15th October 2025, Kathmandu
The Health Insurance Board (HIB) has rolled out a pivotal set of nine decisions focused on streamlining processes and significantly improving service delivery for its insured members.
E-Referral Simplification Health Insurance
This move, centered on E-Referral Simplification, directly addresses numerous complaints regarding tedious and unnecessary procedural hurdles in accessing follow-up care.
The directive aims to simplify Patient Referrals for beneficiaries, especially those battling severe and chronic health issues, marking a critical advancement in the national Health Insurance program.
Announced via an Executive Director-level decision on October 13, this initiative seeks to make the entire treatment process smoother and more efficient.
The HIB has already circularized all affiliated health service providers, mandating the immediate implementation of these new, simplified rules. This decisive action will reduce administrative friction and enhance the quality of Digital Health services.
Cutting Red Tape for Severe and Chronic Diseases
The most significant change is the elimination of repeat referrals for patients with serious ailments.
For severe diseases—such as cancer, heart disease, kidney disease, head injury, spinal injury, sickle cell anemia, Parkinsonism, and Alzheimer’s—patients will only require a single referral from the initial First Service Point.
Subsequent follow-up treatments at the same hospital for the same condition will no longer demand a fresh referral slip. This relaxation also applies to other complex and chronic issues.
Patients dealing with complex eye health problems, asthma, or severe mental illness now benefit from this same “one-time referral” policy for follow-up care at the same facility. The move recognizes the continuous nature of care required for these long-term conditions.
Prioritizing Vulnerable and Elderly Groups
The HIB has specifically tailored the new rules to protect and prioritize vulnerable populations.
Groups including families holding Ultra-Poor identity cards, the severely disabled, leprosy patients, HIV-infected persons, complex tuberculosis patients, senior citizens aged 70 years or above, and Female Community Health Volunteers are now exempt from repeat Patient Referrals for follow-ups at the same hospital after their initial referral.
This decision is a testament to the Health Insurance program’s social safety net goal. It removes a significant bureaucratic barrier that disproportionately affected those with limited mobility or resources, making quality Health Insurance access truly equitable.
Enhancing Internal Hospital Efficiency
The Board also introduced protocols to improve the internal flow of patients within hospitals.
If a patient is referred for one condition but immediately requires a diagnosis from another department within the same hospital, a seamless internal referral must occur.
This ensures faster diagnosis and treatment without forcing the patient to return to the First Service Point for a new referral.
Furthermore, any follow-up required in a department subsequent to an internal referral is also exempt from needing a new referral document.
This streamlines care pathways and supports a more integrated approach to patient management, utilizing Digital Health tools to facilitate communication between departments.
Supporting Continuity of Care
Several decisions directly focus on maintaining care continuity. A referral issued for a specific disease will remain valid for all subsequent check-ups related to that same condition, eliminating repetitive administrative work.
Similarly, patients who receive emergency services will only need one referral for their initial follow-up appointment related to the emergency.
Should a referral center lack the necessary services, the hospital must now ensure service availability at the nearest alternative hospital before effecting the final Patient Referrals.
The entire set of nine decisions represents a major overhaul, substituting bureaucratic hurdles with common-sense, patient-centric procedures based on the principle of E-Referral Simplification.
These measures significantly contribute to realizing the full potential of the national Health Insurance program.