Simplification of Referral System Procedure for CGHS Beneficiaries

All CGHS beneficiaries (in all CGHS Cities) shall be permitted for seeking OPD consultation from Specialists at Private hospitals empanelled under CGHS after being referred by any Medical Officer/CMO of CGHS Wellness Centre

F.No. Z15025/117/2017/DIR/CGHS
Z15025/117/2017/DIR/CGHS/EHS
Government of India
Ministry of Health & Family Welfare
Department of Health & Family Welfare
EHS Section

Nirman Bhawan, New Delhi
Dated the 15th January, 2018

Office Memorandum

Sub: Simplification of referral system under CGHS

With reference to the above mentioned subject the undersigned is directed to state that this Ministry has been receiving representations for simplification of procedure for CGHS beneficiaries to undertake treatment at private hospitals empanelled under CGHS. The guidelines issued earlier on referral/ permission under Office Memoranda No S 11011/6/96 -CGHS (P) dt. 11/6/97 and 02/09/99, S-12020/4/97 -CGHS (P) dt. 07/04/1999. S 1101 l/l/200-CGHS (P) dt. 10/04/2001 and RA/Cons/Hyd/09-10/CGHS-IV, dated 11/06/2010 and Z.15025/105/2017/ DIR/CGHS dt. 09/11/2017 has been reviewed and it has now been decided to revise the guidelines for consultation and treatment at CGHS empanelled private hospitals as per the details given under:

i) All CGHS beneficiaries (in all CGHS Cities) shall be permitted for seeking OPD consultation from Specialists at Private hospitals empanelled under CGHS after being referred by any Medical Officer/CMO of CGHS Wellness Centre. The referral may be mentioned on the computer generated Prescription slip. After consultation at empanelled hospitals beneficiary shall report back to concerned wellness centre, where MO/CMO would endorse listed investigation and issue medicines as per guidelines mentioned below. For unlisted investigation/treatment procedure CMO Incharge shall submit the prescription to competent authority for consideration in case of pensioner beneficiaries. Serving employees shall seek permission for unlisted investigation/treatment procedure from their department as per prevailing guidelines.

ii) The medicines prescribed by specialists shall be supplied by CGHS as per the available generic name at the CGHS Wellness Centre. In case the medicine prescribed by the Specialist is available by an alternative brand name having the same composition, it shall be supplied by the brand name available at CGHS Wellness Centre.

If, the medicine prescribed by the Specialist is not available at CGHS Wellness Centre either by generic name or alternate brand name, it shall be indented by the same brand name through Authorized Local Chemist.

iii) With reference to OM Z.15025/105/2017/DIR/CGHS dated 09/11/2017, it is clarified that the validity of the advice of Central Government /State Government Specialist / CGHS Medical officer for listed treatment procedures shall be treated as valid for three months unless mentioned otherwise and no other referral (permission) letter is required to undergo, the treatment procedure at any of the empanelled Hospitals. It is also clarified that once a specific treatment procedure (listed) has been advised by a Specialist of Central Government /State Government or a CGHS Medical officer, it is the option of CGHS beneficiary to undergo at any of the CGHS empanelled hospitals of his/her choice and it is not compulsory that Specialist /CGHS Medical officer shall refer the beneficiary for treatment to any CGHS recognized hospitals.

iv) In case of Haemo-Dialysis, the advice for treatment can be made upto six months and in such cases the advice shall be valid for upto six months.

v) In case of Radio-therapy / Chemotherapy advised by a Government Specialist the advice shall be valid for all the cycles of Radio-therapy/Chemotherapy. The specialist has to specify the specific Radio-therapy procedure. Self-attested (by beneficiary) photo-copies of the permission letter is required to be submitted.

vi) In case of post-operative follow up treatment in six conditions as specified in OM dated 10.04.2001, permission for follow-up treatment shall be required from competent authority.

vii) In case of non-listed investigations / treatment procedures permission from competent authority is required to be obtained.

2. This issues with the approval of competent authority in supersession of earlier guidelines.

sd/-
[Dharminder Singh] Under Secretary to Government of India

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