CGHS-Revised guidelines for Referral Process in CGHS-reg. OM dated 28.06.024 & SOP dated 02.09.2024
I/3687286/2024
Government of India
Ministry of Health A Family Welfare
(EHS Section)
Nirman
Bhawan. New Delhi Dated the 28-06-2024
OFFICE
MEMORANDUM
Subject: Revised
guidelines for Referral Process In CGHS-reg.
In partial modification of MoHFW OM No.
Z.15025/117/DIR/CGHS/EHSS dated 15.01.2018 and 10.12.2018. the undersigned is
directed to convey approval of the Competent Authority for issue of revised
guidelines for referral procedures for Consultation. Investigations and
Treatment in Government and Private hospitals (empanelled with CGHS). as per
details given below:
A.
In continuation of OM No
Z.15025/18/2020 dated the 09.10.2020 the term "Government hospital",
shall also include all AIIMSs, Institutions of National Importance (INIs),
North East Institutions, Tata Memorial Hospital and all other medical
institutions referral permission/endorsement shall
consultation investigation/ treatment
investigations/procedures.
B Treatment at Private
empanelled hospital(s):
i.
Single
referral for Specialist Consultation: A referral issued by any Medical
Officer of a CGHS Wellness Centre will be valid for three montns. During this period, the beneficiary may consult two more
specialists i.e. up to total of three specialists, if recommended by
the primary specialist. A maximum 6 consultations shall be allowed during this
validity period of 3 months.
ii. Investigation and treatment Procedures advised
by specialist of empanelled private hospital after referral by CGHS: No further endorsement from CGHS shall be
required for undergoing routine listed investigations and minor procedures, not
requiring admission in the hospital, as advised by the specialist,
within the validity period of 3 months from the date of issue of the initial
referral. However. Referral/endorsement from CGHS shall be required for special
investigations like CT Scan. MRI Scan, PET Scan and any other investigation
costing over Rs. 3.000/- and the referral will be valid for 3 months.
iii.
Correspondingly,
referral/ endorsement would be required from Medical Officer of CGHS for any
procedure requiring admission in the hospital, which would be valid for 3
month.
iv. Unlisted Investlgation(s) and treatment
procedures advised by the Specialist of CGHS empaneled hospital: Permission for undergoing
such
investigations and treatment procedures shall be considered as per the
delegated powers vide OM Z. 15025/14/2023/ DIR/CGHS dated 27.12.2023 in case of
pensioners and OM No. S 12020/4/97-CGHS(P) dated 07.04.1999 in case of serving
employees, i.e.
a.
CGHS
(Additional Director/ Director) in case of Pensioner beneficiaries.
b. Head of the Department/ Office (HOD/HOO) in case
of serving employee(s)
v. In partial modification of O.M. No.
Z15025/35/2019/
DIR/CGHS/CGHS(P) dated 29.05.2019, the special
provision for CGHS beneficiaries to avail Consultation/investigations/treatment
procedures shall hereinafter apply to CGHS beneficiaries aged 70 years and
above, as against 75 years prescribed in OM as mentioned above dated 29.05.2019.
The other conditions shall remain unchanged. The beneficiaries can also
avail of the services through tele-consultation facility available through e-Sanjeevani 2.0
(https://esanjeevani.mohfw.gov.in/).
vi. In case of treatment under emergency and post-operative
follow-up treatment, the instructions shall remain as per extant rules.
Reference Instructions:
a. O.M. No. S.I1011/29/2019-EHS dated 13.09.2019.
b.
O.M. No.
Z15025/35/2019/DIR/CGHS/CGHS(P) dated 29.05.2019 (regarding post-operative
follow-up treatment).
Signed by
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To
1. All Ministries and Departments of the Government
of India through the CGHS website
2. Addl. Director, CGHS(HQ)/ Addl. DDG(CGHS)/ Addl.
Directors. CGHS of Cities / Zone.
3. All CGHS Wellness Centres through concerned AD,
CGHS
4. MCTC, CGHS with the directions to upload the document
on CGHS Website (www.cghs.gov.in).
5. All HCOs empanelled under CGHS through CGHS
website.
