Claims Process Map

India's Cashless Health Insurance
Claims Process Map

How hospitals, insurers, TPAs, and NHCX operate across the pre-authorization to settlement lifecycle — a structured process intelligence view across five leading Indian hospitals, five payers, and India's national health claims exchange.

ABDM Ecosystem NHCX Protocol Cashless Claims TPA Workflow IRDAI Regulated
00 —

End-to-End Flow Overview

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Hospital / Provider
Initiates Pre-Auth
→
🔗
NHCX Gateway
Routes & Acknowledges
→
🏛️
Insurer / TPA
Reviews & Decides
→
✅
Auth Decision
Approve / Deny / Query
→
🏥
Treatment & Discharge
Claim Settlement
01 —

Hospital Pre-Authorization Process (5 Hospitals)

What is Pre-Authorization? Pre-authorization (pre-auth) is the formal approval sought by a hospital from an insurer or TPA before planned treatment is administered, confirming coverage, estimating liability, and triggering cashless claim processing. In emergencies, hospitals must notify within 24–48 hours of admission.
🏥

Apollo Hospitals

Pan-India · Private · NABH Accredited · ~70 hospitals
  • 1
    Patient Registration & Insurance Desk Activation Patient presents insurance card / ABHA ID at Apollo's dedicated Insurance & TPA Desk. Desk team verifies policy number, TPA empanelment status, and sum insured via Apollo's internal HIS (Hospital Information System).
  • 2
    Treating Physician Clinical Note The treating consultant fills out a clinical summary including provisional diagnosis, ICD-10 code, proposed procedure (procedure/package code), expected duration of stay, and estimated cost — entered into Apollo's Hospital Information System for structured input.
  • 3
    Pre-Auth Form Compilation Insurance Desk compiles the pre-auth package: completed pre-auth form, supporting lab/radiology reports, referral letters, ID proof, and policy copy. Apollo's desk staff cross-verify documents against the insurer's pre-auth checklist (stored internally per payer).
  • 4
    Submission via Payer Portal / NHCX Request is uploaded to the respective TPA/insurer portal (e.g., Medi Assist portal, Star Health portal, or via NHCX for integrated payers). Apollo's IT team maintains API integrations with major TPAs. NHCX-linked payers receive claims via standardized FHIR-based protocol.
  • 5
    Tracking & Follow-up Apollo's insurance team tracks pre-auth status via the TPA/insurer portal and by phone follow-up. IRDAI's Master Circular (effective July 31, 2024) mandates insurers respond to pre-auth requests within 1 hour. For planned cases the industry target is same-day turnaround; emergency cases are expedited. If queries are raised, the medical records team coordinates with the treating consultant to provide additional documents.
  • 6
    Authorization Letter Receipt & Admission On approval, Apollo receives a Letter of Authorization (LOA) specifying approved amount, room category, procedure codes, and validity period. Patient is admitted; LOA is filed in the patient record. If denied, patient is informed and billing team activates reimbursement mode.
  • 7
    Concurrent / Enhancement Requests During admission, if treatment scope changes (e.g., complications requiring ICU), Apollo's team files an enhancement/revision pre-auth immediately. Detailed clinical notes justify the enhancement.
🏨

Fortis Healthcare

Pan-India · Private · NABH · ~28 hospitals
  • 1
    Centralised Insurance Coordination (Illustrative) Large hospital chains like Fortis typically centralise their insurance and TPA coordination across their network — routing all pre-auth requests through a dedicated insurance operations team with per-payer specialists. This model prevents duplication and ensures consistent communication across units. The specific operational structure varies by organisation.
  • 2
    Eligibility Pre-Check via E-Card Scan Patient's insurance e-card is scanned at OPD or Emergency. Fortis's system auto-populates policy details via TPA API. Real-time eligibility check confirms active coverage, room rent limits, and procedure-specific sub-limits.
  • 3
    Doctor's Pre-Auth Form (PAF) Initiation Treating doctor completes the Pre-Authorization Form electronically within Fortis's HIS. PAF includes: chief complaint, diagnosis, proposed line of treatment, implants if any, and expected LOS (Length of Stay).
  • 4
    Document Packaging & Submission The centralised insurance team compiles the full dossier (PAF + clinical notes + investigations) and submits through TPA-specific portals or NHCX. All submissions are timestamped for TAT compliance monitoring — IRDAI's Master Circular 2024 mandates a 1-hour response window for pre-auth and 3-hour window for discharge authorization.
  • 5
    Query Management Module The insurance team uses a query management system to track and respond to TPA queries. Clinical coordinators are responsible for gathering the required additional information from treating doctors and medical records. Prompt responses to queries are critical — delays extend the pre-auth cycle and may result in denial. All query-responses are archived for audit and dispute resolution.
  • 6
    Discharge & Final Bill Submission On patient discharge, the insurance team prepares the final claim package (discharge summary, itemized bill, implant invoices) and submits for final settlement. IRDAI's Master Circular 2024 mandates that final discharge authorization be issued within 3 hours of the hospital's request.
🏛️

Manipal Hospitals

South & Pan-India · Private · NABH · ~36 hospitals
  • 1
    Insurance Helpdesk Triage Manipal's Insurance Helpdesk (present in each hospital) is the first touchpoint. Staff triage whether the case is planned or emergency. For planned admissions, pre-auth is initiated 48–72 hours in advance. Emergency cases are intimated to TPA/insurer within 24 hours of admission.
  • 2
    Document Checklist Handover Desk provides patient with a customized insurance document checklist (varies by TPA). Required: valid photo ID, insurance card, policy copy, treating doctor's prescription/referral, past medical records relevant to current diagnosis.
  • 3
    Treating Doctor Pre-Auth Sign-off Treating doctor completes and signs the Pre-Authorization Request Form. Form captures: ICD-10 diagnosis code, proposed procedure, implant details (if any), expected stay, and clinical justification for procedure. Doctor's NABH registration number is included.
  • 4
    Multi-Channel Submission Manipal submits to insurers via: (a) TPA-specific portals for non-NHCX payers, (b) NHCX protocol for integrated insurers, (c) Fax/email for legacy payers. They maintain a payer-wise SOP binder updated quarterly.
  • 5
    Approval Receipt & Patient Communication On receiving LOA, Manipal's desk immediately informs the patient and treating team. Approval limits are communicated clearly. Patient is made aware of any non-payable components they must pay out-of-pocket.
  • 6
    Concurrent Review for Long-Stay Cases For ICU or long-stay patients, Manipal's team proactively files concurrent review requests every 3–5 days to justify continued hospitalization and seek enhanced authorization for extended stay.
❤️

