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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
iv | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management
v
OFFI
WOR
ICE OR
RKING
RDER
GROU
FOR C
UPS
CREATTION OF JOINNT
vi | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management
vii
MEMBERS OF THE SUB GROUP (4)
Sl No Name Designation Organization Role
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.
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
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
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
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
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
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
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:
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
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:
11
Timing:
Diagnosis:
Procedure:
Bill Summary:
Attachments:
text
e-Claim document - Encryption and Security
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
13
Routing - the main function of the HCP
Monitoring Data available to Regulators from NHCP
Regulatory reporting to Insurance Information Bureauby Insurers
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
15
Separaating Claiim data frrom Cliniical Data
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
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.
18 | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management
CONCLUSION
IRDAI - NHA Joint Working Group: Sub Group on IT
IRDAI - NHA Joint Working Group: Sub Group on IT
IRDAI - NHA Joint Working Group: Sub Group on IT
IRDAI - NHA Joint Working Group: Sub Group on IT

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IRDAI - NHA Joint Working Group: Sub Group on IT

  • 1. Hkk ch fo fo çk
  • 2.
  • 3.
  • 4.
  • 5. 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
  • 6. iv | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management
  • 8. vi | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management
  • 9. vii MEMBERS OF THE SUB GROUP (4) Sl No Name Designation Organization Role
  • 10.
  • 11. 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.
  • 12. 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
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. 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
  • 18. 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:
  • 19. 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
  • 20. 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:
  • 22. 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
  • 23. 13 Routing - the main function of the HCP Monitoring Data available to Regulators from NHCP Regulatory reporting to Insurance Information Bureauby Insurers
  • 24. 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
  • 25. 15 Separaating Claiim data frrom Cliniical Data
  • 26. 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
  • 27. 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.
  • 28. 18 | IRDAI-NHA Joint Working Group: Sub Group on Common IT Infrastructure for Health Insurance Claims Management CONCLUSION