CGHS Rules: If you are a central government employee and a beneficiary of the Central Government Health Scheme (CGHS), here’s an update for you. It’s crucial for CGHS beneficiaries to understand the Rs 3,000 requirement. If you’re a central government employee, pensioner, or CGHS beneficiary, don’t make the mistake of getting a test done directly at a hospital after receiving a doctor’s prescription. Getting a test done at the wrong place or failing to obtain a necessary referral could result in your medical reimbursement claim being delayed.
The Rs 3,000 limit isn’t the maximum limit for reimbursement, but rather plays a crucial role in determining where a test can be performed and whether a CGHS referral or prior permission will be required. The CGHS has now clarified several rules regarding follow-up consultations, medical tests, and referral treatment.
What are the guidelines for tests valued at Rs 3,000 or less?
If a doctor at a CGHS-approved hospital prescribes a test under Rs 3,000, it is generally required to be carried out at the same facility where the consultation took place. If you prefer to have the test done at a different CGHS-approved hospital or diagnostic center, you must obtain a referral or permission from the CGHS Wellness Center beforehand. Why is caution advised for tests surpassing Rs 3,000? For tests exceeding Rs 3,000, a CGHS referral may be mandatory. This applies to major tests like CT scans, MRIs, and PET scans. Simply assuming that a test prescribed at a CGHS hospital can be done elsewhere is not accurate.
It is crucial to consider the test location and referral guidelines. Validity of consultation for 7 days post-visit As per CGHS, a specialist consultation acquired in an OPD remains valid for seven days within the same specialty. During this period, necessary follow-ups, tests, or relevant procedures can be conducted, adhering to CGHS regulations. Eye examination regulations Tests like refraction, tonometry, and fungal examination are covered in the consultation fee for an eye specialist and should not be billed separately.
Obtain advance authorization for undisclosed tests If a test or procedure recommended by your doctor is not listed in CGHS’s predefined services, you must seek approval from the appropriate department or office before undergoing the test. Otherwise, your test expenses might not be reimbursed.