Background

The National Health Policy 2017 has the stated objective of Universal Health Coverage. The government is already providing cover to nearly 40% of the population from lower economic segments with PM-JAY. This is expected to expand to cover about 70% of the population over time. The number of claims from Government sponsored schemes is expected to see a significant increase with both increase in awareness and wider coverage of the population. It is important that the adoption of an electronic claims system happens before the large scale usage of claims becomes a reality.

The joint working group of NHA and IRDAI (2019) recommends the creation and adoption of a Health Claims Data Exchange Gateway and standardization of e-claims and other related documents to enable the ecosystem to move to a low cost paperless ecosystem that inherently allows for innovation. This will include adoption of open standards by all the actors in the Health Insurance Eco‐system.

Based on the recommendations from NHA & IRDAI, the HCX working groups have created a open specification for enabling health claims exchange. The detailed specifications are available here.

Introduction

The FHIR Implementation Guide for Health Claims Data Exchange Specifications is based on FHIR Version R4 and defines the minimum conformance requirements for exchanging claims-related information between relevant actors - payors, providers, beneficiaries, regulators, observers.

Purpose

The purpose of this implementation guide is to provide essential and minimum artefacts that can be captured and exchanged as per Health Claims Data Exchange Specifications 1.0.

How to read this Guide

This Guide is divided into several pages which are listed at the top of each page in the menu bar.

• Home: The home page provides the introduction, purpose, and scope of Health Claims Data Exchange Specifications 1.0.
• Artifacts: These pages provide detailed descriptions and formal definitions for all the FHIR objects defined in this guide.
  • Profiles:This page lists the set of Profile that are defined in this guide to exchange claims data.
  • Terminology:This page lists the value sets defined for FHIR Implementation Guide for HCX profiles.
• Downloads: This page provides links to downloadable artefacts.