NHCX: Streamlining Health Insurance Claims

The National Health Authority (NHA) and the Insurance Regulatory and Development Authority (IRDAI) in India collaborated to create the National Health Claim Exchange (NHCX), a digital platform for health claims. The Ayushman Bharat Digital Mission (ABDM) aims to enhance healthcare services throughout India.

Overview of the Current Claim Processing

Presently, patients who come to a hospital for care are given the insurance company's card or the information of their policy, whichever is issued by the Third Party Administrator (TPA). The State Health Agency (SHA) issues the card if it's part of the Pradhan Mantri Jan Arogya Yojana (PMJAY). The hospital then logs onto each payer's claim processing portal and uploads the necessary files to initiate the pre-authorization or claim approval process. It is just intended for a particular plan or program.

The State Health Agency, the Insurance Company, or the Third Party Administrator (TPA) will use their internal claims processing system to validate and digitize the pre-authorization/claim form upon receipt. The relevant team will subsequently decide on the claims. While over 90% of claims are auto-adjudicated in many industrialized countries, a sizable component of the adjudication process in India is currently manual.

Challenges of the Current Process

There is a…