Narayana Health

Pan-India · Private · Affordable Cardiac Focus · ~19 hospitals
  • 1
    High-Volume Pre-Auth Operations Team Narayana Health, known for high volumes (especially cardiac, orthopedic, oncology), operates a dedicated pre-auth operations team at each unit. Team has per-payer specialists who know that insurer's pre-auth nuances — critical for reducing query rates.
  • 2
    Package-Based Cost Estimation Narayana's operational model revolves around packaged pricing. Desk team prepares cost estimates using NH's package rates (aligned with CGHS/insurance tariffs). Package codes are cited in the pre-auth form, reducing disputes at settlement.
  • 3
    PMJAY / Government Scheme Pre-Auth (Parallel Track) Narayana is a major PMJAY empanelled hospital. Government scheme pre-auths go through the state's SHA (State Health Agency) portal via the Transaction Management System (TMS) — a completely separate track from private insurance. PMJAY pre-auth involves beneficiary eligibility verification and treatment package selection from approximately 1,950 procedures across 27 specialties.
  • 4
    TPA Portal / NHCX Submission (Private Insurance) For private insurance, NH team submits via TPA portals. NHCX-linked payers receive a standardized FHIR Claim (pre-authorization) resource. NH maintains integration with Medi Assist, Vidal Health, and other major TPAs.
  • 5
    Query Resolution & Clinical Team Loop If TPA raises medical queries, the case is escalated to the treating consultant within 30 minutes. Narayana's culture of physician involvement in pre-auth query resolution reduces query cycle time significantly.
  • 6
    Discharge Planning & Final Claim Filing Discharge planning is initiated 24 hours before expected discharge. Final itemized bill, discharge summary, OT notes, implant stickers, and medication bills are compiled and submitted to TPA within 3 hours of discharge sign-off per IRDAI's 3-hour mandate.
🔬

Max Healthcare

Delhi NCR Focus · Private · NABH · ~22 hospitals
  • 1
    Corporate & Retail Insurance Desk Segregation (Illustrative) Large hospital networks typically segregate corporate group policy patients and retail/individual policy patients into separate insurance desk queues — corporate accounts are managed through employer empanelment arrangements while the retail desk handles walk-in insurance patients. The specific desk structure varies by hospital.
  • 2
    Pre-Admission Counseling & Policy Review Before filing pre-auth, the insurance counselor reviews the policy document with the patient: room rent limits, co-pay clauses, exclusions, waiting period status, and sub-limits for specific procedures. This is standard practice across empaneled hospitals to prevent LOA-to-bill mismatch disputes at discharge.
  • 3
    Digital Pre-Auth Form (e-PAF) via Hospital HIS Treating doctor fills the pre-authorization form within the hospital's HIS. In more digitally mature hospitals, the system auto-populates patient demographics and past visit history. Diagnosis and procedure codes (ICD-10 / procedure/package codes) are required fields — code accuracy is critical to avoiding queries from the TPA or insurer.
  • 4
    Document Completeness Review Before Submission The insurance desk reviews the document package for completeness before submission — checking for missing items such as implant quotations, investigation reports, or referral letters. More digitally advanced hospitals use workflow checklists or automated flags for this; others rely on experienced desk staff. Incomplete submissions are the primary cause of TPA queries.
  • 5
    Multi-Portal & NHCX Submission with IRDAI SLA Tracking Submission happens via TPA portals, NHCX (for integrated payers), or direct insurer APIs. IRDAI's Master Circular 2024 (effective July 31, 2024) mandates insurers respond to pre-auth requests within 1 hour and issue final discharge authorization within 3 hours.
  • 6
    LOA Management & Room Allocation Optimization On receiving LOA, Max's room allocation team assigns the appropriate room category (as approved in LOA). If patient requests upgrade, differential billing is calculated and patient consent is obtained before admission.
  • 7
    Discharge & Claim Submission within IRDAI 3-Hour Window Max's team targets final claim submission within 3 hours of discharge — in line with IRDAI's cashless mandate. Final bill, discharge summary, and supporting documents are submitted digitally. Any shortfall is billed directly to the patient at discharge.
02 —

Payer Process — Insurers & TPAs (5 Entities)

Payer Side of Pre-Auth: Once the hospital submits a pre-auth request, the payer (Insurer or TPA) takes over. Their process involves eligibility verification, medical necessity review, fraud check, decision-making, and LOA issuance — all within IRDAI-stipulated turnaround times.
⭐

Star Health & Allied Insurance

Insurer · In-House Claims Processing · No External TPA
Pre-Auth Process — Insurer Side
Phase 1 — Receipt & Triage (0–30 min)
Star Health's in-house pre-auth team (no TPA intermediary) receives the pre-auth request via: (a) Star's hospital provider portal, (b) NHCX for integrated hospitals, or (c) email/fax for legacy providers. A unique pre-auth reference number is generated. Case is triaged: routine, urgent (emergency), or high-value (₹2L+).
Phase 2 — Eligibility & Policy Verification (30–60 min)
  • Policy activeness, premium payment status confirmed
  • Waiting period check for the stated diagnosis
  • Sum insured balance and sub-limits verified
  • Co-pay and room rent eligibility mapped
  • Previous claims checked for cumulative limits
Phase 3 — Medical Necessity Review (within IRDAI 1-hr mandate)
Star's in-house Medical Officers (MO) review clinical justification. They check: diagnosis-procedure alignment, ICD-10 and procedure code appropriateness, and expected LOS against clinical norms. They may issue a "query" requesting additional clinical notes, previous treatment records, or specialist opinion. Star Health reports settling 90% of cashless claims in under 2 hours (per their official claims page).
Phase 4 — Fraud & Anomaly Screening
Star's claims team screens for anomalies including: duplicate claim patterns, cost estimates significantly above market norms, and implant billing irregularities. Cases flagged for investigation may take additional time to process. Star Health processes all claims in-house — this integrated model is cited as a key reason for their reported speed.
Phase 5 — Decision & LOA Issuance
Decision options: (a) Full Approval with LOA specifying approved amount and validity, (b) Partial Approval (approved for initial phase, balance on review), (c) Denial with reasons as per IRDAI-mandated written format, (d) Query requiring additional documents. LOA is sent to hospital and policy email simultaneously.
Phase 6 — Concurrent Review & Enhancement Handling
Star's MO team conducts concurrent reviews for long-stay patients. Enhancement requests are reviewed within 2 hours. Discharge authorization is issued within 3 hours of receiving the hospital's discharge request — IRDAI mandate compliance.
🌿

