In an effort to make healthcare more accessible for government employees and retirees, the Ministry of Health and Family Welfare (MoHFW) has introduced new guidelines for Central Government Health Scheme (CGHS) cardholders. These updates are aimed at simplifying the referral process for consultations, investigations, and treatments at both government and empanelled private hospitals.
The changes, outlined in an Office Memorandum (OM) dated September 24, 2024, come as a response to queries received after a previous memorandum issued in June. In a statement, the MoHFW explained, “The directorate has received several queries seeking clarification on various clauses of the OM.” To address these concerns, the ministry has now issued a Standard Operating Procedure (SOP) to make the process clearer for all CGHS beneficiaries.
Key Updates to the CGHS Referral Process
- Emergency Situations: No Referral Required
One of the most significant updates is that in emergency situations, beneficiaries no longer need a CGHS referral or endorsement to receive cashless treatment at empanelled hospitals. The healthcare organisation (HCO) can provide immediate care based on an emergency certificate issued by the hospital’s treating specialist.
The claim, along with the emergency certificate, must be uploaded to the BCA portal by the hospital. For unlisted procedures or investigations, the hospital should request approval through the NHA portal, without needing additional clearance from the local CGHS AD Office.
- Simplified Process for Special Consultations
Under the new guidelines, referral memos for consultations issued by CGHS Medical Officers will be valid for three months. During this period, the primary consultant (to whom the beneficiary is referred) can direct the patient to up to two additional specialists in different fields if necessary.
A maximum of six consultations is permitted under a single referral, including repeat consultations for ongoing treatment of acute illnesses. However, this applies only to referrals from CGHS Medical Officers and not to those issued by specialists in government hospitals.
To ensure proper documentation, empanelled healthcare organisations must keep a self-attested scanned copy of the referral while returning the original to the beneficiary.
Follow-up visits, investigations, or minor procedures must be conducted at the same empanelled hospital where the original consultation took place. Each follow-up visit, conducted on separate days, should be logged as an individual claim in the BCA portal.
- No Referral Needed for Beneficiaries Aged 70 and Above
In a major relief for elderly beneficiaries, the new guidelines eliminate the need for a referral for those aged 70 years and above. Senior CGHS cardholders can directly consult with specialists at empanelled hospitals and undergo any listed investigations or procedures without a referral. However, for unlisted procedures or investigations, approval from CGHS authorities is still required.
- Special Cases: No Time Limit on Follow-Up Consultations
Beneficiaries suffering from certain critical medical conditions can now benefit from unlimited follow-up consultations without needing repeat referrals or endorsements. These conditions include:
- Post-cardiac surgery
- Post-organ transplant
- Post-neurosurgery
- End-stage renal disease
- Cancer treatment
- Autoimmune disorders
- Neurological disorders
This update ensures that those requiring continuous care can access the treatment they need without unnecessary administrative hurdles.
What These Changes Mean for CGHS Beneficiaries
The new guidelines are a positive step towards making the healthcare process smoother and more efficient for CGHS cardholders. The elimination of referrals in emergencies, easier access for seniors, and no time limit for follow-up consultations in critical cases are designed to reduce delays and improve the overall patient experience.
By streamlining the referral process and clarifying existing procedures, the government aims to ensure that CGHS beneficiaries can focus more on their health and less on navigating complex systems.
The problem is with the Empanelled Hospitals. They often do not accept the beneficiary without referral and even they accept, they insist for payment for consultation and tests. They don’t accept to extend cashless facility. Many Hospitals refuse to admit the patient under the pretext that Beds are not available. If payment is made they happily admit.