NATIONAL

HEALTH CLAIMS
EXCHANGE
A Digital Public Good Created by National Health Authority, Ministry of Health and Family Welfare,
Government of India to enable standardized and faster claims processing for better patient
experience with reduced operations costs

About NHCX under ABDM

National Health Claims Exchange (NHCX) is a recommendation of Joint Working Group of
Insurance Regulatory and Development Authority (IRDAI) and National Health Authority (NHA).
NHCX aims at:
1. Standardization & Interoperability of Health Claims
2. Seamless exchange of data, documents and images between payer (insurance
company/TPA/Govt scheme administrator) & Provider (hospital/lab/poly clinic)
3. Data exchange with FHIR compliant e-claims format through a single gateway using standard
protocols (APIs)
4. Enable transparent and efficient claims processing
5. Reduce operational cost related to claims processing

Leveraging ABDM Building Blocks:

Adoption of key components of ABDM and PMJAY will help insurance industry gain
efficiencies and greater penetration.

Ayushman Bharat Health Facility Health Professional

Health Account
(ABHA) Number is
used for the purpose of
uniquely identifying
citizens.
Registry (HFR) is a Registry (HPR) is
single source of truth for verified database of all
all the health facilities in healthcare professionals
the country. in the country.

Stakeholders of NHCX

Payers Providers Insured person

Hospital, Clinics,
State Health Diagnostic chains, PMJAY Beneficiaries,
Agency, Insurance Labs, Pharmacies Health insurance
company or TPA policy holders etc
 Current Health Claims Settelment Process

•Fills claim forms by hand

•Scans supporting Insurance
documents company 1 Digitize
Beneficiary
walks-in with •Upload to multiple portals and
Insurance card provided by the Insurance verify forms
Insurance
companies / TPA’s to raise company 2
& track claims

Insurance
company 3 Manually
Claims are submitted to Adjudicate
multiple insurance companies Claims
Hospital
(Submits Claims) (Adjudicates Claims)

Challenges:
- Lack of authenticated data
- Manual, non-digital and tedious claims adjudication process
- Non-standardies processes among Insurers, TPAs, and Providers
- High cost of processing each claim

Simplified Health Claims Settelment Process

Common claim
standard format Digitally verify
(FHIR objects) to be Insurance submitted
used across Govt / company 1
Validate the meta forms
Digital KYC Pvt Health claims
data (sender &
defined by NHA
with ABHA receiver info) and
route to designated
Insurance
Insurer / TPA
company 2
National Health Auto Adjudicate
Claims Exchange Claims
Open APIs (NHCX) Insurance
company 3

Routes to designated
Insurer/TPAs
Hospital Manually Adjudicate
(Submits Claims) (Adjudicates Claims) some Claims
Proposed Benefits for Stakeholders

The introduction of NHCX will lead to multiple benefits for the stakeholders and the
insurance sector.

BENEFICIARY PROVIDER PAYERS

• Reduced wait time. • Single Payer Network • Reduction in overhead

• Faster preauthorization
and discharge approvals
from insurance
companies
• Reduced cost of
insurance premiums
• More types of claims
coverage in future
including, OPD,
Pharmacy Bills etc.
• Universal claims format
• Faster payments by
payers
• Improved patient
experience
• Better visibility of claims
status
• Paperless operations
operational costs
• Enabling new
processes/rules for auto
adjudication, control
fraud and abuse
prevention
• Reduction in claims
processing cost per each
claim
• Paperless operations
• Better quality of data for

Key use cases

Industry and regulators

1. Check Coverage 2. Preauth Request 3. Predetermination 4. Claim

eligibility Submission Request Submission Submission

5. Payment 6. Communication 7. Reprocess

Status Request Request

Getting started with the NHCX

The onboarding process for NHCX is a two-step process:
1. Sandbox testing and certification

API Integration Sandbox

Registration
and Testing Certifications

2. NHCX- Go-Live on live instances

Participants will be provided with their unique participant id and production access secret
credentials to move to production environment and start the exchange of claims related
information across payers and providers.
 Provider Onboarding

Payer Onboarding

For any concerns and queries related to

the NHCX write to: For any concerns and queries related to
Sandbox Integration process:
Dr Basant Garg (Additional CEO) Visit: sbxhcx.abdm.gov.in
addlceo@nha.gov.in or scan QR Code
Shri Kiran Gopal Vaska (Executive Director-IT)
ed.it@nha.gov.in Write to: abdm@nha.gov.in

NATIONAL HEALTH AUTHORITY

9th Floor, Tower-I, Jeevan Bharti Building, Connaught Place, New Delhi-110001

nha.gov.in | abdm.gov.in @AyushmanNHA