In an office memorandum, UPSC referred to clarifications received from CGHS headquarters on issues that had frequently come up while processing medical reimbursement claims.
The clarification does not introduce a new CGHS reimbursement scheme. Instead, it sets out how existing guidelines should be followed in certain situations.
Tests costing up to ₹3,000
If a specialist at a CGHS-empanelled hospital or healthcare organisation prescribes a test or investigation costing up to ₹3,000 per test, the beneficiary must get it done at the same hospital where the primary consultation took place.
If the beneficiary wants to undergo the test at another CGHS-empanelled hospital, healthcare organisation or diagnostic centre, they must first obtain a referral or endorsement from a CGHS Wellness Centre.
Referral needed for expensive investigations
A referral or endorsement from CGHS will also be required for certain specialised investigations, including CT scans, MRI scans and PET scans, as well as any other investigation costing more than ₹3,000.
This means beneficiaries should not assume that a prescription from a specialist automatically allows them to get an expensive diagnostic test done at another empanelled facility and claim reimbursement later.
Consultation valid for seven days
The clarification also states that each consultation will be considered valid for seven days, provided the subsequent consultation relates to the same medical specialty.
For example, a follow-up consultation with the same specialty within this seven-day period would fall under the validity period specified in the clarification.
Eye consultation covers three services
For eye-related consultations, the consultation fee will include refraction, tonometry and fundus examination, according to the clarification.
Unlisted procedures need prior permission
Another important point concerns unlisted investigations or procedures.
If a specialist at a CGHS-empanelled hospital recommends an investigation or procedure that is not listed under CGHS, the beneficiary must obtain prior permission from the concerned department or office before undergoing it.
What beneficiaries should do
The clarification is particularly relevant when a beneficiary is planning diagnostic tests after consulting a specialist at an empanelled hospital.
Before getting a test done elsewhere, beneficiaries should check whether a CGHS referral or endorsement is required. For an unlisted investigation or procedure, they should obtain the required departmental permission beforehand.
The UPSC memorandum, issued with the approval of the competent authority, advised its staff and officials to follow these CGHS guidelines to avoid problems while processing medical reimbursement claims.
The clarification refers to earlier CGHS communications dated June 28, 2024, September 2, 2024 and October 3, 2025. It is therefore best understood as a clarification of the existing reimbursement process rather than a blanket change in CGHS medical benefits.
