 dated 26/10/2023), the
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referral will be valid for 03 months. Sign and stamp of the referring government doctor/CAPF
doctor (the stamp of hospital is also acceptable) is required.
d. Referral can be made by doctors of Army Medical Corps (AMC) also.
e. The person having a valid referral from CAPF/Govt. Doctor will be eligible for treatment/
investigation from any CGHS hospital empaneled under Ayushman CAPF scheme across India.
f. Stamp on the computer generated CGHS referral slip is not required.
*As per MHA’s guidelines issued on 03.06.2024, referral given on OPD slip with date shall have the above-
mentioned components.
33. Does the referral slip mention the details of HCO, where services can be availed using referral ID?
The referral slip does not mention the details of the referred HCO. Beneficiary may avail health services
at any of the empaneled HCOs as per their choice.
34. What is the validity period of the referral?
The validity of referral letter varies as per the kind of referral given. The referral stays valid for 01 month,
or 03 visits/maximum 03 different specialties are allowed in the same referral. For the treatment of
cancer and chronic cases (name of diseases is mentioned as per MHA letter number E-3648533/MHA/P-
II/23/828 dated 26/10/2023), the referral will be valid for 03 months. Sign and stamp of the referring
government doctor/CAPF doctor (the stamp of hospital is also acceptable) is required.
35. Will beneficiaries get services in the HCOs without referral?
The beneficiaries will not get health services in the HCOs without referral; except in case of medical
emergency or in case of OPD consultations and listed procedures for beneficiaries aged 75 years and
above.
36. Can a beneficiary buy medicines from any pharmacy using referral slip*?
Once a patient is referred for OPD treatment, beneficiary can buy medicines from any registered
pharmacy. Purchasing medicine from in-house pharmacy of the hospital is not mandatory. Non-
availability certificate is not required for medicines purchased from outside. However, the drug license
number and GST number should be mentioned on the invoice bill issued by concerned pharmacy. If MRP
of the medicine is mentioned in the invoice, then it will be ensured that approved amount is not more
than the MRP. Medicine/investigation/consultation/ charges/bills should be within the period of referral
i.e., 30 days for all cases except cancer and chronic cases which is valid for 90 days. No signature and
stamp on the invoices are required if it is a computer-generated bill.
*As per MHA’s guidelines issued on 03.06.2024
37. What if beneficiary has lost the referral slip?
Beneficiary will need to get a fresh referral letter for uploading the scanned copy and entering the referral
details manually on the TMS portal. Without referral, beneficiary will not be able to avail cashless
healthcare services in empaneled HCO.
38. How many times CAPF beneficiaries can consult specialists at private empaneled HCO?
Beneficiary can consult up to three different specialists in the same HCO and total 9 consultation can be
availed in one referral letter. The allowance for 3 different specialties needs to be mentioned on the
referral slip.
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39. Can beneficiary use referral slip multiple times?
Yes, provided the services mentioned in the referral letter have not been utilized fully and validity period
is active. However, for specified physiotherapy procedures, beneficiary can undergo physiotherapy
without new referral for 30 days from the date of prescription/start of treatment. Beyond that new
referral shall be required.
40. If multistage treatment required, does beneficiary need to get separate referral for each treatment
stage?
No, same referral letter can be utilized if validity period is active.
41. What if the validity of referral letter has expired before completing all the stage of treatment?
Beneficiary needs to get a new referral letter in such case. However, if the specialist (treating doctor) of
CGHS approved hospital/PMJAY hospital advice some other investigations/diagnostic procedures, then
another referral is not required.
42. Does beneficiary need to submit the original referral letter to treating HCOs?
No, HCO will keep a scan copy of the same for uploading on the TMS portal.
Discharge
43. Who performs the activities related to discharge in TMS?
Medco performs the discharge related activities in the system that include updating of discharge date,
updating amount of drug and consumable (wherever applicable), uploading all the documents in the
system etc.
44. How will medicines at discharge be covered for?
CAPF follows the CGHS guidelines wherein a capped amount of maximum INR 2000 is allowed. The
medicines issued are covered by CGHS when provided for maximum of 7 days. If prescription of lesser
duration is provided, the latter will be considered. Only the essential medicines will be considered by
CGHS- No vitamins, tonics, cough syrup, injections nutritional supplements and other non-essential ones
are considered. This covers discharge from all possible episodes of care- conservative management as
well as HCO stay for surgery.
Grievance related
45. What are the cases under which a beneficiary may raise a grievance?
As on date, Ayushman CAPF scheme has been rolled out across the country in CGHS empaneled private
hospitals which have signed MoU with NHA, and all the public and private hospitals empaneled under
AB PM-JAY scheme. Beneficiary, if need be, may raise a grievance in following cases:
1) If the empaneled private HCO is refusing to provide services as per the CAPF guidelines
2) If the empaneled private HCO is asking for payment of cashless services
3) Any other relevant issues related to admission, treatment, etc.
46. How can a beneficiary raise a grievance?
For raising the grievance against CGHS empaneled hospitals, beneficiary may contact CGHS wellness
centers nearby or their own wellness centers or AD-CGHS office. Wellness centers may get the grievance
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resolved by contacting the respective AD-CGHS. However, grievances related to eligibility under the
scheme may be handled by the respective forces.
For grievance against private hospitals empaneled under AB PM-JAY scheme, beneficiary may visit
https://cgrms.pmjay.gov.in/GRMS/loginnew.htm portal to raise the grievance. For more information,
beneficiaries may call on toll-free helpline number 14588.
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