6. Director. AllMS as per list: JIPMER, Puducherry;
PGIMER, Chandigarh;
7. DDG NIC Health with the request to modify the
CGHS application.
8. Sh. Jitendra Singh. CDAC, Noida
9. CEO & MD NHA with the request to kindly
inform the Claim Processing Doctors regarding the referral process.
10. LACs/ ZACs through Addl. Directors. CGHS.
11. Sanctioning Authorities in CGHS.
12 CMO
Hospital Cell. CGHS HQ.
13. All CGHS empanelled private hospitals
through Additional Director of concerned city
F.No.Misc.2011/103/NHA
ISSUES/2023(comp.No 8289407)
Office of the Director
Directorate of CGHS
CGHS Bhawan, R K Puram
Sector-13 New Delhi -110066
OFFICE
MEMORANDUM
New
Delhi, 2/9/2024
Regarding the CGHS referral OM Z.15025/19/2024/DIR/CGHS/EHS, Comp No.
8281286) dated June 28, 2024, the directorate has received several queries
seeking clarification on various clauses of the OM
In response to inquiries regarding various clauses within
the aforementioned OM, a
Standard Operating Procedure (SOP) has been developed. This SOP aims to:
Enhance understanding: Provide a clear explanation of the OM's contents.
Standardize bill uploads: Ensure uniformity in uploading medical
bills to the TMS portal.
All
HCOs are required to adhere to the guidelines outlined in the attached SOP when handling
referrals and uploading bills to the TMS portal.
The SOP comes
into effect from the date of issue of this OM.
Enclosure: Standard Operating Procedure (Sop) For Health Care Organizations To
1. All
Ministries and Departments of the Government of India through
the CGHS website
2. Addl. Director, CGHS(HQ)/ Addl. DDG(CGHS)/ Addl. Directors, CGHS of
Cities / Zone.
3. All CGHS Wellness Centres
through concerned AD, CGHS
4. MCTC,
CGHS with the directions to upload the document on CGHS Website (www.cghs.gov.in).
5. All HCOs empanelled under
CGHS through CGHS website.
6. Director. AIIMS
as per list; JIPMER, Puducherry: PGIMER, Chandigarh
7. DDG NIC Health with the request
to modify the CGHS application.
8. Sh. Jitendra
Singh, CDAC. Noida
9. CEO & MD NHA with the request
to kindly inform the Claim Processing
Doctors regarding the referral process.
10. LACs/ ZACs through Addl.
Directors, CGHS.
11. Sanctioning Authorities in CGHS.
12. CMO Hospital
Cell, CGHS HQ.
13. All CGHS empanelled private hospitals through
Additional Director of concerned city
Copy of Information to:
1.
PPS to Secretary (H&FW), MoHFW
2. PPS to Secretary (Personnel), DoPT, MoPPG&P
3. PPS to Secretary (DARPG &DoPPW), MoPPG&P
4. PPS to AS & DG CGHS
5. PPS to JS (MoHFW),
CGHS
1.
Emergency cases:
In emergency cases, HCO shall not insist
for referral or endorsement from CGHS and shall provide
cashless treatment to eligible beneficiaries based on the emergency
certificate given by the treating empanelled hospital specialist. The claim
shall be uploaded to BCA portal
along with emergency certificate issued by
the treating specialist. The referral or endorsement is not required for emergency unlisted
investigations/treatment also. For emergency unlisted
procedure/investigation the hospital shall raise enhancement/approval through
NHA portal. There is no need for approval from local CGHS AD Office.
2.
Validity of referral for Specialist consultation:
As per OM Z 15025/19/2024/DIR/CGHS/EHS dated 28th June 2024, the consultation memo is valid for 3 months.
The primary consultant refers to the specialty for which the referral is issued by CGHS Medical Officer. Up to two additional
specialists from different fields can be consulted if advised by the primary
consultant, with a maximum of six consultations allowed, including repeat
consultations with the same specialist for acute illnesses. This shall apply
only to primary referrals issued by CGHS Medical
Officers and shall not be applicable for referral from Government hospital
specialists.