Niva Bupa Health Insurance

Standalone Health Insurer · In-House + Limited TPA
Pre-Auth Process — Insurer Side
Phase 1 — Multi-Channel Ingestion
Niva Bupa accepts pre-auth via: Niva Bupa Provider App (preferred), NHCX protocol, email (scanned forms), and their B2B API for large empaneled hospital chains. All channels funnel into a single pre-auth queue in their Claim Management System (CMS).
Phase 2 — Automated Eligibility Engine
An automated rules engine (built on their digital-first architecture) instantly validates: member ID, policy status, network hospital status, room eligibility, sub-limit applicability. Passes within seconds; failures trigger manual review.
Phase 3 — Digital Document Review
Niva Bupa's digitally mature infrastructure processes pre-auth documents rapidly. The insurer publicly commits to responding to pre-auth requests within 30 minutes for active policies where all documents are submitted to their satisfaction (per their official claims page). Routine, low-complexity cases may receive near-instant confirmation; others are routed for Medical Officer review.
Phase 4 — Human MO Review (Complex Cases)
Cases with AI-confidence score below threshold are routed to Medical Officers. MOs review using clinical guidelines, policy terms, and historical claims data. They can issue queries, partial approvals, or escalate to Senior MO/Chief Medical Officer for high-value claims.
Phase 5 — Decision Communication & Digital LOA
Digital LOA is sent via Provider App, email, and NHCX (for integrated hospitals). Contains: approved amount, approved procedures, room category, validity period, and non-payable list. Denial letters include reason code and grievance redressal information as per IRDAI norms.
Phase 6 — Final Settlement Authorization
Within 3 hours of discharge intimation, Niva Bupa issues final cashless authorization — in line with the IRDAI Master Circular 2024 mandate. For reimbursement claims (non-cashless), Niva Bupa targets settlement within 7 working days of complete document submission. Customer is notified via SMS/email at each milestone.
🏦

New India Assurance (PSU)

Public Sector Insurer · Uses External TPAs (Medi Assist, MedSave etc.)
Pre-Auth Process — Insurer & TPA Side
Phase 1 — TPA-Mediated Receipt
New India routes pre-auth through empanelled TPAs (Medi Assist, MedSave, Heritage Health etc. depending on geography and corporate account — note: Paramount TPA has merged into Medi Assist). Hospital submits to the relevant TPA portal. TPA serves as the operational front-end for New India.
Phase 2 — TPA Policy & Eligibility Check
TPA's system fetches policy data from New India's server via API. Checks: policy validity, sum insured, specific benefits, waiting periods, and network status of the requesting hospital. PSU insurer policies often have government-mandated benefits (e.g., CGHS-equivalent rates) that the TPA must apply.
Phase 3 — TPA Medical Review Team
TPA's medical review team (qualified doctors) evaluates the clinical case. They issue queries if documents are incomplete or if the claimed procedure seems disproportionate. Queries are routed back to the hospital via portal messaging. TPA must respond within defined SLAs set in the TPA–New India service agreement.
Phase 4 — Insurer Concurrence for High-Value Claims
For claims above the TPA's delegated authority threshold (defined in the TPA–insurer service agreement, which varies by arrangement), the TPA's recommendation is sent to New India's regional or zonal office for concurrence before the LOA is issued. This dual-layer approval structure is characteristic of PSU insurers and can extend total pre-auth TAT beyond that of private standalone health insurers.
Phase 5 — LOA & Claim Limit Communication
TPA issues LOA on New India's behalf, specifying approved amount and applicable CGHS/market rates. Any tariff discrepancy between hospital's rates and NI's approved rates is flagged upfront to avoid discharge disputes.
Phase 6 — Final Claim Processing & Settlement
TPA processes the final claim after discharge and submits to New India for financial settlement. PSU settlement timelines can be 15–30 days. Hospitals often follow up through the TPA. NHCX integration aims to compress this cycle for NI-empaneled hospitals.
🔄

Medi Assist (TPA)

India's Largest TPA · 32 Insurance Partners · 21+ Years
Pre-Auth Process — TPA Operational Side
Phase 1 — Intimation & Pre-Auth Request Receipt
Hospital submits pre-auth request via: Medi Assist Provider Portal, MediAssist mobile app (for smaller providers), NHCX (for integrated hospitals), or API for large chain hospitals. Medi Assist reports receiving 10 million+ claims annually across 32 insurance partners (per their official site). Auto-acknowledgment with reference number is instant.
Phase 2 — Eligibility Verification Engine
Medi Assist's system queries the partner insurer's policy database in real time. Checks: active member, policy validity, sum insured, applicable riders, waiting period status per diagnosis, room rent limit per policy, and specific sub-limits. This runs in under 2 minutes for most cases.
Phase 3 — Medical Scrutiny (Triage-Based)
Cases are triaged into: (a) Straight-Through Processing (STP) — routine low-complexity cases auto-approved if parameters match, (b) Medical Review — routed to Medi Assist's MO team for clinical evaluation, (c) Investigation Desk — high-value, pattern-flagged, or excluded-condition cases. MA's MOs check diagnosis-procedure alignment, LOS benchmarks, and cost against market norms.
Phase 4 — Query Generation & Resolution Loop
Queries are issued via portal messaging with specific reasons. Hospital must respond within 2–4 hours (planned) or 1 hour (emergency). MA's system auto-escalates unanswered queries. On response, MO reviews within 30 minutes for urgent cases.
Phase 5 — Pre-Auth Decision & LOA Issuance
MA issues LOA per the insurer's authorization limits. Approved amount, procedure codes, approved room type, and validity are specified. Partial approvals include "balance on review" clauses. Denials include policy reference and reason. All LOAs are digitally signed and stored in MA's system (accessible to hospital, insurer, and patient via app).
Phase 6 — Concurrent & Discharge Authorization
MA's concurrent review team monitors long-stay cases. Daily clinical updates from hospital are required for ICU/prolonged admissions. Discharge authorization is issued within 3 hours of hospital's final bill submission. MA performs final bill scrutiny: checks for non-payables, tariff compliance, and duplicate billing before authorizing settlement to the insurer.
Phase 7 — Settlement Facilitation
Medi Assist submits verified final claim to the partner insurer for payment. MA tracks payment status and follows up on behalf of the hospital. Dispute escalation and re-adjudication are handled by MA's claims review team. Final settlement advice is shared with the hospital via portal.
🛡️

