Clarification regarding existing CGHS Guidelines – UPSC advised officials to follow the guidelines

Clarification regarding existing CGHS Guidelines – UPSC advised officials to follow the guidelines

F No. D-12015/420/2024-Admn-IV
Union Public Service Commission
Administration-IV Section

Dated the 11th August, 2026

OFFICE MEMORANDUM

Subject: Clarification regarding existing CGHS Guidelines.

The undersigned 1S directed to refer to CGHS OM No. Z/15025/19/2024/DIR/CGHS/EHS dated 28.06.2024, SOP dated 02.09.2024 and CGHS OM No. 5-16/CGHS(HQ) /HEC/2024(Part-I) dated 03.10.2025 and to say that certain issues relating to reimbursement of medical claims have frequently been noticed in this office during scrutiny/processing of claims due to lack of clarity in the existing CGHS guidelines/instructions.

2. Accordingly, the issues were taken up with the CGHS (HQ) for necessary clarification and in response, the CGHS (HQ) has conveyed the following guidelines:-

1. Subsequent follow-up consultations/investigations/minor procedures can be done only at the same empanelled hospital where primary consultation was availed.
   1. If any investigation/test amounting up to Rs. 3000/- (each test/investigation) is prescribed by the Specialist of an empanelled hospital/HCO, the investigation/test must be undertaken at the same hospital/HCO, where primary consultation has been taken.
   2. If the beneficiary wants to get the tests/investigations done from any other CGHS empanelled hospital/HCO/Diagnostic Centre, he/she has to take prior referral /endorsement from CGHS Wellness Centre.
   3. 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/-.
2. Each consultation will be considered valid for a period of 7 days, provided it pertains to the same specialty.
3. Eye consultation fees include refraction, tonometry and fundus examination.
4. Prior permission of the Department/Office is mandatory for undergoing an unlisted investigation /procedure advised by specialist of a CGHS empanelled hospital.

3. All the staff/officials are advised to follow the aforesaid guidelines issued by the CGHS (Ministry of Health & Family Welfare) for hassle-free medical reimbursement.

4. This issues with the approval of the Competent Authority.

(Subhasis Roy)
Under Secretary, (Admn.)

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