CGHS medical reimbursement rules clarified: Know ₹3,000 test limit, referral rules for employees and pensioners

The Central Government Health Scheme (CGHS) has clarified how beneficiaries should undertake follow-up consultations, diagnostic tests and investigations at empanelled hospitals, including when a referral is required for reimbursement.

According to an ET report, the clarification follows a request from the Union Public Service Commission (UPSC), which had flagged recurring issues while scrutinising medical reimbursement claims. The UPSC issued an office memorandum dated 11 August 2026 setting out the clarifications on existing CGHS guidelines.

The clarification is relevant to central government employees, pensioners and other eligible CGHS beneficiaries.

Tests up to ₹3,000 should generally be done at the same hospital

If a CGHS beneficiary receives a primary consultation at an empanelled hospital and the specialist prescribes a follow-up investigation costing up to ₹3,000, the test should be undertaken at the same hospital or healthcare organisation where the consultation took place.

If the beneficiary wants to get the investigation done at another CGHS-empanelled hospital, healthcare organisation or diagnostic centre, prior referral or endorsement from the CGHS Wellness Centre is required.

For investigations costing more than ₹3,000, a CGHS referral is required. This includes major diagnostic investigations such as CT scans, MRI scans and PET scans.

The ₹3,000 figure is therefore not a cap on medical reimbursement. It is a threshold relevant to where the investigation can be undertaken and whether prior referral is required.

The clarification also says that follow-up consultations, investigations and minor procedures should generally be undertaken at the same empanelled hospital where the primary consultation was obtained.

Consultation remains valid for seven days

An OPD consultation is valid for seven days within the same speciality. This means a beneficiary who consults a specialist can use that consultation for relevant follow-up within the seven-day period, subject to the applicable CGHS conditions.

The current CGHS memorandum of agreement with empanelled hospitals also specifies that an OPD consultation is valid for seven days within the same specialty.

The CGHS clarification also addresses eye consultations. The consultation fee covers procedures including refraction, tonometry and fundus examination, meaning these should not be charged separately. The current CGHS empanelment terms similarly include these examinations within the eye consultation fee.

Prior permission needed for unlisted investigations

The clarification also covers investigations or procedures that are not part of the listed CGHS services.

If a specialist at a CGHS-empanelled facility recommends an unlisted investigation or procedure, the beneficiary must obtain prior permission from the concerned department or office before proceeding

For beneficiaries, the key takeaway is that the ₹3,000 threshold should not be interpreted as a reimbursement ceiling. Instead, beneficiaries need to pay attention to where a test is prescribed, where it is conducted and whether CGHS referral or prior permission is required before undergoing the procedure. These requirements can affect whether a subsequent medical claim is admissible.

The clarification is intended to remove ambiguity in the processing of CGHS medical reimbursement claims and provide greater clarity to beneficiaries and government offices handling such claims.