ICICI Lombard General Insurance

Private Sector Insurer · In-House TPA (IL Health Care) + External TPAs
Pre-Auth Process — Insurer Side
Phase 1 — Omnichannel Intake
ICICI Lombard receives pre-auth via: their Provider Portal, NHCX for integrated hospitals, their in-house claims unit ICICI Lombard Health Care, or external TPA portals for select policies. Acknowledgment and reference number issuance is automated upon receipt.
Phase 2 — Automated Rules Engine & Policy Bind
IL's claims management system runs a rules engine that maps the pre-auth request to specific policy terms. Checks include: member enrollment, policy status, applicable product (retail vs. corporate group), network hospital status, and room category entitlement. This is completed within minutes via their tech-first infrastructure.
Phase 3 — Digitized Document Review
Uploaded documents are processed through ICICI Lombard's AI document reader — extracting diagnosis, procedure, and cost information automatically. The system flags inconsistencies (e.g., diagnosis-procedure mismatch, cost outliers) for MO attention. Routine cases may be auto-approved (STP mode).
Phase 4 — Medical & Financial Review
Complex cases are reviewed by the MO team who validates medical necessity against ICICI Lombard's clinical protocols. Financial analysis is performed: approved amount calculation considering room-rent proportionate deductions, co-pay, and sub-limit caps. Queries are issued via portal with specific response templates to standardize hospital responses.
Phase 5 — Multi-Level Authorization for High-Value Claims
ICICI Lombard applies a tiered internal authorization structure where higher-value or clinically complex claims are escalated to senior Medical Officers or designated approving authorities. The specific thresholds are governed by internal policy and not publicly disclosed. This ensures oversight while maintaining speed for standard routine cases.
Phase 6 — LOA & Digital Workflow
LOA is issued digitally through Provider Portal and NHCX. LOA includes: approved amount, procedure-specific approvals, room category, validity, and a list of explicitly non-covered items. All LOAs are archived in ICICI Lombard's claims system for audit.
Phase 7 — Real-Time Discharge & Claim Settlement
ICICI Lombard's system receives discharge notification via NHCX or Provider Portal. Within 3 hours, discharge authorization is issued per the IRDAI mandate. Final claim settlement (TDS, hospital payment) is processed in approximately 15 days. Customer and hospital are notified at each stage via SMS/email/portal.
03 —

NHCX — National Health Claims Exchange

NHA + IRDAI Initiative · Part of ABDM Ecosystem

How NHCX Sits in the Pre-Authorization Process

NHCX is India's national digital gateway for health claims. It acts as an interoperable, standardized exchange layer between hospitals and payers — eliminating fragmented multi-portal submissions and enabling real-time, auditable, and time-bound claims processing under a single protocol.

🔀

Single Submission Gateway

Hospitals submit pre-auth and claim requests once through NHCX. The platform validates, structures, and routes them to the correct insurer — eliminating the need to manage 40+ separate payer portals.

📋

FHIR-Based Standardization

NHCX uses HL7 FHIR (Fast Healthcare Interoperability Resources) standards. All pre-auth requests, LOAs, queries, and claim documents follow a structured, machine-readable format — enabling automation and audit.

🕐

Real-Time TAT Enforcement

NHCX is designed to monitor turnaround times at each transaction step, with timestamps enabling measurement of compliance against IRDAI's 1-hour pre-auth and 3-hour discharge mandates. Providing regulators visibility into payer TAT performance is a stated design goal of the platform.

🔒

Secure & Auditable Trail

Every transaction on NHCX is digitally signed, timestamped, and stored. This creates an immutable audit trail for disputes, fraud investigation, and regulatory oversight by NHA and IRDAI.

🏛️

ABDM Integration

NHCX integrates with ABHA (health ID), HFR (hospital registry), and HPR (doctor registry). Patient ABHA ID linkage enables seamless identity verification and longitudinal health record access.

📊

Regulatory Intelligence Layer

A core design goal of NHCX is to provide NHA and IRDAI with aggregated data on claims volumes, approval rates, denial patterns, and payer TAT performance — enabling data-driven supervision. This regulatory intelligence capability is intended to grow as platform adoption scales.

NHCX Pre-Authorization Flow — Step by Step
1
Hospital Initiates Pre-Auth via NHCX API

The hospital's HIS (Hospital Information System) sends a structured FHIR Claim (pre-authorization) resource to the NHCX gateway via secure HTTPS API. The request contains: patient ABHA ID, provider HFR ID, treating doctor HPR ID, diagnosis (ICD-10), procedure/package codes, estimated cost, and supporting document references.

2
NHCX Routing Envelope Validation

NHCX validates the routing envelope of the incoming request — checking that the sender is a registered provider, the receiver is a licensed payer, and the message is correctly addressed. The medical payload is encrypted end-to-end; NHCX cannot see inside it and does not validate clinical content. NHCX acknowledges the request immediately and routes it to the correct insurer or TPA — the insurer's own system then performs content validation upon receipt.

3
Payer Routing & Delivery Confirmation

NHCX routes the pre-auth request to the correct insurer or TPA and immediately acknowledges receipt to the hospital with a timestamped tracking reference — the hospital does not wait for the insurer's response synchronously. The insurer processes the request in their own system and the decision arrives later as a callback (FHIR ClaimResponse) routed back through NHCX to the hospital.

4
Payer Reviews & Issues Response via NHCX

The insurer/TPA reviews the pre-auth in their system and submits their response (approval, denial, or query) back to NHCX as a FHIR ClaimResponse or CommunicationRequest resource. All queries and responses flow through NHCX — maintaining a single thread with full traceability.

5
Hospital Receives LOA via NHCX

The insurer's approval (LOA) is routed back to the hospital's HIS via NHCX as a structured FHIR ClaimResponse. Hospital staff confirm receipt and proceed with admission or treatment. NHCX serves as the delivery channel — the LOA is issued by and held in the insurer's own system.

6
Concurrent Review & Enhancement via NHCX

Mid-treatment enhancement requests (e.g., scope change, ICU upgrade) are submitted as amendment requests through NHCX. The payer's response is routed back via the same channel. Transaction timestamps are designed to enable measurement of compliance against IRDAI TAT norms — providing a foundation for future regulatory accountability.

7
Discharge Intimation & Final Claim via NHCX

At discharge, hospital submits the discharge notification and final claim request via NHCX. This triggers the 3-hour TAT clock for discharge authorization. The final claim (itemized bill, discharge summary, supporting documents) follows as a FHIR Claim resource. Payer reviews, authorizes, and confirms settlement intent — all through NHCX.

8
Regulatory Reporting & Analytics

NHCX is designed to aggregate transaction data that would enable NHA and IRDAI to monitor payer TAT performance, denial rates, and query patterns across the ecosystem. Providing this regulatory intelligence layer — enabling data-driven supervision of insurer compliance with cashless mandates — is a core stated objective of the platform as it scales.

