CGHS rule update for emergency cases:
In emergency cases, Healthcare Organisations (HCOs) will not require a referral or endorsement from CGHS and will provide cashless treatment to eligible beneficiaries based on an emergency certificate issued by the treating empanelled hospital specialist. The claim must be uploaded to the BCA portal along with the emergency certificate from the treating specialist.
Referral or endorsement is also not needed for emergency unlisted investigations or treatments.
For emergency unlisted procedures or investigations, the hospital should request an enhancement or approval through the NHA portal. Local CGHS AD Office approval is not necessary.
CGHS referral rule update: For special consultations
As per the earlier Office Memorandum, consultation memos are valid for three months. The primary consultant refers to the specialty for which the referral is issued by the CGHS Medical Officer. Up to two additional specialists from different fields can be consulted if advised by the primary consultant.
A maximum of six consultations is allowed, including repeat consultations with the same specialist for acute illnesses.This applies only to primary referrals issued by CGHS Medical Officers, not to referrals from Government hospital specialists. HCOs must retain a scanned, self-attested copy of the referral and return the original to the beneficiary.The total number of consultations, cross-consultations, or reviews based on a primary referral issued by the CGHS Medical Officer is limited to six within three months.
When issuing a referral, the quantity option for consultation should remain at the default value of ‘1’. This does not limit the number of consultations.
Subsequent follow-up consultations, investigations, or minor procedures must be conducted at the same empanelled hospital where the primary consultation took place. This is not valid at another Health Care Organization. Each subsequent follow-up visit based on the first referral from the CGHS Medical Officer, occurring on separate days, should be submitted as a separate claim on the portal.
CGHS rule update: No referral is required for beneficiaries aged 70 years and above
No referral is required for beneficiaries aged 70 years and above to consult any specialist in empanelled hospitals. Any listed investigations and procedures can be performed without further referral. However, approval from CGHS authorities is required for unlisted procedures/investigations.
CGHS rule update: Follow-up special cases
The beneficiaries suffering from below mentioned conditions are permitted to avail consultations and
investigations without any time limit based on the primary referral.
No repeat referral / endorsement from CGHS is required for follow-up consultations or investigations:
• Post-cardiac surgery cases
• Post-organ transplant cases
• Post-neurosurgery cases
• End-stage renal disease
• Cancer treatment
• Autoimmune disorders
• Neurological disorders
