CGHS Reimbursement: New Test & Referral Rules Explained

If you’re a Central Government Health Scheme (CGHS) beneficiary, like a government employee or pensioner, there are new clarifications regarding your medical reimbursement rules you need to know.

These updated guidelines from CGHS address when you’ll need referrals or prior approvals for various tests, follow-ups, and other medical procedures, aiming to streamline the process for everyone.

Understanding the New Test Rules

The rules for getting medical tests done now depend on their cost and where you choose to have them.

• Investigations costing up to Rs 3,000 should generally be conducted at the same empanelled hospital where your initial consultation took place.
• For tests that exceed Rs 3,000, such as CT, MRI, and PET scans, a prior referral from CGHS is mandatory before you proceed.
• If you decide to go to a different empanelled facility for tests under Rs 3,000, you will need a referral from your CGHS Wellness Centre.

Consultations and Other Procedures

Beyond tests, CGHS has also clarified rules for consultations and specific procedures.

• Your medical consultations remain valid for seven days if you are seeing the same medical specialty.
• Eye consultation fees now clearly cover refraction, tonometry, and fundus examination within the stated charges.
• Any medical procedures not explicitly listed require prior permission from the relevant department before you undergo them.

These clarifications were issued to resolve recurring issues in processing medical reimbursement claims, a concern previously highlighted by the Union Public Service Commission (UPSC).