The document proposes a Health Claims Platform (HCP) to enable electronic paperless claim processing. The HCP would standardize the e-claim format, use encryption and routing to enable a digital claims ecosystem. It discusses design principles like non-repudiability, open APIs, and consent-based data sharing. The HCP aims to reduce costs, improve user experience and enable innovation. It also covers creating personal health records and ensuring high quality medical coding standards. An implementation roadmap includes stakeholder engagement, sandbox testing and medical coding certification.

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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

7. v
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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

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:

21. 11
Timing:
Diagnosis:
Procedure:
Bill Summary:
Attachments:
text
e-Claim document - Encryption and Security

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