Procedures for deriving Specialist Services Referrals
Under CGHS Act, the beneficiary, whenever requiring or needing consultation services with a specialist medical/healthcare professional for expert opinion, will be referred to CGHS Polyclinics or hospitals based on the consultant’s availability for that particular speciality for eg. Pediatrician, Gynaecologist, Dermatologist, Cardiologist, Neurologist etc Due to certain reason if a consultant for the concerned speciality is not available in CGHS, the beneficiary of CGHS will be referred to the concerned OPD (Out-Patient Department) of a Government Hospital or Municipal General Hospital.
Government employees drawing a Basic Pay exceeding Rs. 12,000/- per month, can benefit from direct consultation with CGHS Medical Specialists and Consultants in Government or Municipal Hospital, but are not eligible for consultations in private recognized hospitals under CGHS Act. Procedure for Admission in Recognized Hospitals
The procedures for admission in hospitals recognized under CGHS are enlisted below:
1. Permission letter will be invariably issued prior to the admission of the patient in the hospital.
2. Pre-requisite permission will be strictly given for a surgical procedure and not for general medical management or general consultations.
3. Beneficiary will be required to furnish the following documents for getting an admission memo:
a. Photocopy of valid CGHS card
b. Request letter from CGHS beneficiary regarding the choice of hospital/diagnostic centre.
c. Photocopy of the specialist’s professional advice or opinion in the concerned field from a Govt./Municipal/CGHS hospital or clinic.
4. In case of medical emergency, the private hospital recognized under CGHS, shall not deny or refuse admission or demand advance deposit from the concerned beneficiary. However, the private hospital recognized under CGHS, shall provide credit facilities to the concerned patient on production of a valid CGHS card. The private hospital recognized under CGHS, shall submit the medical bills for reimbursement based on CGHS approval rates to the concerned HOD (Head of Department) of the beneficiary (i.e. serving government employee) or to the Joint Director, CGHS, in case pensioners entitled for benefits under this scheme. It shall be the responsibility of the beneficiary to submit a xerox copy of CGHS card and to take admission in entitled class as per the provisions of the Act. It is the sole responsibility of the hospitals to intimate CGHS office or its concerned branch-office, within 24 hours in case of emergency admission of the beneficiaries who are entitled under CGHS.
5. Based on the merits of the case study on an individual basis, the CMO (Chief Medical Officer) In-charge of the concerned dispensary, to which the CGHS beneficiary is attached, will issue Permission Letter regarding admission to recognized hospital. This decision can be on the basis of the CMO’s own judgment or it could be based upon the recommendations made by the medical specialists from CGHS or Government Hospitals or Municipal Hospitals.