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File No.
No. S-12020/4/97-CGHS(P)
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Issued From · Date
Nirman Bhavan, New Delhi · 7th April, 1999
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| Government of India · Ministry of Health & Family Welfare · Department of Health | |
SUPERSEDEDThis OM has been superseded by OM No. Z.15025/79/2/DIR/CGHS dated 5th October 2016, which in turn has been partially modified for Para (v) by OM No. Z.15025/14/2023/DIR/CGHS dated 27th December 2023.
HISTORICAL
This is a historical reference document. It has been superseded — refer to the 2016 and 2023 OMs for current operative delegation powers.
Office Memorandum
Subject
Delegation of Powers under CGHS relating to referral system, permission cases and ex-post-facto approval — Regarding.
✦ ✦ ✦ ✦
The undersigned is directed to say that the matter regarding delegation of powers under CGHS has been under consideration of the Government for some time past so as to reduce the delay in obtaining facilities under CGHS including ex-post-facto approval of medical claims preferred by CGHS beneficiaries and it has now been decided to delegate the powers for referral system, permission cases, and ex-post-facto approval as indicated below:
Part A — Referral System
| Sl. | Case / Situation | Delegated Power / Provision |
|---|---|---|
| 1. | Procedures / investigations for which there is no prescribed CGHS rate for CGHS recognised private hospitals / diagnostic centres. | Permission for tests / procedures (estimates not more than Rs. 20,000/-) may be granted by HOD (serving employees) and by Head of CGHS covered cities (pensioners), provided tests / procedures are recommended by Govt. Specialist. Reimbursement limited to AIIMS rate (Delhi & outside Delhi). If AIIMS rate not fixed, reimbursement at actuals. |
| 2. | In case of medical emergency, beneficiary may go directly to private recognised / Government referral hospital and submit an MRC after discharge. | Powers delegated to Heads of CGHS Organisations in various CGHS covered cities for both pensioners and serving employees to decide which cases fall under the "emergency" category. |
| 3. | In pregnancy cases — permission for tests / procedures, estimates of which are not more than Rs. 20,000/-. | Once pregnancy is diagnosed / confirmed by Government / CGHS doctors (including MO at dispensary level), the HOD of concerned Department / Ministry may permit admission for confinement purpose in private hospitals recognised under CGHS. |
| 4. | Beneficiary, despite facility being available in the city, chooses to get treatment in a CGHS recognised hospital in another city. | Powers for grant of such permission delegated to Heads of CGHS organisations in various CGHS covered cities, both for pensioners and serving employees, but without grant of TA/DA. |
| 5. | Pensioners: permission for treatment in another city for procedures / tests advised by Govt. / CGHS specialists and not available in the same city. | Permission may be granted to pensioner beneficiaries by Head of CGHS Organisation in the various CGHS covered cities on basis of specific advice from treating Govt. specialist. TA limited to nearest city by shortest route. In case of deviation, prior permission of Director, CGHS may be obtained. |
| 6. | In case of emergency in respect of pensioners / serving employees. | Since prior permission may not always be possible in emergency, treatment taken by CGHS beneficiaries in emergency will be considered on merits even if from a non-recognised private hospital. Power for granting ex-post-facto approval in emergency is delegated to the Head of the concerned CGHS covered city. |
| 7. | Treatment in private recognised hospital. | Referral may be made on recommendation of the treatment procedure by the Govt. specialist for indoor treatment in private hospitals recognised under CGHS. Permission for both pensioners and serving employees for a period of six months for follow-up treatment may be given by the Head of CGHS covered city from the date of discharge. |
Part B — Permission Cases
| Sl. | Case / Situation | Delegated Power / Provision |
|---|---|---|
| 1. | Cases where permission is to be given for items with ceiling rates (e.g. pacemakers, Rotablatar, total joint replacement, etc.). | When treatment is taken with prior permission and ceiling rates have been fixed for implant purchase, the procedure of calling 3 quotations is not required. The Head of CGHS organisation of the concerned city may grant permission directly. |
| 2. | Permission for items for which Standing Committees exist and the Standing Committee has recommended the case. | Permission may be given by the Ministry of Health and Family Welfare for items notified by CGHS. |
| 3. | Supply of Oxygen cylinder, Leucocyte filter, Infusion pump, etc. | Permission may be given by the Ministry of Health and Family Welfare on the recommendations of the Standing Committee for items notified by CGHS. |
| 4. | Air travel. | Permission may be given by the Ministry of Health and Family Welfare on the basis of the recommendation of Director, CGHS. |
| 5. | Permission for highly expensive procedures like BMT, Cardiac Defibrillator, Carotid Stents, etc. as per Govt. ceiling rates or where there is no policy decision. | M/o HFW notifies equipment / instruments / implants for domiciliary use with specific ceiling rates. Permission for any instrument / equipment / implant outside the notified list will be dealt by the M/o HFW on a case-to-case basis, in consultation with DGHS / Finance Division. |
Part C — Ex-post-Facto Approval
| Sl. | Case / Situation | Delegated Power / Provision |
|---|---|---|
