CGHS Standard Operating Procedure (SOP) for Health Care Organizations (HCOs)

F.No.Misc.2011/103/NHA ISSUES/2023(comp.No 8289407)
Office of the Director
Directorate of CGHS
CGHS Bhawan, R K Puram Sector-13
New Delhi -110066

New Delhi,
2/9/2024

OFFICE MEMORANDUM

Regarding the CGHS referral OM Z.15025/19/2024/DIR/CGHS/EHS, Comp No.8281286) dated June 28, 2024, the directorate has received several queries seeking clarification on various clauses of the OM.

In response to inquiries regarding various clauses within the aforementioned OM, a Standard Operating Procedure (SOP) has been developed. This SOP aims to:

• Enhance understanding: Provide a clear explanation of the OM’s contents.
• Standardize bill uploads: Ensure uniformity in uploading medical bills to the TMS portal.

All HCOs are required to adhere to the guidelines outlined in the attached SOP when handling referrals and uploading bills to the TMS portal. The SOP comes into effect from the date of issue of this OM.

Dr.Satheesh Y.H
Director, CGHS.

Summary of the Standard Operating Procedure For HCOs

Emergency Cases:

• No Referral Required: In emergencies, HCOs must provide cashless treatment to eligible beneficiaries based on the emergency certificate from the treating specialist. The claim should be uploaded to the BCA portal with the emergency certificate. No referral or endorsement is needed for unlisted emergency procedures or investigations.
• NHA Portal: For unlisted emergency procedures/investigations, HCOs should seek approval via the NHA portal without requiring local CGHS AD Office approval.

Referral Validity for Specialist Consultation:

• Consultation Memo Validity: As per OM No. Z.15025/19/2024/DIR/CGHS/EHS dated June 28, 2024, consultation memos are valid for 3 months. The primary consultant may refer the patient to a specialty for which the referral is issued by the CGHS Medical Officer. Up to two additional specialists can be consulted if advised, with a maximum of six consultations, including repeat consultations for acute illnesses.
• Document Retention: HCOs should retain a scanned, self-attested copy of the referral and return the original to the beneficiary.
• Consultation Limits: The total consultations/cross-consultations/reviews based on the primary referral are restricted to six within 3 months.
• Follow-Up Consultations: Subsequent consultations, investigations, or minor procedures must be performed at the same empanelled hospital where the primary consultation occurred.

Special Provisions for Pensioners Aged 70+

• No Referral Required: Beneficiaries aged 70+ can consult any specialist in empanelled hospitals without a referral. Listed investigations and procedures can be conducted without additional referral. However, unlisted procedures/investigations require approval from CGHS authorities.

Planned Unlisted Investigations & Procedures:

• Permission Guidelines: For planned unlisted investigations and procedures, permission should be obtained per the delegation of financial rules:
  • Pensioners: Approval by Additional Director/Director
  • Serving Employees: Approval by HOD/HOO

Follow-Up for Special Cases:

• No Time Limit: Beneficiaries with certain conditions can avail consultations and investigations without time limits based on the primary referral.

Process Flow for Handling Referrals in TMS Portal:

• Referral Letter Handling:
  • Photocopy Acceptance: HCOs must accept self-attested photocopies of referral memos.
  • Patient Registration: Upon arrival, register the patient in the TMS system.

Click here for the OM and SOP