Onboard NHCX to streamline health-claim settlement, IRDAI nudges insurers

Advises firms, TPAs to test, adopt National Health Claims Exchange specifications and data profiles as part of e-claim standards

Published - June 15, 2023 09:15 pm IST - HYDERABAD

Insurance regulator IRDAI wants all insurers and third-party administrators (TPAs) to test and adopt the National Health Claims Exchange (NHCX) specifications and its data profiles as part of e-claim standards.

“Insurers may on-board the NHCX platform as soon as possible... also get the healthcare providers in their network to join at the earliest,” Chief General Manager (Health) Yegnapriya Bharath said.

Along with other building blocks of Ayushman Bharat Digital Mission, NHCX is poised to be a gateway for exchanging claims-related information among various stakeholders. It is designed to be interoperable and machine-readable, auditable and verifiable as well as help ensure the information exchanged is accurate and trustworthy, IRDAI said in a communication to all insurers, except the two specialised insurance companies, and TPAs.

NHCX has been conceived to enable seamless interoperability of health-claims processing.

The current health insurance claims settlement process is mostly manual, non-digital and the also is no proper data flow/administration in the system leading to delays in claim processing. It seeks to address the lack of standardisation, in the claims processing, across the ecosystem. Besides delays, the processes also varying significantly among insurers, TPAs and health care providers resulting in high processing costs.

The specifications of NHCX are envisioned to enable an open network based on an open protocol, which the National Health Authority has already adopted, with the objective of creating interoperability in the health claims data exchange, the regulator said. The insurers/ TPAs will be able to send responses for each Fast Healthcare Interoperability Resources Standard (FHIR) based on the e-claim submitted by providers on the NHCX through standard protocols. FHIR standards define how healthcare information can be exchanged between different computer systems regardless of how it is stored in those systems, IRDAI said.

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