| 1. | Treatment without recommendation of CGHS / Govt. specialist, but with permission of CMO in-charge of CGHS dispensary in a recognised private hospital within approved ceiling rates. | Powers delegated to Heads of CGHS organisations in CGHS covered cities for both pensioners and serving employees. |
| 2. | Treatment in private hospitals recognised under CGHS without prior permission. | Powers delegated to Heads of CGHS organisations in CGHS covered cities for both pensioners and serving employees. |
| 3. | Emergency cases within approved ceiling rates — treatment in private recognised hospitals under CGHS. | Powers delegated to Heads of CGHS organisations in CGHS covered cities for both pensioners and serving employees. |
| 4. | Emergency cases within ceiling rates — treatment taken in private unrecognised hospital. | Powers delegated to Heads of CGHS organisations in CGHS covered cities for both pensioners and serving employees. |
| 5. | Cases where prior permission for CGHS recognised Govt. referral hospital was granted for a procedure, but at time of actual operation an additional device / artificial appliance / procedure was used for which no prior permission was taken. | Powers delegated to Heads of CGHS organisations in CGHS covered cities for both pensioners and serving employees. |
| 6. | Ex-post-facto permission for treatment in Govt. referral hospitals like AIIMS, PGI Chandigarh, etc. | For serving employees: HOD of the concerned Ministry / Department / Office may decide. For pensioners: Head of the CGHS organisation of the concerned CGHS covered city may decide. |
| 7. | Treatment under emergency in private recognised hospitals under CGHS — approval to be given as per approved rates for approved procedures / appliances / devices. | Powers delegated to Heads of CGHS organisations in CGHS covered cities for both pensioners and serving employees. |
| 8. | Treatment taken under emergency but approval to be given above the approved rates. | Ministry of Health and Family Welfare may decide in special circumstances depending on the merits of each case. |
| 9. | Relaxation of CGHS Rules. | Ministry of Health and Family Welfare will decide. |
| 10. | Air travel permission / ex-post-facto approval for air travel undertaken for medical treatment. | Ministry of Health and Family Welfare will decide. |
| 11. | Reimbursement of treatment / test for which there is no prescribed rate under CGHS. | Powers delegated to Heads of CGHS organisations. Reimbursement as per AIIMS rate / actual, whichever is less, or per actual if no AIIMS rate — both for CGHS Delhi and CGHS outside Delhi. |
Part D — Monetary Limit for Settlement / Sanction (Item 12)
Subject to the approval of Head of CGHS organisation / Ministry of Health and Family Welfare (where prescribed), the monetary limit for issuing sanction for settlement of individual Medical Reimbursement Claims / to accord permission / grant of medical advance is as under:
| Sl. | Authority | Monetary Limit |
|---|---|---|
| a) | HOD — in case of serving employee beneficiaries | Rs. 2,00,000/- |
| b) | Head of the concerned CGHS covered city — in case of pensioner CGHS beneficiaries | Rs. 2,00,000/- |
| c) | Director, CGHS | Rs. 2,00,000/- to Rs. 5,00,000/- |
| d) | Ministry of Health and Family Welfare | Above Rs. 5,00,000/- |
General Conditions
| These orders will come into effect from the date of issue. |
| The above orders are issued with the approval of Secretary (Health) and concurrence of JS&FA vide Dy. No. 1766/99-JS&FA dated 23.3.99. |
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(Braham Dev)
Under Secretary to the Government of India
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REF
OMs Referenced in this Order — Direct Links
OMs
Later OMs that Supersede or Modify this Order
SUPERSEDEDThis OM has been fully superseded by the 2016 OM listed below. The 2016 OM was in turn partially modified for unlisted procedures (Para v) by the 2023 OM.
| Date | Subject & File No. | Link |
|---|---|---|
| 05.10.2016 |
No. Z.15025/79/2/DIR/CGHS SUPERSEDES THIS OM Revised delegation for pensioner CGHS beneficiaries — Paras (i)–(iv) fully operative; Para (v) partially modified in 2023. |
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| 27.12.2023 |
No. Z.15025/14/2023/DIR/CGHS LATER OM Partially modifies Para (v) of the 2016 OM — Director CGHS raised to Rs. 3L, AS&DG raised to Rs. 5L for unlisted procedures / implants. |
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| 28.06.2024 |
No. Z15025/19/2024/DIR/CGHS/EHS LATER OM Revised Referral Guidelines — builds on 2016 & 2023 OMs for delegated powers on unlisted procedures (Section B.iv). |
SUMMARY
Quick Reference
No. S-12020/4/97-CGHS(P) · 07.04.1999 · Superseded by OM dated 05.10.2016
| ► | Part A — Referral System (7 cases): Delegation to Heads of CGHS organisations for emergency, non-emergency, pregnancy, inter-city and follow-up referrals. Rs. 20,000/- ceiling for non-rated procedures. |
| ► | Part B — Permission Cases (5 cases): Items with ceiling rates — Heads of CGHS cities. Standing Committee items, Air travel, Highly expensive procedures (BMT, Cardiac Defibrillator, Carotid stents) — Ministry of HFW. |
| ► | Part C — Ex-post-Facto Approval (11 cases): Most cases — Heads of CGHS organisations. Cases above approved rates & relaxation of rules — Ministry of HFW. |
| ► | Part D — Monetary Limits (Item 12): HOD (serving employees) Rs. 2L | Head of CGHS covered city (pensioners) Rs. 2L | Director CGHS Rs. 2–5L | Ministry of HFW above Rs. 5L |
| ► | Current operative order: This OM is superseded — refer to OM dated 05.10.2016 and OM dated 27.12.2023 for current delegated powers. |
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