Revised guidelines for Referral Process in CGHS – MoH&FW O.M. dated 28.06.2024

 Revised guidelines for Referral Process in CGHS – MoH&FW O.M. dated 28.06.2024

Modifications:

1.      Previous Guidelines Modified:

o    Partial modifications to MoHFW OM No. Z.15025/117/DIR/CGHS/EHSS dated 15.01.2018 and 10.12.2018.

o    Revised guidelines for referral procedures for Consultation, Investigations, and Treatment in Government and Private hospitals (empanelled with CGHS).

 

Key Points:

A. Inclusion of Government Hospitals:

• Continuation of OM No. Z.15025/18/2020 dated 09.10.2020.
• “Government hospital” includes all AIIMSs, Institutions of National Importance (INIs), North East Institutions, Tata Memorial Hospital, and all other central government medical institutions.
• No referral/permission/endorsement required for consultation, investigation, or treatment procedures, including unlisted ones.

B. Treatment at Private Empanelled Hospitals:

• Single Referral for Specialist Consultation:
• Valid for three months.
• Beneficiary can consult up to three specialists (including primary specialist).
• Maximum of 6 consultations allowed within 3 months.
• Investigations and Treatment Procedures:
• No further endorsement required for routine listed investigations and minor procedures (non-hospitalization) within the validity period of 3 months.
• Referral/endorsement required for special investigations (e.g., CT Scan, MRI, PET Scan) costing over Rs. 3,000/-.
• Referral/endorsement required for procedures requiring hospitalization, valid for 3 months.
• Unlisted Investigations and Treatment Procedures:
• Permission as per delegated powers (vide OM Z.15025/14/2023/DIR/CGHS dated 27.12.2023 for pensioners and OM No. S 12020/4/97-CGHS(P) dated 07.04.1999 for serving employees):
• CGHS (Additional Director/Director) for pensioner beneficiaries.
• Head of Department/Office (HOD/HOO) for serving employees.

C. Special Provision for CGHS Beneficiaries:

• Age limit for availing consultation, investigations, and treatment procedures reduced to 70 years (previously 75 years as per OM dated 29.05.2019).
• Other conditions remain unchanged.
• Tele-consultation available through e-Sanjeevani 2.0 (https://esanjeevani.mohfw.gov.in/).

D. Emergency and Post-Operative Follow-Up Treatment:

• Instructions as per extant rules.
• Reference Instructions: O.M. No. S.11011/29/2019-EHS dated 13.09.2019 and O.M. No. Z 215025/35/2019/DIR/CGHS/CGHS(P) dated 29.05.2019 (regarding post-operative follow-up treatment).

File No.: 215025/19/2024/DIR/CGHS/EHS(Comp No. 8281286)
/3687286/2024
Government of India
Ministry of Health & Family Welfare
(EHS Section)

Nirman Bhawan. New Delhi
Dated the 28-06-2024

OFFICE MEMORANDUM

Subject: Revised guidelines for Referral Process in CGHS-reg.

In partial modification of MoHFW OM No. Z.15025/117/DIR/CGHS/EHSS dated 15.01.2018 and 10.12.2018. the undersigned is directed to convey approval of the Competent Authority for issue of revised guidelines for referral procedures for Consultation, Investigations and Treatment in Government and Private hospitals (empanelled with CGHS), as per details given below:

A. In continuation of OM No Z.15025/18/2020 dated the 09.10.2020 the term “Government hospital”. shall also include all AIIMSs, Institutions of National Importance (INIS), North East Institutions, Tata Memorial Hospital and all other medical institutions under central government. No referral ‘‘permission/endorsement shall be required for undergoing consultation investigation/ treatment procedure including unlisted investigations/ procedures.

B. Treatment at Private empanelled hospital(s):

i.Single referral for Specialist Consultation: A referral issued by any Medical Officer of a CGHS Wellness Centre will be valid for three months. During this period. the beneficiary may consult two more specialists i.e. up to total of three specialists, if recommended by the primary specialist. A maximum 6 consultations shall be allowed during this validity period of 3 months.

      ii.            Investigation and treatment Procedures advised by specialist of empanelled private hospital after referral by CGHS: No further endorsement from CGHS shall be required for undergoing routine listed investigations and minor procedures, not requiring admission in the hospital. as advised by the specialist, within the validity period of 3 months from the date of issue of the initial referral. However, Referral/endorsement from CGHS _ shall be required for special investigations like CT Scan, MRI Scan. PET Scan and any other investigation costing over Rs. 3.000/- and the referral will be valid tor 3 months.

    iii.            Correspondingly, referral’ endorsement would be required from Medical Officer of CGHS for any procedure requiring admission in the hospital. which would be valid for 3 month.

    iv.            Unlisted investigation(s) and treatment procedures advised by the Specialist of CGHS empaneled hospital: Permission for undergoing such investigations and treatment procedures shall be considered as per the delegated powers vide OM Z.15025/14/2023/ DIR/CGHS dated 27.12.2023 in case of pensioners and OM No. S 12020/4/97-CGHS(P) dated 07.04.1999 in case of serving employees. i.e.

a.      CGHS (Additional Director/ Director) in case of Pensioner beneficiaries.

b.     Head of the Department/ Office (HOD/HOO) in case of serving employee(s)

      v.            In partial modification — of O.M. No. Z 215025/35/2019/DIR/CGHS/CGHS(P) dated 29.05.2019, the special provision for CGHS beneficiaries to avail Consultation/ investigations/ treatment procedures shall hereinafter apply to CGHS beneficiaries aged 70 years and above. as against 75 years prescribed in OM as mentioned above dated 29.05.2019. The other conditions shall remain unchanged. The beneficiaries can also avail of the services through tele-consultation facility available through e-Sanjeevani 2.0  (https ://esanjeevani.mohfw.gov.in/).

    vi.            In case of treatment under emergency and post-operative follow-up treatment, the instructions shall remain as per extant rules. Reference Instructions:

a.      O.M. No. S.11011/29/2019-EHS dated 13.09.2019.

b.     O.M. No. Z 215025/35/2019/DIR/CGHS/CGHS(P) dated 29.05.2019 (regarding post-operative follow-up treatment).

Signed by
Hemlata Singh
Under Secretary to the Go BeBe aaa
Tel 011-23061778.