All health care organisations (HCOs) are required to adhere to the guidelines outlined in the attached SOP when handling referrals and uploading bills to the TMS portal, the memorandum said.
In a move to streamline healthcare access, the Ministry of Health and Family Welfare (MoHFW) has issued revised guidelines for the Central Government Health Scheme (CGHS). These updates are aimed at easing the referral process for consultations, investigations, and treatments at both government and empanelled private hospitals.
Earlier this month, CGHS Director through an Office Memorandum informed about the new guidelines simplifying referral process for CGHS beneficiaries. These revised guidelines were issued through an Office Memorandum on June 28 this year.
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Regarding the CGHS referral dated June 28, 2024, the OM said that the directorate received several queries seeking clarification on various clauses of the June memorandum.
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 health care organisations (HCOs) are required to adhere to the guidelines outlined in the attached SOP when handling referrals and uploading bills to the TMS portal, the memorandum said. The SOP comes into effect from the date of issue of this OM.
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What are the key changes in the referral process for CGHS beneficiaries?
Access to government hospitals:
Beneficiaries can now access services at all major government hospitals, including AIIMS and Tata Memorial Hospital, without needing prior referral or endorsement. This includes consultations and treatment for unlisted procedures.
Private hospital consultations:
A single referral from a CGHS Wellness Centre will be valid for three months, allowing beneficiaries to consult up to three specialists. A maximum of six consultations is permitted during this period.
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Investigations and procedures:
Routine investigations and minor procedures do not require additional endorsements within the three-month referral period.
For specialized tests costing over Rs 3,000, a referral will be necessary. Similarly, procedures requiring hospitalization will also need prior approval.
Age criteria adjusted:
The age limit for accessing these services has been lowered from 75 to 70 years, expanding eligibility for more beneficiaries.
These revisions are expected to enhance access to healthcare services and reduce bureaucratic hurdles for CGHS beneficiaries, making it easier for them to receive timely medical attention.
