A Single Platform for All Your Cashless Health Insurance Claims Soon

Jun 03, 2024 / Reading Time: Approx. 5 mins

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A Single Platform for All Your Cashless Health Insurance Claims Soon

With the IRDA of late taking significant steps in the interest of policyholders, it appears now that this digital platform, which will serve as a single window for all your health insurance claims, will see the light of the day soon in the next 2 to 3 months.

What Is NHCX?

The NHCX is developed by NHA (along with the IRDA) and the Union Ministry of Health and Family Welfare as a part of the Ayushman Bharat Digital Mission to support the vision of Pradhan Mantri Jan Arogya Yojana (PMJAY)

The NHCX digital platform brings together all parties involved in the health insurance claim settlement process at one place, such as the 'payers', which include insurers, Third Party Administrator (TPAs), government-scheme administrators, the 'providers' (hospitals, healthcare facility centres, laboratories, etc.), the other relevant entities, and the beneficiary, i.e. the insured or policyholder for cashless claim settlement.

Stakeholders of NHCX

(Source: www.abdm.gov.in)

This enables automation of the health claim-related information exchange between payers, providers, beneficiaries, and other relevant entities. The specifications provide for an interoperable, machine-readable, auditable, verifiable, and open standard-based structure protocol for communication between entities, ensuring that the information being exchanged is accurate and trustworthy.

The Benefit of NHCX

NHCX will facilitate message exchange for the cashless health claims process and enable standardised and faster claims processing for better patient experience with reduced operations costs, as against the current practice where for health insurance claims, the insured and his relative, the provider, are subject to rigamarole, long wait time, additional paperwork, and costs.

Infographic 1: Current Health Insurance Claim Process

(Source: www.abdm.gov.in)

At the insurer's end, at present, while the data is digitised, the claims are manually authenticated and adjudicated. Thereafter, the decision is conveyed back to the hospital, and the patient is discharged. The challenge under this system is:

- Lack of authenticated data

- Non-standardised processes among Insurers, TPAs, and Providers

- The tedious manual claim adjudication process

- High cost of processing each claim

- And policyholders have to wait for a long time until the health insurance claim is settled

That said, recognising the hardships and inconvenience caused to the policyholder, the insured and his/her relatives in this lengthy process (where despite the doctor's discharge note and discharge formalities completed the hospital or the healthcare centre does not discharge the patient/policyholder until the cashless claim is settled), the IRDA recently has directed that that final authorisation for cashless health insurance claims (when the patient/policyholder is advised discharge) must come from the insurer within three hours of request from the hospital.

[Read: Your Health Insurance Just Got Better: New IRDA Regulations Explained]

For a simplified health claim settlement process, now leveraging on the Ayushman Bharat Digital Mission building blocks, i.e., Ayushman Bharat (ABHA) Number (a 14-digit unique number to identify the citizen health records), the Health Facility Registry (a single source of truth for all health facilities in the country) and Health Professionals Registry (a verifiable database of all healthcare professionals in the country).

Infographic 2: Simplified Health Insurance Claim Process

(Source: www.abdm.gov.in)

All one needs to do is digital KYC with ABHA, the hospital shall submit the claim (in a standardised format across government and private hospitals), and the data will be validated and routed to the respective insurer/TPA by the NHCX to adjudicate claims. The insurer will digitally verify and adjudicate it, and the hospital/healthcare centre will process the discharge. The policyholders and hospitals/healthcare centres can track the claim status online.

Setting up of NHCX is expected to make the process rather seamless and hassle-free for the policyholder, reduce the operational cost related to claim processing, and enable transparent and efficient cashless claims processing.

[Read: Your Ultimate Guide to Cashless Health Insurance]

In short, all stakeholders -- the beneficiary, provider, and payer -- are expected to accrue benefits of NHCX. For the policyholder/insurer, it would reduce the frustratingly long wait for claim settlement, improve the experience, for providers standardise the claim process, reduce paperwork errors, and, in the case of payers, reduce the operational overhead costs, reduce cost per claim, control fraud and abuse (owing to transparency).

Over and above, in this age where data is new oil, the health insurance industry and regulator will have better quality data to offer a better experience to policyholders (including product pricing), thus enhancing their trust and confidence.

Currently, insurance companies are conducting awareness programmes for hospitals and healthcare providers to onboard them on the NHCX platform.

Infographic 3: Provider and Payer Onboarding Process on NHCX

(Source: www.abdm.gov.in)

The more providers and payers on the NHCX platform, the more beneficial it will be for the ultimate beneficiaries, i.e. policyholders.

Keep in mind that having adequate health insurance coverage and an emergency fund helps in effectively dealing with the medical emergency and reduces strain on your personal finances and investments made to achieve the envisioned financial goals.

Make sure you and your family have sufficient health insurance coverage in the interest of your financial well-being. Be thoughtful in your approach.

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ROUNAQ NEROY heads the content activity at PersonalFN and is the Chief Editor of PersonalFN’s newsletter, The Daily Wealth Letter.
As the co-editor of premium services, viz. Investment Ideas Note, the Multi-Asset Corner Report, and the Retire Rich Report; Rounaq brings forth potentially the best investment ideas and opportunities to help investors plan for a happy and blissful financial future.
He has also authored and been the voice of PersonalFN’s e-learning course -- which aims at helping investors become their own financial planners. Besides, he actively contributes to a variety of issues of Money Simplified, PersonalFN’s e-guides in the endeavour and passion to educate investors.
He is a post-graduate in commerce (M. Com), with an MBA in Finance, and a gold medallist in Certificate Programme in Capital Market (from BSE Training Institute in association with JBIMS). Rounaq holds over 18+ years of experience in the financial services industry.

Disclaimer: This article is for information purposes only and is not meant to influence your investment decisions. It should not be treated as a mutual fund recommendation or advice to make an investment decision in the above-mentioned schemes. Use of this information is at the user's own risk. The user must make his own investment decisions based on his specific investment objective and financial position and use such independent advisors as he believes necessary.

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