NHCX Ecosystem Actors
National Health Authority (NHA)
IRDAI
Hospitals (HFR-registered)
Insurers & TPAs (34 live on NHCX, Jul 2024)
TPAs (IRDAI-licensed)
Patients (ABHA ID holders)
State Health Agencies (PMJAY)
04 —

Master Process Mapping — All Actors by Phase

Phase Activity Hospital Action Payer (Insurer/TPA) Action NHCX Role Who Leads
P-01 Patient Admission & ID Verification Collect insurance card / ABHA ID; verify network status None yet ABHA ID validation (if integrated) Hospital
P-02 Clinical Assessment & Pre-Auth Form Treating doctor prepares diagnosis, procedure code, estimated cost, PAF None yet None Hospital
P-03 Document Compilation Insurance desk compiles PAF, clinical reports, ID proof, policy copy None yet None Hospital
P-04 Pre-Auth Submission Submits via TPA portal, insurer portal, or NHCX API Receives request; auto-acknowledgment issued Validates routing envelope (sender and receiver both registered); routes to correct payer; timestamps receipt and issues acknowledgment to hospital Hospital + NHCX
P-05 Eligibility Verification Tracks status; prepares to respond to queries Confirms policy validity, sum insured, waiting periods, sub-limits, network status Passes policy query to insurer's system; returns eligibility confirmation Payer
P-06 Medical Necessity Review Available to respond to MO queries within 1–2 hours Medical Officer reviews diagnosis-procedure alignment, LOS, cost norms, clinical justification Hosts query-response thread; timestamps all communications Payer MO
P-07 Query Issuance & Response Medical records / consultant responds to payer queries with supporting documents Issues structured query via portal / NHCX; reviews hospital response Routes query to hospital; routes response to payer; SLA clock runs Both + NHCX
P-08 Fraud & Anomaly Screening None (hospital-side unaware unless flagged) Runs fraud and anomaly screening; checks for duplicate claims, overbilling patterns, cost outliers; escalates flagged cases to internal investigation team NHCX provides transaction history patterns to payer upon request Payer
P-09 Pre-Auth Decision Awaits LOA; if denied, activates reimbursement mode; if approved, proceeds with admission Issues Approval (LOA), Partial Approval, or Denial with documented reason per IRDAI format Routes LOA / denial from insurer to hospital via NHCX; delivery confirmed with timestamp Payer
P-10 Treatment & Concurrent Review Files enhancement requests for scope change / LOS extension Concurrent review MO monitors long-stay cases; approves/denies enhancements Routes enhancement requests; SLA-tracks concurrent review responses Both + NHCX
P-11 Discharge Planning Prepares itemized final bill, discharge summary, OT notes, implant stickers Awaits discharge notification; prepares for 3-hour authorization window None Hospital
P-12 Discharge Intimation Sends discharge notification via NHCX / portal Receives discharge notification; 3-hour TAT clock starts (IRDAI mandate) Delivers discharge notification; starts 3-hour TAT clock in NHCX system NHCX
P-13 Final Claim Submission Submits complete final claim package via NHCX / portal Receives, reviews final claim; scrutinizes for non-payables, tariff compliance, duplicate billing Routes final claim; stores documents; provides structured claim record to insurer Both + NHCX
P-14 Discharge Authorization Receives discharge authorization; patients pays non-payables, co-pay Issues discharge authorization within 3 hours; specifies approved final amount and deductions Delivers discharge authorization digitally; timestamps for regulatory record Payer
P-15 Final Settlement & Payment Receives payment from insurer (7–14 days); reconciles with final bill Processes payment to hospital; settlement advice issued; TDS deducted if applicable NHCX settlement data feeds into NHA / IRDAI analytics; aggregate data stored Payer / Insurer
IRDAI Mandate on 3-Hour Discharge Authorization: As of July 31, 2024, IRDAI's Master Circular mandates that all cashless insurance claims must be authorized within 3 hours of receiving the hospital's discharge request. The mandate applies to all insurers regardless of submission channel. NHCX's timestamped transaction architecture is designed to make TAT measurement and regulatory monitoring possible at scale — this is a stated design objective of the platform as adoption grows.
As-Is Reality · The Problem We Are Solving

The Normalised Pre-Authorization Workflow —
How Indian Hospitals Actually Operate Today

Before NHCX, before standardisation — this is the operational reality across India's hospital network. Every hospital navigates a fragmented maze of TPA portals, insurer-specific forms, fax machines, email threads, and phone calls — for every single cashless claim. The steps below represent the normalised, cross-hospital as-is workflow: what every hospital must do, the structural friction at each stage, and why the current system creates friction for patients, hospitals, and payers alike.

30+
IRDAI-licensed TPAs in India
Source: IRDAI / Fincover, late 2024
~22%
Of claimed value disallowed or
repudiated in FY2023–24 (by value)
Source: IRDAI Annual Report 2023–24
72%
Health claims processed via
TPAs (not in-house) in FY24
Source: IRDAI Annual Report 2023–24
20–46 days
Avg. reimbursement claim
settlement TAT (SecureNow, 2022)
Source: SecureNow / Business Standard
1 hr / 3 hrs
IRDAI mandated pre-auth /
discharge TAT (effective Jul 2024)
Source: IRDAI Master Circular 2024
📋 Methodology & Source Disclosure
The regulatory figures in this section (IRDAI TAT mandates, claims volumes, TPA share, denial rates, settlement timelines) are sourced from: IRDAI Annual Reports 2023–24 and 2024–25, the IRDAI Master Circular on Health Insurance Business 2024 (effective July 31, 2024), Lok Sabha data (Finance Minister, December 2025), and the SecureNow reimbursement claims study (Business Standard, 2022). The process workflow descriptions — covering hospital desk operations, payer review steps, and submission channels — are derived from publicly available insurer and hospital documentation (Manipal Hospitals, Medi Assist, Star Health, Niva Bupa, New India Assurance) and represent a normalised composite view of documented industry practice, not a primary survey of named hospital operations. Internal system names, specific unit labels (e.g., "CICC", "AI checker"), and proprietary tool references have been removed or marked illustrative where not publicly confirmed. Readers seeking hospital-specific operational data should consult those organisations directly.
Submission Channel Fragmentation — Illustrative Composite View of Channels Used Across Hospital Networks Today
Hospital
TPA Portal
Insurer Portal
Email / Fax
Phone Follow-up
NHCX (Live)
🏥 Apollo
✓ Primary
✓ Select
Legacy payers
✓ Always
Piloting
🏨 Fortis
✓ Primary
✓ Select
✓ Regular
✓ Always
Piloting
🏛️ Manipal
✓ Primary
Some
✓ Regular
✓ Always
Not Yet
❤️ Narayana
✓ Primary
Some
✓ Regular
✓ Always
Piloting
🔬 Max
✓ Primary
✓ Select
Legacy payers
✓ Always
Piloting
Phase by Phase —