The HCO shall retain
a scanned, self-attested copy of the referral and return the original
to the beneficiary.
The total number
of consultations/cross-consultations/reviews,
etc., on the basis of the primary referral issued by the CGHS Medical Officer
shall be restricted to a maximum
of 6 within a period of 3 months.
The quantity option for consultation shall
be left at the
default
value of ‘1’ when issuing
a referral, as the
number of reviews or follow-ups required cannot be predicted at the time of
issuance. This default value of ‘1’ does
not mean that it is valid for only one consultation.
Subsequent Follow-Up Consultations/Investigations/Minor Procedures can be done only at the same
empanelled hospital where primary consultation is done. This is not valid
in another Health Care Organisation.
Each subsequent follow-up visits based on the first referral from the CGHS Medical Officer,
which is made on separate days, shall not be
clubbed and shall be submitted as a separate claim on the portal.
3.
Special Provisions for Above 70 years
Pensioners: No referral
is required for beneficiaries aged 70+ 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.
4.
Planned Unlisted Investigations & Procedures:
Permission for planned
unlisted investigations and procedures advised
by empanelled hospitals shall be given as per
the delegation of financial rules:
·
Additional Director/Director in the
case of pensioners
·
HOD/HOO in the case of serving employees.
5.
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
Process flow for handling
referrals in TMS portal:
1. Referral Letter
·
Original Referral: The HCO shall not insist
on the original referral; a photocopy of the referral
memo shall be accepted.
·
Self-Attestation: The photocopy
shall be self-attested by the beneficiary with the date, since the TMS
module is yet to implement part utilization and other system changes.
2. Patient Registration
Fill up the mandatory details like communication address, mobile number,
etc. and register
the patient
Select the patient type as either OP or IP
·
Referral Type Selection: Choose “Manual” or “e-referral” based on the referral type.
3. Processing of referral
by MEDCO at Empanelled HCO
·
e-Referral Usage: For the first consultation, the MEDCO shall use e-referral.
·
Subsequent follow-ups: If further review, investigations, or minor procedures are advised by the
primary consultant (the specialty for which the referral has been issued
by the CGHS Medical Officer), follow the steps below using the
manual option.
4. Manual Option for Subsequent Follow-Up
Consultations/Investigations/Minor Procedures not requiring admission.
a)
Investigations: Each investigation costing less than Rs. 3000 (NABH/NABL rate)
can be performed without further referral, except for:
·
CT, MRI, and nuclear
scans, irrespective of the rate, and will require endorsement from the CGHS Medical
Officer.
b) Minor Procedures:
·
No
referral from CGHS Medical Officer
is required for minor procedures not requiring admission.
·
Procedures can be performed at the
same empanelled hospital
with clinical justification.
Referral ID: Use the original referral ID and suffix it with /C2 for the first
review, /C3 for the second review or cross-consultation, etc. This can go up to a maximum of C5, allowing
a total of 6 consultations within 3 months.
For investigations or minor procedures, use ‘Ix’ and ‘Px’ respectively, where ‘x’ is the
number of the corresponding consultation. For e.g.
·
MU3/25JUL2024/2982/P1 for minor procedures not requiring admission.
·
MU3/25JUL2024/2982/I2 for investigations done based on the second
follow-up/cross- consultation.
Treatment Protocol: Select “Referral”. Proceed to add investigations (costing less than Rs 3000, excluding
CT, MRI, PET CT) and minor procedures not requiring admission advised by the
empanelled hospital
specialist.
For beneficiaries aged 70 and above, use the “Non-Referral” option
under the treatment
protocol to book any listed investigation or
procedure advised by the empanelled HCO/Government hospital specialist,
5. Document Upload Requirements
All documents including
discharge summary should
give complete picture
of the course of the
disease. The consultation notes shall be self-explanatory and shall justify the need for follow up visits or cross consultations/ tests and treatments advised without which bills are liable to be rejected
without giving a second chance.
Emergency cases. The emergency certificate indicating nature of emergency condition
issued by treating doctors
should be uploaded along with other relevant documents
For Each Follow-Up Without
CGHS Referral (Follow-Up/Cross-Consultation Based
on Advice of Primary Specialist):
·
Upload the following documents as a single file in the referral letter
option in addition to the
mandatory documents under other options:
·
Primary consultation referral.
