CGHS Updates Rules for Beneficiaries: Key Clarifications on Treatments, Tests, and Referrals

The Central Government Health Scheme (CGHS) has updated its regulations regarding beneficiary consultations and medical investigations. All follow-up treatments and tests costing up to Rs 3,000 should be done at the same facility. For investigations over Rs 3,000, prior referral from CGHS is necessary. Consultations are valid for a seven-day period within the same specialty. Additionally, eye consultation fees now encompass three specific examination procedures.

The Union Public Service Commission (UPSC) recently asked for clarifications from the CGHS regarding its rules for the beneficiary employees. The CGHS has responded with clarifications on various topics, including consultations, tests, investigations, special investigations, diagnosis, eye consultation fee, and the need for prior permissions from the department. In an office memorandum (OM) dated August 11, 2026, the UPSC said that it had sought clarification from the CGHS after noticing recurring issues with reimbursement of medical claims during their review process. The UPSC says that such issues were noticed due to the lack of clarity in the existing CGHS instructions.

1. Follow-up treatment should be in the same hospital: The CGHS says that if a CGHS beneficiary goes to an empanelled hospital for primary consultation, their subsequent follow-up consultations, investigations or minor procedures should also be done at the same hospital.

2. Instructions for tests costing up to Rs 3,000: An important instruction is that if any investigation amounting to up to Rs 3,000 is prescribed by a specialist doctor of an empanelled hospital, it should be undertaken at the same hospital where the beneficiary had gone for the primary consultation.

3. Instructions for tests done at other CGHS hospitals: A prior referral from the CGHS Wellness Centre is required if investigations are done at another CGHS-empanelled hospital or diagnostic centre.

4. Rules for investigations above Rs 3,000: For investigations costing more than Rs 3,000 (e.g., CT, MRI, PET), a referral from the CGHS is required.

5. Consultation valid only for 7 days: Consultations are valid for a period of 7 days, provided they pertain to the same specialty.

6. Eye consultation fee includes three examinations: The eye consultation fee now includes Refraction, Tonometry, and Fundus examination.

7. Prior permission required for unlisted investigation: Prior permission from the concerned department is needed for any unlisted investigation or procedure.