The National Health Authority (NHA) has launched the National Health Claims Exchange (HCX) as a new initiative under the Ayushman Bharat Digital Mission (ABDM). The HCX is designed to streamline the process of health insurance claim settlement and enable interoperability of health claims. This essay discusses the key details, need for HCX, how it will operate, benefits, and the context of NHA, PM-JAY, and ABDM.

Key Details

The NHA has collaborated with the Insurance Regulatory and Development Authority of India (Irdai) for developing the Health Claims Exchange. Initially, the NHA will use the exchange for processing claims under the Pradhan Mantri Jan Arogya Yojana (PM-JAY).

Thereafter, the exchange will be open for insurance players, hospitals, software vendors, among others. The current health insurance claims settlement process in the country is mostly manual, non-digital, and laborious, posing challenges at every stage. The process of exchanging claims lacks standardization leading to high processing costs for each claim.

Need for HCX

To tackle these key challenges and streamline the process of claim settlement, NHA has developed HCX to enable interoperability of health claims. The HCX serves as a protocol for exchanging claims-related information among various actors, including payers, providers, beneficiaries, regulators, and observers. The HCX is designed to be interoperable, machine-readable, auditable, and verifiable, which helps ensure that the information being exchanged is accurate and trustworthy.

How HCX will Operate

The HCX will act as a gateway (with validation and routing capabilities) for the ecosystem. There are two sides to Health Claims Exchange: one is the provider side, which comprises hospitals that provide services, and the other is the payer side, which comprises insurance companies and state governments that make payments. The HCX envisions to standardize the claims process by creating a transparent and rule-based platform that will enable faster claim processing and a better patient experience.

Benefits

The HCX will transform the way health insurance claims are processed as the digital platform will reduce the cost and waiting time for processing a claim. The HCX envisions to standardize the claims process by creating a transparent and rule-based platform that will enable faster claim processing and a better patient experience.

Context of NHA, PM-JAY, and ABDM
  • NHA is an autonomous entity under the Society Registration Act, 1860, for effective implementation of PM-JAY in alliance with state governments.
  • SHA is the apex body of the State Government responsible for the implementation of AB PM-JAY in the State.
  • PM-JAY aims to secure the lives of 50 crore individuals that comprise 10.74 crore poor families, including both rural and urban areas, with a defined benefit cover of Rs 5 lakh per family.
  • The scheme covers nearly 40% of the population targeted towards the poorest and the vulnerable.
  • ABDM aims to create a seamless online platform through the provision of a wide range of data, information, and infrastructure services.
  • The platform will duly leverage open, interoperable, standards-based digital systems.
  • ABDM will enable access and exchange of longitudinal health records of citizens with their consent.
Why In News

The National Health Authority (NHA) is inviting participation in the ‘National Health Claims Exchange (HCX) Sandbox’ as part of the Ayushman Bharat Digital Mission (ABDM).

MCQs about National Health Claims Exchange in India

  1. What is the National Health Claims Exchange (HCX)?
    A. A new initiative under Ayushman Bharat Digital Mission
    B. A manual claims settlement process
    C. An insurance regulatory authority
    D. A health insurance provider
    Correct Answer: A. A new initiative under Ayushman Bharat Digital Mission
    Explanation: The National Health Claims Exchange (HCX) is a new initiative under the Ayushman Bharat Digital Mission to enable interoperability of health claims.
  2. What is the purpose of the Health Claims Exchange?
    A. To increase the cost of processing each claim
    B. To reduce the waiting time for claim processing
    C. To make the claims process more complex
    D. To limit the number of beneficiaries under Pradhan Mantri Jan Arogya Yojana
    Correct Answer: B. To reduce the waiting time for claim processing
    Explanation: The Health Claims Exchange envisions to standardize the claims process by creating a transparent and rule-based platform that will enable faster claim processing and better patient experience.
  3. Who can participate in the National Health Claims Exchange?
    A. Hospitals
    B. Software vendors
    C. Insurance players
    D. All of the above
    Correct Answer: D. All of the above
    Explanation: The National Health Claims Exchange will be open for insurance players, hospitals, and software vendors, among others.
  4. What is the Ayushman Bharat Digital Mission?
    A. A scheme to secure the lives of 50 crore individuals
    B. A platform to access and exchange longitudinal health records of citizens
    C. A registry of healthcare professionals and facilities
    D. All of the above
    Correct Answer: D. All of the above
    Explanation: The Ayushman Bharat Digital Mission aims to create a seamless online platform through the provision of a wide-range of data, information, and infrastructure services, including a health ID for every citizen, healthcare professionals and facilities registries, and more.

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