Standard Operating Procedure For HCOs for Handling CGHS Referrals with effect from 2.9.2024

Directorate of CGHS has issued Standard Operating Procedure For HCOs for Handling CGHS Referrals and uploading bills to the TMS portal with effect from 2.9.2024

SOP for Handling CGHS Referrals

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.

Enclosure: Standard Operating Procedure (Sop) For Health Care Organizations

To

1. All Ministries and Departments of the Government of India through the CGHS
   website
2. Addl. Director, CGHS(HQ)/ Addl. DDG(CGHS)/ Addl. Directors, CGHS of Cities / Zone.
3. All CGHS Wellness Centres through concerned AD, CGHS
4. MCTC, CGHS with the directions to upload the document on CGHS Website (www.cghs.gov.in).
5. All HCOs empanelled under CGHS through CGHS website.
6. Director. AIIMS as per list; JIPMER, Puducherry: PGIMER, Chandigarh
7. DDG NIC Health with the request to modify the CGHS application.
8. Sh. Jitendra Singh, CDAC. Noida
9. CEO & MD NHA with the request to kindly inform the Claim Processing Doctors regarding the referral process.
10. LACs/ ZACs through Addl. Directors, CGHS
11. Sanctioning Authorities in CGHS.
12. CMO Hospital Cell, CGHS HQ.
13. All CGHS empanelled private hospitals through Additional Director of concerned city

Copy of Information to:

1. PPS to Secretary (H&FW), MoHFW
2. PPS to Secretary (Personnel), DoPT, MoPPG&P
3. PPS to Secretary (DARPG &DoPPW), MoPPG&P
4. PPS to AS & DG CGHS
5. PPS to JS (MoHFW), CGHS

Standard Operating Procedure For HCOs

STANDARD OPERATING PROCEDURE (SOP) FOR HEALTH CARE ORGANIZATIONS (HCOS)

Emergency cases:

In emergency cases, HCO shall not insist for referral or endorsement from CGHS and shall provide cashless treatment to eligible beneficiaries based on the emergency certificate given by the treating empanelled hospital specialist. The claim shall be uploaded to BCA portal along with emergency certificate issued by the treating specialist. The referral or endorsement is not required for emergency unlisted investigations/treatment also. For emergency unlisted procedure/investigation the hospital shall raise enhancement/approval through NHA portal. There is no need for approval from local CGHS AD Office.

Validity of referral for Specialist consultation:

As per OM Z 15025/19/2024/DIR/CGHS/EHS dated 28th June 2024, the consultation memo is valid for 3 months. The primary consultant refers to the specialty for which the referral is issued by CGHS Medical Officer. Up to two additional specialists from different fields can be consulted if advised by the primary consultant, with a maximum of six consultations allowed, including repeat consultations with the same specialist for acute illnesses. This shall apply only to primary referrals issued by CGHS Medical Officers and shall not be applicable for referral from Government hospital specialists.

The HCO shall retain a scanned, self-attested copy of the referral and return the original to the beneficiary.

The total number of consultations/cross-consultations/reviews, etc., on the basis of the primary referral issued by the CGHS Medical Officer shall be restricted to a maximum of 6 within a period of 3 months.

The quantity option for consultation shall be left at the default value of ‘1’ when issuing a referral, as the number of reviews or follow-ups required cannot be predicted at the time of issuance. This default value of ‘1’ does not mean that it is valid for only one consultation.

Subsequent Follow-Up Consultations/Investigations/Minor Procedures can be done only at the same empanelled hospital where primary consultation is done. This is not valid in another Health Care Organisation.

Each subsequent follow-up visits based on the first referral from the CGHS Medical Officer, which is made on separate days, shall not be clubbed and shall be submitted as a separate claim on the portal.

Special Provisions for Above 70 years Pensioners

No referral is required for beneficiaries aged 70+ to consult any specialist in empanelled hospitals. Any listed investigations and procedures can be performed without further referral. However, approval from CGHS authorities is required for unlisted procedures/investigations.

Planned Unlisted Investigations & Procedures:

Permission for planned unlisted investigations and procedures advised by empanelled hospitals shall be
given as per the delegation of financial rules:

• Additional Director/Director in the case of pensione
• HOD/HOO in the case of serving employees.

Follow-Up Special Cases:

The beneficiaries suffering from below mentioned conditions are permitted to avail consultations and
investigations without any time limit based on the primary referral

Process flow for handling referrals in TMS portal:

1. Referral Letter

• Original Referral: The HCO shall not insist on the original referral; a photocopy of the referral memo
  shall be accepted.
• Self-Attestation: The photocopy shall be self-attested by the beneficiary with the date, since the TMS
  module is yet to implement part utilization and other system changes.

1. Patient Registration

• Register the Patient: Upon arrival, register the patient in the TMS system.

Download / Read SOP for Health care Organisation