Central Government Health Scheme (CGHS) - Referral Procedure

Procedure for Reference

Govt. CMO (Chief Medical Officer) In-charge of the dispensary gives professional and personal advice to the patients regarding specific treatment or surgical procedure or pathological tests required by him or her based on individual case-study. The requisite permission is granted by the CMO (Chief Medical Officer) In-charge to the government employees to undergo such tests at one of the recognized Hospitals or Diagnostic centre under the purview of Central Government Health Scheme. In case of retired government employees viz. pensioner CGHS beneficiaries, ex-Members of Parliament, Freedom Fighters, ex-Governors, retired Supreme Court and High Court judges etc. the permission to avail medical benefits provided under this CGHS is granted by Chief Medical Officer In-charge of that concerned dispensary. In case of Honorable Members of Parliament, the requisite permission is granted by and by Rajya Sabha Secretariat. In case of Serving Govt. employees, the requisite permission to avail medical facilities is given by HOD (Head of the Department), as the case may be. In case of serving employees and pensioners of Autonomous bodies covered under CGHS, the requisite permission for availing healthcare benefits under CGHS scheme is acceded by the respective HOD (Head of the Department) of such Autonomous institutions.

If the beneficiary under this scheme seeks permission to avail healthcare products or services from a CGHS recognized hospital in another CGHS city, other than the city from where his/her name is registered, the prerequisite permission regarding the same shall be granted by Addl. Director or Joint Director CGHS of the concerned city. However, in such cases no TA (Traveling Allowance)/DA (Daily Allowance) shall be permitted. Similarly no TA/DA allowances shall be granted, if the treatment facilities required by a particular individual are available within the same city of his/her residence. TA (Travel Allowance) is permitted as per entitlement, if no treatment facilities are available in the city of residence of that particular Government Employee. In case of pensioners, medical reimbursement shall be considered by HOD (Head of Department) or Joint Director or Additional Director of CGHS.

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Availing the facilities of OPD (Out-Patient Department) treatment in private hospitals is not permitted under CGHS Act. Exception is granted only in case of satellite cities of Delhi viz. Noida, Gurgaon, Faridabad and Ghaziabad. However, the CMO (Chief Medical Officer) In-charge can directly refer the beneficiaries of this healthcare scheme to recognized hospitals included under the ambit of this Act, incorporating post-operative follow-up cases pertaining to Cardiac ailments, Cancer treatment, Kidney transplantation, Hip/Knee Joint Replacement, Neurosurgery and RTA (Road Traffic Accident) related cases.

All OPD medicines should be collected through the concerned dispensary except in instances of medical emergencies. In post-operative cases for the conditions as stated above, permissible under the regulations of CGHS Act, the beneficiaries may purchase their medicines from the chemist/pharmacist and thereafter claim for the reimbursement of reasonably incurred medical expenses. However, Utilization Certificate from the treating physician or medical consultant is required to be submitted for claiming reimbursement.