To ensure standardisation and interoperability of health claims, seamless exchange of data, documents and images between payer and provider
India is in the process of setting up a national health claims exchange that will ensure standardisation and interoperability of claims. This means that instead of individual service providers sending claims to insurance companies on their own, every claim will be sent to this exchange, from where it will be processed. This will be one of the digital health public goods initiatives that India will showcase at the World Health Assembly later this month.
National Health Claims Exchange (NHCX) is a recommendation of Joint Working Group of Insurance Regulatory and Development Authority (IRDAI) and National Health Authority (NHA). According to the plan the Ayushman Bharat Health Account (ABHA) Number will be used for the purpose of uniquely identifying citizens. For the beneficiary this will mean reduced wait time, faster preauthorization and discharge approvals from insurance companies, reduced cost of insurance premiums, more types of claims coverage in future including, OPD, Pharmacy Bills etc. For providers that is hospitals, this will mean a single payer network, universal claims format faster payments by payers, improved patient experience, better visibility of claim status and paperless operations.Â
For insurance companies too this will come with benefits such as reduction in overhead operational costs, enabling new processes/rules for auto adjudication, control fraud and abuse prevention, reduction in claims processing cost per each claim, paperless operations and better quality of data for Industry and regulators.
The implementation plan out together by the government also identifies some of the challenges that may emerge. These include lack of authenticated data, manual, non-digital and tedious claims adjudication process, non-standardized processes among Insurers, TPAs, and providers and high cost of processing each claim.