FHIR Implementation Guide for ABDM - Local Development build (v3.1.0). See the Directory of published versions

NHCX Profiles

To support the vision of Pradhan Mantri Jan Arogya Yojana (PMJAY), NHA has created a standardized health claim platform based on the Health Claim Exchange Specification (NHCX) to enable automation of the health claim-related information exchange between payers, providers, beneficiaries, and other relevant entities. The specification provides an interoperable, machine-readable, auditable, verifiable, and open standard-based structure protocol for communication between the entities.

• Key Use cases/Workflows
  

In its initial version, NHCX is focused on facilitating message exchange for the cashless claims process and envisions to facilitate the following information flows:

• Get provider/payor details
• Eligibility check
• Pre auth request flow
• Claims request flow
• Payment notification
• Payment acknowledgement
• Search/fetch claims data for status checks, regulatory compliance, etc.

Apart from the ABDM exchange specifications, this Implementation Guide also cater to the resources and artifacts required for NHCX. Following resources specifically can be referred for NHCX:

• Health Claim Artifacts
  Following artifact are profile based on Bundle resource of FHIR R4.0.1:
  
  

  Name	Based On	Definition
  ClaimBundle	Bundle	The profile is based on a Bundle of type collection, where all the supporting information required for processing claim can be shared. Multiple entries can be added in a bundle to provide information like financial, clinical, provision of health care services with payors and for reporting to regulatory bodies and firms which provide data analytics. The bundle can be generated depending on the nature of the request defined by 'use' element in a claim resource, like preauthorization, predetermination and claim and can be shared over NHCX ecosystem.
  ClaimResponseBundle	Bundle	The profile is based on a Bundle of type collection, where adjudicated response to a Claim, Predetermination or Preauthorization related information is carried. Multiple entries included in a bundle carries the information and provides application level adjudication results.
  CoverageEligibilityRequestBundle	Bundle	The profile is based on a Bundle of type collection, where all the information required to process Coverage Eligibility Request can be shared. Depending on the purpose of the request like validation, discovery,auth-requirement and benefit data can be included in the etries of a bundle.
  CoverageEligibilityResponseBundle	Bundle	The Coverage Eligibility Response Bundle is a Bundle profile with type collection. The bundle profile provides the response and plan details from the processing of an CoverageEligibilityRequest resource.
  InsurancePlanBundle	Bundle	This profile is based on a Bundle of type collection, providing a description of a health insurance package that consists of a comprehensive list of covered benefits (referred to as the product), associated costs (known as the plan), and supplementary details regarding the offering, such as ownership and administration, coverage area, contact information, and more.

• Other Resources
  
  

  Name	Based On	Definition
  Claim	Claim	This profile sets minimum expectations for the providers and payors, insurers, to exchange the financial information, and supporting clinical information.
  ClaimResponse	ClaimResponse	This profile represents application level adjudication outcomes, or an application level error, that occur as a result of processing a supplied Claim resource, which could be a functional corollary of a Claim, Predetermination, or Preauthorization.
  Communication	Communication	This profile sets the minimum requirement for documenting any communication, whether it is planned or unsuccessful. A communication refers to the exchange of information from a sender to a receiver, and these entities can encompass patients, practitioners, related individuals, organizations, or devices. The resource serves as a record of these interactions.
  CommunicationRequest	CommunicationRequest	This profile sets the minimum requirement for a communication to be carried out, serving as a record of the communication request. In this context, a communication refers to the transmission of information from a sender to a receiver. The requester initiates the communication by asking the sender to convey the payload to the intended recipient. The sender and receivers involved in this process can encompass patients, practitioners, related persons, organizations, and devices.
  Coverage	Coverage	This profile aims to capture essential identifiers and descriptors of an insurance plan through the Coverage resource. It encompasses information that is typically found on an insurance card and can be utilized to cover the costs, either partially or entirely, for healthcare products and services.
  CoverageEligibilityRequest	CoverageEligibilityRequest	This profile sets minimum expectations for CoverageEligibilityRequest to provide patient and insurance coverage information to an insurer for them to respond, in the form of an CoverageEligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.
  CoverageEligibilityResponse	CoverageEligibilityResponse	This profile provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource.
  InsurancePlan	InsurancePlan	This Profile describes a health insurance offering comprised of a list of covered benefits (i.e. the product), costs associated with those benefits (i.e. the plan), and additional information about the offering, such as who it is owned and administered by, a coverage area, contact information, etc.
  PaymentNotice	PaymentNotice	This resource provides the status of the payment for goods and services rendered, and the request and response resource references.
  PaymentReconciliation	PaymentReconciliation	This profile provides the bulk payment details associated with a payment for goods and services rendered by a provider to patients covered by insurance plans offered by that payor.
  Task	Task	This profile describes an activity that can be performed and tracks the state of completion of that activity. It is a representation that an activity should be or has been initiated, and eventually, represents the successful or unsuccessful completion of that activity.