Normalised As-Is Pre-Auth Workflow

🚶
Phase 01
Patient Arrival & Insurance Identity Establishment
Apollo
Patient walks to the dedicated Insurance & TPA Desk at the OPD or Emergency entrance. Desk staff asks for the insurance card or TPA e-card. The card number is manually entered into Apollo's HIS to pull up the member record. If the patient doesn't have the physical card, they call the TPA helpline on the patient's behalf to verify membership.
Fortis
Patient presents at the front desk. If an insurance card is available, it's scanned at the insurance helpdesk. For corporate employees, the insurance desk checks the corporate empanelment records to validate whether the employer-insurer combination is a network arrangement. No e-card? Staff calls the TPA directly to verify.
Manipal
Patient submits insurance card and photo ID at the Insurance Helpdesk. Desk confirms the hospital is empaneled with the stated insurer/TPA. If the patient's TPA is not one Manipal commonly works with, staff refers to a binder/spreadsheet of TPA contacts to identify the correct submission point.
Narayana
Patient presents at OPD or Emergency. For PMJAY patients, the Ayushman card is verified via the SHA portal (a completely separate track). For private insurance, the insurance desk verifies the TPA card and calls the TPA helpline to confirm active membership and sum-insured balance before any treatment is initiated.
Max
Corporate patients go to the corporate insurance desk; retail patients to the general insurance desk. Both desks manually capture: policy number, member ID, insurer name, TPA name (which may be different from insurer), group/retail policy type, and employee ID for corporate patients. This data is then cross-verified via a TPA portal login or phone call.
⚠ Pain Points at This Stage
  • No real-time, standardised eligibility API — verification is largely manual or requires a separate TPA portal login per insurer
  • Patient often doesn't have their card; hospital staff must make phone calls to TPA helplines — average wait: 10–20 minutes
  • Corporate policy details (TPA vs. insurer vs. broker intermediary) are frequently unclear to the patient, causing confusion
  • PMJAY / government scheme patients must be routed to an entirely separate system (SHA portal) — staff must know which track applies
🩺
Phase 02
Clinical Assessment & Treating Physician Documentation
Apollo / Fortis / Max
Treating consultant examines the patient and prepares a clinical note in the hospital's EMR. This note — formatted for internal medical records — is then separately translated into a pre-auth form. The doctor must re-enter: chief complaint, provisional diagnosis (ICD-10 code), proposed procedure (procedure/package code), expected LOS, and a clinical justification paragraph. This duplication of effort is standard practice: clinical note for records, pre-auth form for the insurer.
Manipal / Narayana
Doctor writes a clinical summary by hand or dictates it to a medical transcriptionist. The insurance desk then picks up the written note and transfers data onto the pre-auth form. In smaller or less tech-enabled Manipal/Narayana units, the pre-auth form is still a physical paper form — filled out by hand and then scanned for submission. The doctor's signature and NABH registration number must appear on the form.
⚠ Pain Points at This Stage
  • Every insurer and TPA has its own pre-auth form template — Apollo/Max staff maintain 15–25 different form templates for different payer combinations
  • ICD-10 and procedure/package code accuracy is critical but doctors rarely code — insurance desk staff must interpret clinical notes and assign codes, risking errors
  • Clinical justification language must match the insurer's medical policy guidelines or risk automatic query — but those guidelines are not standardised across payers
  • Doctor's time for form completion is uncompensated and competes with patient care time
📂
Phase 03
Document Compilation & Pre-Auth Package Preparation
All Hospitals (Normalised)
The insurance desk assembles the pre-auth package. Standard components: (1) Completed pre-auth form signed by treating doctor, (2) Patient's photo ID (Aadhaar/PAN/Passport), (3) Insurance card / TPA e-card copy, (4) Policy copy (if available), (5) Referral letter or OPD prescription, (6) Relevant investigation reports (blood reports, imaging, ECG, etc.), (7) Previous treatment records if applicable (e.g., prior hospitalisation for same condition), (8) Implant/prosthesis quotation if a device is involved, (9) Anaesthesiologist note for surgical procedures. Each document must be scanned at adequate resolution (min 200 DPI) — poor scan quality is a common cause of query.
Manipal / Narayana
At units with lower digital maturity, documents are physically collected from the ward/lab/OT, compiled into a folder, and then handed to a data entry operator who scans and uploads each document individually. This physical-to-digital handoff creates delays and is a point of loss/error — reports go missing, wrong patient files get attached.
Max
The insurance desk reviews the document package for completeness before submission — checking for missing implant quotations, investigation reports, or referral letters. In more digitally mature hospitals, workflow checklists or automated flags assist this review; in others it is experience-driven. Document compilation time varies based on case complexity and how quickly clinical departments can supply the required records.
⚠ Pain Points at This Stage
  • Each TPA has a different checklist — no standardised document set exists; hospitals maintain payer-wise SOPs that become outdated as payers change requirements
  • Implant quotations require vendor coordination which can take 1–3 hours — delaying the pre-auth submission for surgical cases
  • Patient often cannot produce past records on demand — hospital staff must track down discharge summaries from previous admissions via phone or physical retrieval
  • Document size limits on TPA portals (e.g., max 2MB per file) force staff to compress/split PDFs, adding friction
📤
Phase 04
Pre-Auth Submission — Via Fragmented Channels
All Hospitals (Normalised)
The insurance executive logs into the relevant TPA or insurer portal — each of which has a different URL, login credentials, navigation structure, and upload interface. With approximately 17 IRDAI-licensed TPAs (following several industry mergers) plus direct insurer portals, hospitals managing a broad payer mix maintain separate portal access for each. Some payers still only accept submissions via: (a) scanned PDF emailed to a claims inbox, (b) faxed form to a TPA fax number, (c) WhatsApp (informal, used by some smaller TPAs), or (d) phone intimation followed by document email. A single pre-auth submission thus requires the insurance executive to know: the correct portal URL, credentials, the form format this payer requires, whether they accept email/fax, and what email ID or fax number to use.
Narayana (PMJAY parallel)
PMJAY cases go through the SHA (State Health Agency) portal via the Transaction Management System (TMS) — a completely separate system with state-specific logins. The hospital must select the correct PMJAY package code from approximately 1,950 procedures across 27 specialties. A wrong package selection causes immediate rejection.
⚠ Pain Points at This Stage
  • Insurance executives must maintain and manage separate portal credentials for each TPA and insurer — with approximately 17 IRDAI-licensed TPAs (after recent mergers) plus direct insurer portals, credential management and portal downtime are constant operational issues
  • No single submission triggers all payers — each requires a separate manual upload even if the underlying documents are identical
  • Email/fax submissions have no guaranteed delivery confirmation — hospitals have no proof of submission if the TPA claims they didn't receive it
  • Portal downtime during peak hours (evenings, weekends) delays emergency pre-auths — patients wait in beds without treatment start
  • Time of submission varies significantly depending on portal responsiveness, document readiness, and staff load — incomplete documents or portal downtime can extend this well beyond the IRDAI-mandated 1-hour response window
⏳
Phase 05
Waiting Period — Payer Acknowledgment & Initial Review
All Hospitals (Normalised)
After submission, the hospital enters a waiting period with no real-time status visibility. The pre-auth request sits in the TPA's/insurer's queue. The hospital has no dashboard showing where in the review process the request is — whether it's been assigned to a Medical Officer, whether a query has been drafted but not yet sent, or whether it's been approved but not communicated. The only way to get status is to: (a) check the TPA portal for any status update (requires another login), (b) call the TPA helpline and wait on hold, or (c) send a follow-up email and wait for response.
⚠ Pain Points at This Stage
  • Zero real-time visibility into payer-side review progress — hospitals operate completely blind during the review window
  • Average acknowledgment from TPA: 30 minutes to 2 hours; actual medical review: additional 2–4 hours
