The National Health Authority (NHA) and the Insurance Regulatory and Development Authority (IRDAI) in India collaborated to create the National Health Claim Exchange (NHCX), a digital platform for health claims. The Ayushman Bharat Digital Mission (ABDM) aims to enhance healthcare services throughout India. 

Overview of the Current Claim Processing 

Presently, patients who come to a hospital for care are given the insurance company's card or the information of their policy, whichever is issued by the Third Party Administrator (TPA). The State Health Agency (SHA) issues the card if it's part of the Pradhan Mantri Jan Arogya Yojana (PMJAY). The hospital then logs onto each payer's claim processing portal and uploads the necessary files to initiate the pre-authorization or claim approval process. It is just intended for a particular plan or program.  

The State Health Agency, the Insurance Company, or the Third Party Administrator (TPA) will use their internal claims processing system to validate and digitize the pre-authorization/claim form upon receipt. The relevant team will subsequently decide on the claims. While over 90% of claims are auto-adjudicated in many industrialized countries, a sizable component of the adjudication process in India is currently manual.  

Challenges of the Current Process 

There is a lack of consistency in the present claim exchange mechanism throughout the ecosystem. The majority of data communication takes either manually or using PDF means. Furthermore, no recognized health standards exist. The procedures used by TPAs, providers, and insurers differ greatly. 

NHA, in collaboration with industry experts, has developed a standard domain definition and NHCX protocol to tackle these difficulties. The publication has been made available for industry participants, including insurance companies, TPAs, and state health agencies, to provide comments. The goal of this cooperative and open endeavor is to produce a set of open, broadly accepted Health Claims data Exchange Specifications that the general public can use for free. The public can now review the Cashless Claims Specifications, and NHA is willing to have discussions about them.  

Each component of the proposed claims network is outlined in the National Health Claims Exchange Specifications, which also provide for vendor and technology neutrality, flexibility in response to evolving requirements, and the encouragement of creativity and inclusivity.  

Key points about NHCX 

Purpose and Functionality 

NHCX acts as a single point of contact between hospitals, policyholders, and health insurance providers.  

Its principal objective is to replace laborious manual methods with a standardized, digital system, thereby streamlining the health claim filing process.  

The platform serves as a conduit for information relating to claims to be shared between different players in the healthcare and insurance industry.   

Stakeholders Involved 

Health Insurance firms: NHCX offers a standardized platform for effectively processing and resolving claims for health insurance firms.  

Hospitals and Service Providers: To verify claims, hospitals can use NHCX to submit information about their treatments, costs, and other pertinent factors.  

Policyholders: The streamlined procedure made possible by NHCX is advantageous to people wishing to file claims for health insurance.   

Benefits of NHCX 

Faster claim processing: NHCX is a single platform for insurers, hospitals, and other healthcare providers to share claim data securely. This eliminates the need for manual paperwork and facilitates faster claim approvals.  

Improved Interoperability: The platform ensures seamless exchange of standardized health information across different healthcare systems. This reduces the chances of errors and delays due to data incompatibility. Enhanced transparency: NHCX promotes transparency in the claim settlement process. Policyholders can easily track the status of their claims and access relevant information.  

Benefits for all stakeholders: NHCX is expected to benefit all parties involved by streamlining the process. Patients will experience quicker claim settlements, hospitals will receive faster reimbursements, and insurers can improve operational efficiency.  

Current Challenges Addressed 

• Under the current procedure, hospitals receive patients' health plan details and use those details to start the claims process
• Hospitals use the insurer's platform to enter treatment information, such as cost and length of stay
• Based on diagnosis reports, the insurer confirms the claim and grants approval

However, this procedure is cumbersome and time-consuming because it involves managing numerous businesses, patients, and portals.   

NCHX is believed to be accessible across India from the launch date, and sources said it will initially provide a connection between stakeholders of already-linked 50 insurance companies and 250 hospitals, with more hospitals and insurers to join in the future. 

Major players that have already finished integration with NHCX are: 

• Aditya Birla Health Insurance Company Limited
• Star Health and Allied Insurance Co. Ltd
• Bajaj Allianz Life Insurance
• HDFC ERGO General Insurance
• ICICI Lombard General Insurance Company Limited
• New India Assurance
• TATA AIG General Insurance Company Limited
• United India Insurance Co. Ltd.

NHCX is the next major reform in the insurance industry. IRDAI has earlier approved 'Bima Sugam' another revolution in the insurance sector to provide an online marketplace for insurance, to help policyholders compare premiums and features of all categories of insurance products. buy insurance products including life, health, motor and travel insurance.