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IRDAI - NHA Joint Working Group: Sub Group on IT

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IRDAI - NHA Joint Working Group: Sub group on common IT infrastructure report 11-09-2019

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IRDAI - NHA Joint Working Group: Sub Group on IT

  1. 1. Hkk ch fo fo çk
  2. 2. iii TABLE OF CONTENTS EXECUTIVE SUMMARY 1 The Current Landscape in Claims Processing for Health 2 Claims Processing in Retail / Group Health Insurance 2 Claims processing under Ayushman Bharat 4 Health Claims Projections Requirements -- Volume growth, Cost of Processing, and Outpatient coverage 5 Health Claims and the need for on-time payment 6 Towards Electronic Paperless Claim Processing 6 Overview of the proposed Health Claims Platform 6 Design Principles of the Health Claim Platform 8 Digital Services to be provided by the Health Claims Platform 9 The e-Claim document 10 e-Claim document -- Encryption and Security 11 Enabling a digital claims eco-system via multiple HCP providers 12 Routing -- the main function of the HCP 13 Monitoring Data available to Regulators from NHCP 13 Regulatory reporting to IRDAI by Insurers 13 Governance and Setting of Standards to be used by HCP 14 Towards Personal Health Records for All 14 Personal Health Records -- An overview 14 Separating Claim data from Clinical Data 15 Implementation Roadmap 16 Engagement and feedback of stakeholders 16 Ensuring high quality Medical Coding 17 Sandbox and software developer engagement 17 Conclusion 18
  3. 3. iv | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management
  4. 4. v OFFI WOR ICE OR RKING RDER GROU FOR C UPS CREATTION OF JOINNT
  5. 5. vi | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management
  6. 6. vii MEMBERS OF THE SUB GROUP (4) Sl No Name Designation Organization Role
  7. 7. 1 EXECUTIVE SUMMARY key recommendations e-Claim any health insurance claim e-discharge Health Claims Platform (HCP) e-facility e-facility digital contracts Policy Markup Language.
  8. 8. 2 | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management Health Claims Platform Providers design principles non-repudiability verifiability and explainability data privacy consent-based data sharing open APIs extensible/flexible financial model Medical Coding Personal Health Records THE CURRENT LANDSCAPE IN CLAIMS PROCESSING FOR HEALTH Claims Processing in Retail / Group Health Insurance
  9. 9. 3 The pro The Cu Stakeh 1. H 2. In ocess is as urrent Sy holders: Hospitals f nsurers an Figure s follows: ystem has face challe nd TPAs 1. Current P s Challen enges Processing S nges and System for C Limitatio Claims ons Acrosss Variouus
  10. 10. 4 | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management 3. II 4. 5. P Claims B Patients’ s process cost of pr user exp sing unde Figure 2 rocessing perience er Ayush : Current Cl man Bha laims Proces arat ssing under PMJAY
  11. 11. 5 Closed Ecosystem -- Yet another process for Hospitals Insurers and ISA’s role cost of processing offline support. Health Claims Projections Requirements - Volume growth, Cost of Processing, and Outpatient coverage
  12. 12. 6 | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management Health Claims and the need for on-time payment TOWARDS ELECTRONIC PAPERLESS CLAIM PROCESSING Overview of the proposed Health Claims Platform
  13. 13. 7 e-c claim Hea validate data claim alth Claim e option s Platform nallysecure key m (HCP) e Figure 3 enabler fo route e or innovat everypayer ion singlecom r collect mi mmone- nimum
  14. 14. 8 | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management auto-adjudication fraud waste and abuse control. e-claim standard Health Claims Platform Design Principles of the Health Claim Platform 1. Non-repudiability: Verifiability Explainability: Extensible and Flexible Schemas: Open APIs and Standards: Strong Data Privacy: Consented Data Sharing: Incentive aligned design: Multi Provider model:
  15. 15. 9 Digital Services to be provided by the Health Claims Platform Coverage Eligibility: Get Public Key: Pre-auth Service: Smart Contracts: Claim Service: Provider Facility Info Management: e-facility
  16. 16. 10 | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management Policy Details: Policy Markup Language (PML) Digital Contract Management: The e-Claim document Patient: Insurance: Payee: Care Team:
  17. 17. 11 Timing: Diagnosis: Procedure: Bill Summary: Attachments: text e-Claim document - Encryption and Security
  18. 18. 12 | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management Enabling a digital claimss eco-sysstem via multiple HCP provviders
  19. 19. 13 Routing - the main function of the HCP Monitoring Data available to Regulators from NHCP Regulatory reporting to Insurance Information Bureauby Insurers
  20. 20. 14 | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management Governance of the HCP ecosystem, TOWARDS PERSONAL HEALTH RECORDS FOR ALL Personal Health Records - An overview
  21. 21. 15 Separaating Claiim data frrom Cliniical Data
  22. 22. 16 | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management IMPLE Engag MENTAT ement an TION ROA nd feedba ADMAP ack of staakeholders
  23. 23. 17 Ensuri Sandb ing high q ox and s quality M oftware d Medical Co develope oding certi r engage ification co ement ourse in mmedical codding.
  24. 24. 18 | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management CONCLUSION

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