The Central Government Health Scheme (CGHS) helps beneficiaries and their dependents. It allows them to go to Ayurvedic hospitals. They can also visit other medical facilities in India. But the common fear is getting a successful “CGHS claim.” A common mistake people make is confusing a referral with a recommendation.
On June 28, 2024, officials updated the CGHS referral rules. Now, they are simpler, making healthcare easier and stress-free. Let us review the referral rules to avoid delays.
When Do You Need a CGHS Referral?
The referral is important because treatment depends on it. It answers questions like, “Where should I get the treatment?” and “Who benefits from it?”
1) Treatment at Government Hospitals
CGHS beneficiaries can visit government hospitals for treatment.
- No referral is required for consultations, investigations, diagnoses, or treatment.
- CGHS beneficiaries and their dependents can visit CGHS hospitals. They can get OPD care, tests, or procedures.
- The same rule applies to each CGHS cardholder
Some of the reputed and well-known government hospitals are:
- AIIMS hospitals
- Institutes of National Importance (INIs)
- Northeast Medical Institutions
- Tata Memorial Hospitals
- Other Central Government Medical Institutions
Note: Beneficiaries can get tests or treatments not listed under CGHS. They don’t need a referral.
2) Treatment at Private Empanelled Hospitals
The CGHS rules are different for private hospitals. They are not the same as for CGHS-empanelled government hospitals. Let’s look at them.
For all the CGHS beneficiaries below the age of 70 years, a referral is needed.
- A Medical Officer (MO) or CMO in charge at a CGHS Wellness Center must issue a referral. The referral helps the health seeker visit a specialist. They receive authentic treatment at CGHS-empanelled private hospitals.
3) Tele-Consultation Option
CGHS allows digital consultation benefits to make treatment accessible for all beneficiaries. This lets health seekers talk to doctors from home. They don’t have to visit the wellness center in person. Now, the interested patients can consult doctors through the e-Sanjeevani 2.0 platform.
But why does the referral system matter?
The referral system helps CGHS in the following ways:
- Ensures health seekers receive specialized care
- Control costs of the treatment that follow the CGHS framework.
- Organization of the Treatment Record and Medical History
Understanding this rule can save time and effort for CGHS cardholders. It means treatment can be accessible and clear.
Notable 2024 Updates in the CGHS Referral Process
In June 2024, the Ministry of Health and Family Welfare (MoHFW) altered it to make CGHS easy to understand. This reduced the burden of paperwork. It allows CGHS cardholders to seek treatment without worry. Now, what are these updates? Let’s look at them.
1) Referral Validity Extended: Good news for the beneficiaries. Earlier, an issued referral was valid only for 30 days. After the update, a referral issued by a CGHS wellness center is valid for three months. So, health seekers don’t need to seek treatment in a rush.
2) Multiple Specialists Consultations Allowed: A beneficiary or their dependent can see up to three specialists in three months. This is only after a recommendation from the first specialist.
3) Six Total Consultations Allowed: A health seeker can attend six consultations. This is within a three-month referral period.
4) No More Approval for Routine Tests: CGHS won’t approve extra requests. This is true if doctors suggest minor procedures. Routine check-ups don’t count either. Hospitalization is needed for extra approval.
5) Faster Access to Diagnostic Services: Patients can start treatment right away because they don’t need extra approvals for routine tests.
Special CGHS Provisions for Senior Citizens (70 Years & Above)
| Provision | Details |
| Age Eligibility | Special CGHS provisions apply to beneficiaries aged 70 years and above. |
| Lower Age Threshold for Direct Consultation | Only beneficiaries above the age of 75 years can consult doctors directly. After the update, the age limit is now reduced to 70 years. |
| Direct Specialist Access Without Referral | CGHS beneficiaries above the age of 70 years can get a doctor’s consultation without a referral from a CGHS Wellness Center. |
| Direct Access to Investigations and Procedures | Specialists recommend the listed medical procedures without more referral approval. |
| Hospitalization Coverage or Higher Costs | If the treatment or procedure requires hospital admission, the provision applies. |
| Simple Documentation Process | The hospitals should select the “Non-Referral” option in the CGHS billing portal. They can upload a beneficiary undertaking document for the claim process during the billing process. |
Guidelines for Investigations and Hospitalizations Under CGHS
CGHS beneficiaries and their dependents must know about all investigations. They should also be aware of the hospital treatments CGHS covers. In fact, these guidelines ensure proper documentation, authorization, hassle-free treatment, eligibility, etc.
