Health insurance claims will soon undergo a unified processing system through the National Health Claims Exchange (NHCX), which is currently undergoing trials.
According to a source from the Health Ministry, quoted by The Times of India, “NHCX will establish a standardised format for insurance companies to adhere to when processing claims.”
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Presently, most health insurance providers operate their own platforms and procedures for claim approval.
The National Health Authority (NHA) and the Insurance Regulatory and Development Authority of India (IRDAI) are collaborating to operationalise the National Health Claim Exchange (NHCX), a digital platform for health claims developed by the National Health Authority.
Objectives of NHCX
According to NHA, the objectives of NHCX are to,
– Introduce additional types of claims in insurance policies, such as covering outpatient department (OPD) expenses and pharmacy bills, to broaden the insurance coverage.
– Streamline the receivable cycles and enhance the acceptance of cashless claims, even in smaller healthcare facilities, to expedite claim processing.
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– Enable insurance innovation by implementing new procedures and regulations for automated adjudication, as well as implementing measures to prevent fraud and abuse.
– Standardise the claims processing procedures to minimise operational complexities and foster trust among insurers and healthcare providers through a transparent and rule-based approach.
– Enhance the overall patient experience by improving the efficiency and reliability of the claims process.
How is it going to work?
– Similar to internet and email exchange networks, the NHCX enables the transfer of data packets between different points, ensuring smooth interoperability of health claims processing.
– When patients seek treatment at a hospital, they provide their insurance policy details or a card issued by a third-party administrator (TPA) or insurance company.
– The hospital then accesses the claim processing portal of the respective company and submits the required documents for pre-authorisation or claim approval.
– Upon receiving the pre-authorisation or claim form, the insurance company or TPA authenticates and digitises the form using its internal claims processing portal. The claim is then evaluated by the relevant team.
– Such data exchanges involve PDFs or manual paperwork, leading to longer processing times and increased risk of errors.
