CGHS rules for consultations, tests clarified

Clarification of Central Government Health Scheme (CGHS) rules regarding consultations, tests, and investigations has been provided by the Union Public Service Commission (UPSC). The UPSC sought clarification from CGHS after encountering frequent issues with reimbursement of medical claims due to a lack of clarity in existing instructions. Here are the key points:

1. Follow-up treatment should be in the same hospital: CGHS beneficiaries are instructed to undergo subsequent follow-up consultations, investigations, or minor procedures at the same empanelled hospital where primary consultation took place.

2. Tests costing up to Rs 3,000: If a specialist doctor of an empanelled hospital prescribes an investigation costing up to Rs 3,000, it must be undertaken at the same hospital where the primary consultation was received.

3. Tests at other CGHS hospitals: For investigations at another CGHS-empanelled hospital or diagnostic centre, a prior referral from the CGHS Wellness Centre is mandatory. No referral is required if consultation and tests are performed at the same hospital.

4. Investigations above Rs 3,000: Investigations costing more than Rs 3,000, such as CT scans, MRIs, and PET scans, require a referral from CGHS.

5. Consultation validity: A consultation is valid for a period of 7 days, provided it pertains to the same speciality. For example, a cardiologist's consultation on Monday remains valid until Sunday.

6. Eye consultation fee: The eye consultation fee includes three procedures - refraction, tonometry, and fundus examination.

7. Unlisted investigations: If a CGHS-empanelled specialist recommends an unlisted investigation or procedure for a beneficiary, prior permission from the concerned department or office is required.