1) Routine Investigations (Up to ₹3,000): CGHS allows routine diagnostic tests below ₹3,000. There is no extra approval.
2) All the tests must appear in the approved CGHS investigation list.
3) A specialist doctor must prescribe the test. This happens after checking the referral from a CGHS wellness center. In this case, no extra claim from a CGHS Medical Officer (CMO) is required.
4) Special or High-Cost Investigations: Some high-cost tests need approval. This approval is from a CMO for advanced procedures. They are –
- CT Scans
- MRI Scans
- PET Scans
Soon after the referral approval, it lasts for three months. The health seeker should complete the treatment within this period.
5) Importance of Guidelines: Proper protocol helps in smooth cashless treatment. This also prevents unnecessary investigations during hospitalizations.
Emergency Medical Referrals Under CGHS
A case of a medical emergency eases the referral rules. The priority is to save the life first and later think about CGHS provisions.
- Direct Hospital Admission: In an emergency, a CGHS cardholder can go to any private hospital. It must be CGHS-empanelled.
- Immediate Cashless Treatment: The empanelled hospital is liable to start the treatment immediately. And the CGHS beneficiaries should not worry about cashless treatment. They receive a clearance after the doctor issues an emergency certificate.
- Doctors can start urgent tests and procedures right away. This is true even if the tests aren’t in the standard CGHS list.
- Once the patient is stable, the hospital can submit the approval documents via the NHA portal.
- These relaxed rules help CGHS beneficiaries get the urgent care they need. Because paperwork can wait.
CGHS Referral Guidelines for Chronic Conditions and Special Treatments
The Central Government Health Scheme (CGHS) helps its beneficiaries. It provides long-term medical care. But the referral rules are different for critical medical conditions. Let’s understand them.
Chronic Illnesses and Post-Operative Follow-Ups
CGHS health seekers suffering from serious ailments get continued follow-up consultations and investigations without strict time limitations.
Doctors consider these revisits on the basis of primary treatment referral. This benefit applies to health seekers with the following conditions, such as:
- Patients recovering from cardiac surgeries, including coronary angioplasty
- Patients who have undergone organ transplants
- Patients recovering from neurosurgery or brain strokes.
- Individuals suffering from end-stage renal disease (ESRD) or advanced liver failure
- Patients undergoing cancer treatment or long-term cancer follow-ups
- Individuals diagnosed with autoimmune diseases, including rheumatoid arthritis.
- Patients with neurological disorders such as Parkinson’s
Referral Regulations for Ayush and Specialized Treatments
CGHS allows referrals for AYUSH therapies such as Ayurveda, yoga, naturopathy, and others. But the points to remember are the following:
- Referrals are valid for 15 days for AYUSH Care Therapy Centers.
- In case the treatment needs more than 15 days, the referral increases by 15 more days
- A Chief Medical Officer in Charge (CMO) must approve the extension. This helps avoid confusion later.
- For the unlisted treatments or procedures, health seekers must get approval first.
- CGHS pensioners need approval from the Additional Director or the Director of CGHS
- Serving employees need approval from the Head of Department (HOD)
Simple Steps to Follow the CGHS Referral SOP
The CGHS Standard Operating Procedure is helpful. It helps patients avoid treatment delays. Some of the practical steps are
1) Referral ID System: CGHS Ayurvedic hospitals need the original referral number. This allows for follow-up visits. They add a suffix such as C2, C3, or C4 for each consultation.
2) Carry Proper Documents: Hospitals recommend CGHS seekers to bring a self-attested photocopy of the referral memo. (with a clear date)
3) Visit the Same Empanelled Hospital: Go to the same CGHS-empanelled hospital for follow-up consultations. This is where you had your primary treatment.
4) Identify Verification at the Hospital: Hospitals take a geotagged photo of the beneficiary. They upload this photo during registration. It goes to the Transaction Management System (TMS) portal. Where the identity gets verified.
Final Conclusion
So, to understand a referral in simple words, it means to get permission. Now, a CGHS referral means official permission given by a CGHS doctor to seek treatment.
Health seekers looking for the best CGHS India Ayurvedic hospital, VVAC, is the place for you. VVAC, or Vaidyaratnam Vrindavan Ayurveda Chikitsalayam, excels in Panchakarma treatments and holistic healing.
VVAC is a trusted Ayurvedic paradise that spreads across 25 acres on the Shivalik hilltop. Being empaneled with CGHS, Vrindavan Ayurveda Chikitsalayam offers a stress-free CGHS claim process. Listen to our CGHS health seekers’ experience here at VVAC.
