To read further about the
Specifications
To provide your feedback on the
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
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.

Health Claims Exchange Specifications For Cashless Insurance

Benefits of Health Claims Exchange Specifications

Improved patients’ claim
related experience
Faster claims
processing
Better visibility and
tracking of claims
Newer innovative
insurance products
Reduction in claims
processing cost
Better quality data for the
industry and regulators

Health Claims Exchange Specifications
For Cashless Insurance

Benefits of Health Claims Exchange Specifications

Improved patients’ claim related experience
Better visibility and tracking of claims
Reduction in claims processing cost
Faster claims processing
Newer innovative insurance products
Better quality data for the industry and regulators

Partner Organizations

Hospitals
Insurers
HMIS/Claims Platforms/InsureTech
TPAs
Think Tanks
Associations
Community Health

Public Consultation of Health Claims Exchange Specifications for Cashless Health Insurance

Purpose of the consultation:
The key objective of the consultation is to elicit feedback from the industry and the public on the Health Claims Exchange Specifications for Cashless Insurance to ensure that these specifications can eventually be accepted and adopted.
Process to be followed post consultation deadline:
All the consultation inputs will be available publicly. All the inputs received will be reviewed by the Health Claims Exchange Specifications Governance Committee at Swasth and adopted as appropriate. A post consultation report will be published by Swasth based on feedback received.

For more information, reach us on

Public Consultation of Health Claims Exchange
Specifications for Cashless Health Insurance

Purpose of the consultation:
The key objective of the consultation is to elicit feedback from the industry and the public on the Health Claims Exchange Specifications for Cashless Insurance to ensure that these specifications can eventually be accepted and adopted.
Consultation timeline:

Please submit your inputs by October 08, 2021.

Process to be followed post consultation deadline:
All the consultation inputs will be available publicly. All the inputs received will be reviewed by the Health Claims Exchange Specifications Governance Committee at Swasth and adopted as appropriate. A post consultation report will be published by Swasth based on feedback received.

Contacts us for any Query

Health Claims Exchange Specifications Volunteers

Ranjan Pai (Manipal)

Bharathi G (FHPL)

Santosh Viswanathan (ICICI Lombard)

Siddharth Shetty (iSPIRT)

Yashish Dahiya (Policybazaar)