  • Patients admitted to beds pending pre-auth are occupying inpatient resources without confirmed payment — financial risk for hospital
  • Follow-up calls to TPAs to check status consume significant insurance desk staff time — the Medi Assist portal notes that pre-auth requests submitted through network hospitals should be checked after approximately 3 hours, implying this is the expected minimum window
  • Night and weekend submissions face extended waits as TPA medical review teams operate on reduced hours — no regulatory mandate covers pre-auth response during these windows until IRDAI's 2024 directive came into effect
❓
Phase 06
Query Receipt, Interpretation & Response
All Hospitals (Normalised)
The TPA or insurer raises a query — via portal message, email, or sometimes a phone call from a TPA Medical Officer. The query may request: additional clinical records, specialist opinion, past treatment history, medical literature supporting the procedure, revised cost estimate, or clarification on a specific diagnosis code. The hospital's insurance desk receives the query and must: (1) identify which department/doctor can answer it, (2) physically or digitally collect the additional documents, (3) get treating doctor to write an addendum if clinical clarification is needed, and (4) re-upload or email the response via the same channel the query came through.
Manipal / Narayana
Queries received by phone (still common with some PSU insurer TPAs) are noted manually by the desk executive. The executive then has to translate the verbal query into a written response request for the clinical team. If the treating doctor is in OT or on rounds, query response is delayed by hours — and the TPA clock is running.
⚠ Pain Points at This Stage
  • A significant proportion of pre-auth submissions receive at least one query from the TPA or insurer — this is the single biggest source of delay in the current system. IRDAI's FY2023–24 Annual Report shows that by claim count, 11% of health claims were disallowed outright and a further 9.3% repudiated after review; by value, approximately 13% of claimed amounts were disallowed and a further 9% repudiated — indicating widespread documentation, eligibility, and coverage disputes at the claims stage
  • Queries arrive through multiple channels (portal, email, phone) with no unified tracking — the same case can have queries in three places simultaneously
  • TPA query response windows are typically 2–4 hours — missing this window restarts the clock or results in denial
  • Query language is often ambiguous — "provide clinical justification" without specifying what is missing wastes hospital response time
  • Multiple query rounds are common — TPAs may ask for document A, receive it, then ask for document B separately. Each round extends the pre-auth cycle, exposing the hospital to financial risk on in-progress treatments
✉️
Phase 07
Authorization Decision Receipt — LOA or Denial
All Hospitals (Normalised)
If approved, the TPA/insurer issues a Letter of Authorization (LOA). The LOA arrives via: TPA portal (requires login to download), email attachment (PDF), or — for some older payers — fax. The insurance desk downloads/receives the LOA, reviews it against the submitted request: approved amount (is it sufficient?), approved procedure codes (do they match what was planned?), approved room category (does it match current allocation?), and validity period (how many days is this auth valid?). Any discrepancy triggers a call back to the TPA. The LOA is then filed in the patient's physical/digital record and the admitting team is notified to proceed.
Denial Scenario (All Hospitals)
If denied, the reason is communicated via portal/email — often in brief, coded language ("not covered under policy terms," "waiting period applicable"). The insurance desk must explain this to the patient and offer alternatives: (a) pay out-of-pocket and file reimbursement, (b) seek a second opinion and resubmit, (c) escalate to the insurer's grievance cell. Denial management is manual, time-consuming, and stressful for both hospital staff and patients.
⚠ Pain Points at This Stage
  • LOA amounts frequently do not match actual treatment costs — gap must be communicated to and accepted by patient before treatment begins
  • LOA validity periods are short (typically 7–15 days) — if patient's admission is delayed, the LOA expires and a new pre-auth must be filed
  • Partial approvals ("approved ₹1.5L, balance on review") require mid-treatment enhancement requests — another submission cycle
  • Denial reasons are often insufficiently specific — hospitals struggle to know what to resubmit to get a reversal
🏥
Phase 08
In-Patient Treatment & Concurrent Review Management
All Hospitals (Normalised)
Once admitted, the hospital must manage the ongoing insurance relationship. For stays beyond 3–5 days (ICU, complex surgery recovery, chronic illness), the TPA/insurer requires concurrent reviews: regular clinical updates sent to the payer justifying continued hospitalisation. The insurance desk collects daily clinical summaries from the treating team and submits them via the same fragmented channels (portal / email). If the treatment scope changes — a planned cholecystectomy that becomes a more complex procedure due to intraoperative findings — the hospital must file an enhancement / revision request immediately, providing updated clinical notes, revised cost estimate, and surgeon's intraoperative findings.
⚠ Pain Points at This Stage
  • Concurrent review submissions are entirely manual — a daily or every-few-days administrative task consuming clinical and desk staff time
  • Enhancement requests face the same query-response cycle as the original pre-auth — adding another 4–8 hour lag to mid-treatment decisions
  • If the payer does not respond to enhancement requests promptly, the hospital is exposed to financial risk for the additional treatment cost
  • No standardised format for concurrent review updates — each payer wants a different template or level of clinical detail
📋
Phase 09
Discharge Planning & Final Bill Compilation
All Hospitals (Normalised)
The treating doctor issues a discharge note indicating the patient is ready for discharge. The billing team begins compiling the final itemized bill. This involves pulling charges from: (1) Ward/room charges per day, (2) OT and procedure charges, (3) Anaesthesia charges, (4) Nursing charges, (5) Medications and consumables (many of which are "non-payable" under insurance — must be segregated), (6) Implants / prosthetics (with original invoices / sticker labels), (7) Lab and radiology charges, (8) Consultant visit fees (each consultant billed separately). Segregation of payable vs. non-payable charges is a critical and time-consuming step — errors here cause settlement disputes.
⚠ Pain Points at This Stage
  • Non-payable item lists differ across insurers — what Insurer A excludes, Insurer B covers; billing staff must manually apply the right non-payable list per payer
  • Implant sticker collection (required as proof of use) is often delayed — nurses forget to retain stickers, causing billing holds
  • Delayed discharge summaries from doctors hold up the entire billing and claim submission process
  • Final bill compilation time varies by case complexity — surgical and ICU cases with multiple consultants, implants, and extended stays require significantly more time to itemise than routine inpatient admissions
💸
Phase 10
Discharge Claim Submission, Settlement & Reconciliation
All Hospitals (Normalised)
The complete discharge claim package is submitted to the TPA/insurer via the same portal/email/fax channels. The payer reviews the final claim against the pre-auth LOA: did the treatment stay within the approved scope? Are all implant invoices attached? Is the discharge summary consistent with the initial pre-auth diagnosis? The payer may raise a final query (post-discharge) requiring clarification. On final approval, the payer authorises payment to the hospital. The hospital releases the patient — who pays out-of-pocket only the non-payable components, co-pay, and room upgrade differential. The payment from insurer to hospital follows a variable settlement cycle depending on the payer. The hospital's accounts receivable team must track and follow up on each outstanding payment separately across multiple payers, each with their own settlement cycle and remittance format.
⚠ Pain Points at This Stage
  • Post-discharge queries delay final authorization — patient may be held at hospital until the payer confirms, creating patient dissatisfaction and bed blocking
  • Settlement timelines vary considerably by payer: a SecureNow study (Business Standard, 2022) found reimbursement claim settlement averaged 20–46 days across insurers; hospital-side cashless settlement follows a separate but similarly variable cycle
  • Partial settlements (short payments) require manual reconciliation and dispute follow-up — an administrative burden with no standardised resolution process
  • Hospitals managing multiple payers must track each outstanding payment separately — no standard electronic remittance advice (ERA) format exists across India's insurance ecosystem
Summary —

