Clarification regarding existing CGHS Guidelines

CGHS Guidelines Clarification on Medical Claims, Referrals and Reimbursement

F No. D-13015/439/2024-Admn-IV

Union Public Service Commission

Administration Division

Dated: 11 August, 2026

OFFICE MEMORANDUM

Subject: Clarification regarding existing CGHS Guidelines.

The undersigned is directed to refer to CGHS OM No. Z-15011/1/2024/DR-III dated 26.08.2024, SOP dated 09.09.2024 and CGHS OM No. 5-18/CGHS/NEC/2024/Part-D dated 09.10.2025 and to say that certain issues relating to reimbursement of medical claims have frequently been raised in this office during scrutiny/processing of claims due to lack of clarity in the existing CGHS guidelines/instructions.

Accordingly, for smooth processing of claims in the CGHS RCS, the following clarifications are required:

(a) Subsequent follow-up consultations/investigations/referral procedures can be done only at the same recognised hospital where primary consultation was availed.

i. If any investigation/test exceeding Rs. 3000/- which was recommended by the Specialist of the recognised hospital/CGHS, the beneficiary/patient has to undertake at the same hospital/CGHS, where primary consultation has been made.

ii. If the beneficiary wants to get the investigations done from any other CGHS recognised hospital/Diagnostic Centre, he/she has to make prior referral/endorsement from CGHS Wellness Centre.

iii. Referred/recommended from CGHS shall be required for special investigations like CT Scan, MRI Scan, PET Scan and all major investigations costing over Rs. 3000/-.

(b) Each consultation will be considered valid for a period of 7 days, provided it pertains to the same speciality.

(c) The consultation fee includes registration, consultancy and follow-up consultation.

(d) Prior permission of the Department/CGHS is mandatory for undergoing any advanced investigation/procedure advised by specialists of a CGHS empanelled hospital.

All the clarifications are solicited to follow the revised guidelines issued by the CGHS authority of Health & Family Welfare for hassle-free medical reimbursement.

This issues with the approval of the Competent Authority.