·
Consultation notes along with advice for follow-up, cross-consultation, investigation, or
minor procedures not requiring admission.
·
Undertaking from the beneficiaries for the subsequent consultation, investigation or minor procedures(Annexure A).
·
Geotagged photo of the beneficiary. Instructions shall be given regarding
how to upload photos of beneficiaries with geotagging information. This shall be uploaded manually
in the referral letter option until the NHA develops a separate functionality for the same.
For Beneficiaries Aged 70 and Above:
·
Upload the following documents as a single
file in the referral letter
option in addition
to the mandatory documents
under other options:
·
The undertaking from the
70+ beneficiary seeking direct
consultation shall be
mandatorily uploaded
in the referral letter
option while submitting claims(Annexure A).
·
Consultation notes along with advice for any listed investigation or procedure by the
specialist for whom the consultation was sought.
·
Geotagged photo of
the beneficiary.
For Follow-Up Special Cases:
·
Upload the following documents as a single
file in the referral letter
option in addition
to the mandatory documents
under other options:
·
The undertaking from the beneficiary seeking follow-up consultation/investigation for
special cases like post-operative
cardiac cases, post organ transplant cases, ESRD, Cancer
treatment, etc. shall be mandatorily uploaded in the referral letter
option while submitting claims(Annexure A).
·
A
copy of the self-attested permission letter and discharge
summary/treatment notes
confirming that the case fits under the categories mentioned above (point 5).
·
Geotagged photo of
the beneficiary.
To, Date:
The Medical
Superintendent,
…................................................................................... (Name of empanelled hospital
& City)
70 +
beneficiaries/ Follow-up special cases
Letter Ref. No. OM Z15025/35/2019/DIR/CGHS(P) DATED 29-05-2019
Respected Sir/Madam,
I am …. year old CGHS beneficiary ………………….. (Name), ……………… (Ben. ID),........................... (city).
I am a patient of ……………….(Disease) and I want OPD consultation of...................................... (specialty).
or
I am a
follow-up case of Post-cardiac surgery
cases 
Post-organ transplant cases 
Post-neurosurgery cases End-stage renal disease Cancer treatment
Autoimmune disorders 
Neurological
disorders
And, I want follow-up consultation/investigations for................................. (specialty)
Beneficiary’s signature
Letter Ref. No. OM Z15025/19/2024/DIR/CGHS/EHS) DATED 28-06-2024
Respected Sir/Madam,
Subject: - Follow-Up/Cross-Consultation............................. (Specialty) for CGHS Beneficiary
Follow-up Consultation
I, CGHS beneficiary, ………………………….. (Name),................................................................ (CGHS
Beneficiary ID), belonging to.................................................... (City) have been advised
Follow-up /
OPD consultation of......................................................... (Speciality) by the Primary
Consultant
…............................................... (Specialist Name & Specialty) based on the referral issued from
CGHS Wellness Centre.................................................................... (WC
Name & City) bearing Referral
ID
……………………… dated ………
Follow-up Consultation Number: 1
2 3 4 5
Beneficiary’s signature
 |
Subject: - Follow-Up
Investigations (Less Than Rs 3000/- NABH) & Minor Procedures Not Requiring
Admission for CGHS Beneficiary
Follow-up Investigations & Minor Procedures
I, CGHS beneficiary, ……………………… (Name), …………(Ben
ID), belonging to.................. (City) want to
undergo the following Investigations/ Minor Procedures:
…………………………………………………………………………………………………
…………………………………………………………………………………………………
advised by the Primary/Secondary Consultant.............................................. (Specialist Name & Specialty) on
……………(date), based on the referral
issued from CGHS Wellness Centre......................................... (WC
Name &
City) bearing Referral
ID …………………… dated …………….
I have not undergone
the above said investigations based on the same referral
elsewhere.
Beneficiary’s signature
PS: To be uploaded
along with other
documents as per checklist as single file under referral letter in BCA portal.
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