The National Health Claims Exchange (NHCX) is India's public network for health insurance claims. It carries cashless claims and their messages between hospitals and insurers in one standard format. It was set up by the National Health Authority (NHA), under the Ayushman Bharat Digital Mission. IRDAI, the insurance regulator, has asked insurers to connect to it. Private companies also run claims exchanges that connect hospitals to insurers, and some use AI to check and process the claims.
What problem does it solve? India has many insurers and many third-party administrators (TPAs), companies that process claims on behalf of insurers. Each used its own web portal and forms. A hospital's insurance desk had to log in to many portals, fill in different forms and email scanned PDFs. Insurers then had to re-type the data. With NHCX, a hospital sends every claim in one format, and each insurer receives it in the same format. Different systems exchanging data in a format all of them understand is called interoperability.
Here is a typical case. A retired railway employee in Bhubaneswar is admitted to a private hospital for a knee replacement. His family health policy covers the operation. The hospital's insurance desk opens his case in its hospital EHR and sends a pre-authorisation request through NHCX. The request carries the diagnosis, the planned operation and an estimate of ₹2,40,000. IRDAI's rules give the insurer one hour to decide this request. The insurer approves ₹2,10,000, because the room he chose costs more than his policy allows. He is operated on the next morning.
On the day of discharge, the hospital sends the final bill of ₹2,32,000 through NHCX. The insurer has three hours to give its final approval under IRDAI's rules. It approves ₹2,18,000. The other ₹14,000 is for the extra room cost and for items his policy does not cover, such as some consumables. He pays that at the counter and goes home. Weeks later, the insurer pays the hospital by NEFT.
On the insurer's end, the claim is received into the claims management part of its insurance core system. The NHCX format is based on FHIR, an international standard for health data. A claim can also carry the patient's ABHA number, his health ID under the digital health mission. With his consent, it can then be linked to his health records.
The US has a similar job done by private companies, called a healthcare clearinghouse. The difference is that NHCX is a public network, built as part of India's digital health infrastructure.