Unified portal for NHCE to be operational soon, to simplify insurance ecosystem in the country

The unified portal for the National Health Claim Exchange (NHCX), a digital health claims platform developed by the National Health Authority (NHA), is expected to be operational in near future simplifying the insurance ecosystem in the country. This also adds to the digital healthcare initiatives that are under development and implementation through the Ayushman Bharat Digital Mission (ABDM).

The NHCX is envisaged to serve as a gateway for exchanging claims-related information among various stakeholders in the healthcare and health insurance ecosystem. The integration with NHCX would enable seamless interoperability of health claims processing, enhancing efficiency and transparency in the insurance industry and benefiting the policyholders and patients.

The Exchange will be working similar to the internet and email exchange networks enabling the transfer of data packs from one point to another. It would serve as a protocol for exchanging claims-related information among various actors, including players, providers, beneficiaries, regulators and observers.

The Exchange is expected to be operational in the next two to three months, according to agency reports.

Its objectives are to add new types of claims to insurance policies to increase the insurance bases such as Out Patient Department and Pharmacy bills, and reduce receivable cycles and increase acceptance of cashless claims even in smaller hospitals, says ABDM.

With seamless exchange of data, documents and images in between insurance companies, third party agencies, government scheme administrators and the healthcare service providers such as hospitals, laboratories and poly clinics, the portal will be working on an open protocol for claims data exchange.

It is expected to simplify the processes for the payers, such as State Health Agency, Insurance Company or the third party agencies, and providers such as hospitals, clinics, diagnostic chains, labs and pharmacies and the insured persons encouraging more penetration of insurance in the country.

The system will keep the protocol evolvable and extendable, minimalistic and inclusive, ensuring data privacy and security and maintain tamperproof audit trails and digital signatures, in order to ensure vendor neutrality and usage across platforms.

The healthcare and pharmaceutical industry are also looking at the potential of the exchange on insurance claims and policies and the impact of this on the future growth of the insurance sector, which would eventually back the healthcare services and medicine sectors.

Shashank Avadhani – co-founder & CEO – Alyve Health, a health tech startup, said that the launch of the Health Claims Exchange (HCX) will be a pivotal milestone for the health insurance industry in India.

“HCX will replace the onerous and manual claims operations with seamless and secure health data transfer from healthcare providers to insurers,” he said.

With Health ID (ABHA) and HCX, the powerful India Health Stack will enable customer-centric insurers and health platforms to provide instant claim settlements and 100% transparency to customers. At a systemic level, HCX will reduce both opex and fraud, ultimately reducing healthcare costs, he added.

The insurance industry can also adopt key components of the ABDM and PMJAY infrastructure, including the Ayushman Bharat Health Account (ABHA), Health Facility Registry, and the Health Professional Registry, to gain efficiencies and greater penetration.

Under the new system, the digital data of the patient, available with ABHA can be submitted by the hospitals and the common claim standard format submitted at the exchange can be used by the insurance companies to adjudicate claims through the simplified claim settlement process, it added. This would help the industry to digitally verify the submitted forms, auto adjudicate claims and manually adjudicate some claims, thus reducing the opex, says NHA.

For the beneficiaries, who are the patients, this would mean reduced wait time, faster pre authorisation and discharge approvals from insurance companies, reduced cost of insurance premiums, and more types of claims coverage in future including OPD and pharmacy bills.

For the healthcare service providers, the benefits are envisaged to be single payer network, universal claims format, faster payments by payers, improved patient experience, better visibility of claims status and paperless operations.

For the insurance companies, who are the payers, the benefits are reduction in overhead operational costs, enabling new processes and rules for auto adjudication, control fraud and abuse prevention. There would also be a reduction in claims processing cost per each claim and better quality of data for industry and regulators.