A Landmark Judgment for Pensioners' Right to Life and Medical Reimbursement

 

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CGHS BENEFICIARIES: IMPORTANT SOP CHANGES

The Directorate General of CGHS has issued a significant update via Office Memorandum (OM) No. Z.15025/19/2024/DIR/CGHS/EHS (Comp No. 8281286) dated June 28, 2024.

In response to multiple queries regarding the OM, a Standard Operating Procedure (SOP) has been introduced to:

✅ Enhance clarity and understanding of the OM’s contents.

✅ Standardize the uploading of medical bills to the TMS portal.

All empanelled Health Care Organizations (HCOs) must strictly follow the attached SOP while handling referrals and bill uploads.

This SOP is effective immediately from the date of issue.

 

  🚑 Key Highlights of the New SOP

1. Emergency Cases: Immediate, Cashless Treatment

In emergency situations, no referral or endorsement from CGHS is needed.

HCOs must provide cashless treatment based on an emergency certificate issued by their specialist.

Claims must be uploaded to the BCA portal with the emergency certificate.

For emergency unlisted procedures/investigations, hospitals must seek enhancement/approval via the NHA portal — no need for CGHS AD office approval.

2. Referral Validity for Specialist Consultation

Primary referral by CGHS Medical Officer is valid for 3 months.

Beneficiaries can consult the referred specialist.

Up to two additional specialists (if advised by the primary consultant).

Maximum of 6 consultations (including repeat consultations for acute illnesses).

Referrals from Government hospital specialists are not covered by this guideline.

HCOs must:

Retain a scanned, self-attested copy of the referral.

Return the original referral to the beneficiary.

Note: Follow-up visits and investigations must happen only at the empanelled hospital where the primary consultation occurred.

3. Special Provision for Senior Pensioners (70+ years)

Pensioners aged 70 and above do not require a referral to consult specialists at empanelled hospitals.

Listed investigations and procedures can be carried out without referrals.

Approval is needed from CGHS for unlisted procedures/investigations.

4. Planned Unlisted Investigations and Procedures

Permission required based on delegation rules:

Pensioners: Additional Director/Director, CGHS

Serving employees: HOD/HOO

5. Follow-Up for Special Cases (Lifetime Validity of Primary Referral)

No repeat referral needed for follow-up consultations or investigations for:

• Post-cardiac surgery cases
• Post-organ transplant cases
• Post-neurosurgery cases
• End-stage renal disease
• Cancer treatments
• Autoimmune disorders

Neurological disorders

 📝 Conclusion

This updated SOP ensures a smoother experience for CGHS beneficiaries and hospitals alike, streamlining referrals, emergency care, and billing processes.

All stakeholders are requested to familiarize themselves with the new guidelines and ensure full compliance.

                     Quick Reference

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CGHS BENEFICIARIES WELFARTE ASSOCIATION OF INDIA (CBWAI)

        CBWAI (Central Government Health Scheme Beneficiaries Welfare Association of India) is a registered, all-India welfare association.

    All are requested to join by clicking on link https://tinyurl.com/bde9r8vb

 

I kindly request all members and readers to go through this post and share your valuable views, suggestions, or questions in the comments section below. Your feedback will help improve the content and make it more useful for everyone.

          Regards,

Chandra Kant Bapat

National Coordinator, CBWAI