Health Claims Exchange

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Specifications

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Specifications

Background

The current health insurance claims settlement process is manual, non-digital and laborious in nature posing challenges at every stage:

Painstaking tracking of claims and reconciliations

Insurers & TPAs get uncoded data which they have to digitize themselves, relying mostly on manual adjudication and limited fraud analytics

Patient experience for claim processing is cumbersome; minimal communication and limited transparency on the status of their pre-authorization and long wait times

Regulators receive delayed and incomplete data; lack of coding leads to limited analytics

Source:

IRDAI-NHA Joint Working Group

The IRDAI-NHA Joint Working Group recommended creation and adoption of a Health Claims Platform and standardization of e-Claims and other related documents to enable the ecosystem to move to a low cost paperless regime that allows for innovation. To build this, the first step needed was the creation of open claims standards.

Overview

Inspired by the recommendations of the Joint Working Group of NHA and IRDAI (2019), these specifications have been developed over the last 12 months by 50+ volunteers from across the healthcare ecosystem (including Insurers, Hospitals, TPAs, Insurance Technology players and Think tanks), as a part of a transparent, collaborative and open effort anchored by Swasth.

The goal is to create an open, widely agreed Health Claims Exchange Specifications as a public good which can be adopted. Specifications in this context refers to the blueprint of each aspect of the envisioned claims network and are fundamental to the working of the network. They have been carefully designed to be open to support technology and vendor neutrality, evolvable over a period of time thereby helping adapt to changing needs, enable and not restrict innovation or inclusion. These Health Claims Exchange Specifications for Cashless Insurance are now being published for public consultation and we seek your feedback for the same.