Getting health insurance is often easy but to get the claim settled requires a lot of paperwork and time, thereby making it a complicated and hectic process for all the stakeholders – the insurance company, hospitals, labs and patients. To solve this problem and make mediclaim more easy and effective, the Union Health Ministry is making strides with a National Health Claim Exchange (NHCX).
The ministry is setting up NHCX to simplify the health claim filing process. It will act as a single platform for health insurance companies, who pay and the service provider hospitals. Simply put, the platform will act as a single window to settle the health insurance claims.
NHCX - Develped by NHA and IRDAI
NHCX is jointly developed by National Health Authority (NHA) and Insurance Regulatory and Development Authority (IRDAI), a body that regulates the entire spectrum of insurances in India.
Notably, the NHA is responsible for implementing the Ayushman Bharat PM Jan Aarogya Yojana, a widely popular central government health insurance scheme under which an insurance cover of Rs. 5 lakh is provided to a family each year.
"This platform is developed by the National Health Authority (NHA) to ensure faster processing of insurance claims and interoperability," said official sources on Wednesday.
"The National Health Claim Exchange portal is almost ready and likely to be launched in the next two to three months. This portal has been developed as part of Ayushman Bharat Digital Mission (ABDM)," said official sources.
Also, about 40 to 50 insurance companies along with 200 to 250 hospitals will integrate in NHCX.
Limitations in current process of claim settlements
Currently, the patients visiting the hospitals provide their health plan’s details to the hospital, which in turn starts a process for claims. The hospitals then access the insurer’s platform and file the details of the treatment, including expenses, duration of treatments among others.
After getting the details, the insurer verifies the claim by going through diagnosis reports and approves the claim. More often than not, the process goes through online portals, but considering the number of companies and patients and subsequent combinations makes it a very bulky task which goes by processing multiple pdfs, documents and accessing multiple portals.
No need to say the time spent in all this directly affects the time period of administration of treatment to the patients. Sometimes the treatment is delayed for long hours. In fact, many patients complain of denial of claims allegedly on unjust grounds. Hence, a portal like NHCX is crucial for binding the vast digital infrastructure of the health insurance sector.
Single gateway for all settlement
So, NHCX aims to standardise and increase interoperability of health claims with seamless exchange of data, documents and images between a payer (insurance company/TPA/Govt scheme administrator) and Provider (hospital/lab/polyclinic).
It also focuses on the data exchange with FHIR-compliant, e-claims format through a single gateway using standard protocols (APIs), enabling transparent and efficient claims processing, and reducing operational costs related to claims processing.
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