The Employees’ State Insurance Corporation (ESIC) has issued a comprehensive set of guidelines aimed at improving medical facilities and referral services for its insured beneficiaries across the country. The directions, approved by the Competent Authority, are designed to address gaps in service delivery, ensure transparency, and streamline processes for timely and quality healthcare access.
The circular covers everything from referral policy compliance, lab service availability, to monitoring of empaneled hospitals, with a strong emphasis on accountability, digital documentation, and ease of treatment for beneficiaries.
✅ Key Highlights of the Guidelines
1. Referral Policy Compliance
- All Regional Directors (RDs) and Medical Superintendents (MSs) must ensure that ESIC Referral Policy 2023 and its amendments are fully incorporated in the Request for Proposal (RFP) and agreements with empaneled hospitals.
- Example: If no CGHS rate exists for an implant, only 60% of the MRP (including GST) will be reimbursed. Hospitals must not overcharge ESIC or beneficiaries.
2. Strict Adherence to CGHS Package Rates
- Open billing packages (like consultation or ventilator charges) must be avoided unless strictly justified in P1 forms.
- Admission days as per package limits must be followed; extensions need specialist documentation and referral committee approval.
🕒 Timely Action on Emergency Referrals
3. Direct Admission from RD Offices
- Cases must be approved/rejected within 24 hours, and not beyond 48 hours of admission.
- Emergency verification should include proper identity and diagnosis validation, with opinion from the nearest ESIC hospital if required.
🚫 Misclassification of Medical Cases
4. Avoid Unjustified Tertiary Referrals
- Secondary conditions should not be converted to tertiary care without clinical justification.
- Referral Review Committees must regularly check such cases—especially in General Surgery and ICU referrals.
🏥 Infrastructure and In-House Service Strengthening
5. 24×7 Lab and Radiology Services
- Essential emergency diagnostics like CBC, KFT, LFT, ABG, electrolytes, X-Ray must be made available round the clock.
- Referrals made after 4 PM on weekdays / 1 PM on Saturdays must be reviewed the next working day.
🧾 Documentation and Digital Processing
6. Digital Workflow for Approvals
- All documents and approvals (e.g., culture reports for high-cost antibiotics, chemotherapy details, etc.) must be routed through the UTIITSL portal.
- Manual processing allowed only in case of technical issues.
7. Extension of Stay
- A new proforma for extension of hospital stay has been introduced and must be used immediately through the UTIITSL portal.
🔍 Monitoring and Transparency
8. Monitoring of Empaneled Hospitals
- Random visits to empaneled hospitals must be conducted to verify the status of ESI patients.
- Random calls/video verifications of admitted patients should be documented.
9. Display Boards & Beneficiary Information
- Hospitals must display the following in three languages:
- “Patient can choose their empaneled hospital (if referred)”
- “All treatment through ESIC referral in empaneled hospitals is cashless”
- Referral and reimbursement information must be prominently displayed.
🔄 Staff Management and Compliance
10. Rotation of Key Staff
- Mandatory staff rotations every three years for:
- Super Specialty Treatment (SST) in-charge
- Medical Store in-charge
- Compliant with Central Vigilance Commission (CVC) guidelines.
11. Referral Rights Limited
- Referral ID access must be restricted to regular ESIC staff only.
🎯 Overall Objective
The central goal of these guidelines is to:
- Enhance in-house capacity of ESIC facilities.
- Minimize unjustified referrals.
- Promote transparency and beneficiary convenience.
- Ensure timely, quality, and cashless treatment through standardized and accountable systems.
📢 Conclusion
This move is a significant step forward in improving service delivery for over 13 crore ESIC beneficiaries, ensuring that public health funds are efficiently utilized while upholding high standards of medical care. All stakeholders, including ESIC staff and empaneled hospitals, are directed to implement these changes immediately.