CGHS clarifies medical test and referral rules for employees

The Central Government Health Scheme (CGHS) has clarified rules on follow-up consultations, diagnostic tests and medical reimbursements for central government employees and pensioners. The clarification follows a request from the Union Public Service Commission (UPSC), which flagged recurring issues in scrutinising medical reimbursement claims. The UPSC issued an office memorandum dated 11 August 2026 setting out the clarifications on existing guidelines.

Under the new rules, tests costing up to Rs 3,000 prescribed by a specialist must generally be done at the same hospital where the primary consultation took place. If the beneficiary wants the investigation done at another CGHS-empanelled facility, prior referral from the CGHS Wellness Centre is required. For investigations costing more than Rs 3,000, such as CT, MRI or PET scans, a CGHS referral is mandatory. The Rs 3,000 figure is not a reimbursement cap but a threshold for where tests can be done and whether referral is needed.

An OPD consultation is valid only for seven days within the same specialty. Eye consultation fees cover refraction, tonometry and fundus examination, so these should not be charged separately. For unlisted investigations or procedures recommended by a specialist, beneficiaries must obtain prior permission from the concerned department before proceeding. The clarifications aim to remove ambiguity in processing medical claims.