Core Systemic Problems in the As-Is Workflow

🕸️

Extreme Fragmentation

With approximately 17 IRDAI-licensed TPAs (after recent industry mergers) and dozens of direct insurer portals, hospitals must maintain separate credentials, navigate different interfaces, and follow different submission formats for every payer — with no single submission gateway.

📄

No Data Standardisation

Pre-auth forms, document checklists, non-payable lists, and clinical justification requirements differ across every payer. The same patient encounter generates multiple differently-formatted submissions.

👁️‍🗨️

Zero Real-Time Visibility

Once submitted, the hospital has no view into payer-side processing. Status is learned only through phone calls, portal polling, or waiting for the payer to reach out — creating operational anxiety and delays.

📞

Phone-Dependent Coordination

A significant portion of pre-auth coordination happens over phone — TPA helplines, doctor queries, discharge discussions. Phone interactions are untracked, unauditable, and create information gaps.

⏰

TAT Unpredictability

Pre-auth turnaround varies from 2 hours to 3 days depending on the payer, case complexity, time of day, and staffing. Hospitals cannot reliably plan admissions or bed allocation around pre-auth timelines.

🔁

Query Loops Amplify Delay

A significant proportion of pre-auths receive queries from the TPA or insurer. IRDAI FY24 data shows that by claim count, 11% of health claims were disallowed and 9.3% repudiated; by value, ~13% disallowed and ~9% repudiated — documentation gaps and eligibility disputes are primary drivers. Each query round extends the cycle; multiple rounds compound delays significantly.

💰

Cash Flow Uncertainty

Final settlement timelines range from 7 to 45+ days and vary unpredictably by payer. Hospitals extend credit to insurers for weeks, creating significant working capital pressure — especially for smaller hospital chains.

🧾

Manual AR Reconciliation

No standardised electronic remittance format means accounts receivable teams manually reconcile each payment against each claim — an error-prone, labour-intensive process that consumes significant back-office resources.

🏛️

No Regulatory Visibility

IRDAI and NHA have no real-time view into claim processing timelines, payer behaviour, or denial patterns across the system. Oversight is retrospective, data-sparse, and cannot drive timely intervention.

Sources & Disclosures

Regulatory & industry data: IRDAI Annual Report 2023–24; IRDAI Annual Report 2024–25; IRDAI Master Circular on Health Insurance Business, May 2024 (effective July 31, 2024); Lok Sabha written reply by Finance Minister Nirmala Sitharaman, December 1, 2025. TPA count (~17 active after mergers) is based on the IRDAI licensed intermediaries registry.

Settlement TAT data: SecureNow Insurance Broker reimbursement claims study (20–46 days average), reported in Business Standard, April 2022.

Process workflow: Derived from publicly available documentation published by Manipal Hospitals, Medi Assist TPA, Star Health Insurance, Niva Bupa Health Insurance, and New India Assurance. Hospital-specific steps represent a normalised composite of documented industry practice. Internal system names, proprietary tool references, and specific operational metrics not confirmed in public sources have been removed or marked as illustrative.

NHCX data: National Health Authority; India InsurTech Summit (July 2025); Wikipedia — National Health Claims Exchange; NatHealth (June 2025).
Sources · Claims Process Map

Sources & References

All regulatory figures, process descriptions, and institutional data in this document are drawn from publicly available primary and secondary sources. This page lists every source by category, with direct URLs, publication date where available, and a note on what claim each source supports. Sources are organised by topic area matching the three tabs of this process map.

Primary Government / regulatory body
Official Insurer / hospital / TPA official page
Secondary Research / industry analysis
News Verified news publication
Industry Industry body / association
🏛️

1. Regulatory & Government Sources

Type Source / Title Publisher Date Used For URL
Primary IRDAI Annual Report 2023–24 Insurance Regulatory and Development Authority of India Dec 2024 3.26 crore health claims processed; 72% via TPAs; by claim count: 11% disallowed, 9.3% repudiated; by value: ~13% disallowed, ~9% repudiated; ₹15,100 Cr disallowed; ₹31,086 avg payout per claim irdai.gov.in
Primary IRDAI Annual Report 2024–25 Insurance Regulatory and Development Authority of India 2025 3.26 crore claims; 8% repudiation rate; 69% TPA-processed (2.25 crore claims); ~17 active IRDAI-licensed TPAs after industry mergers irdai.gov.in
Primary IRDAI Master Circular on Health Insurance Business 2024 IRDAI May 29, 2024 (effective Jul 31, 2024) 1-hour pre-auth TAT mandate; 3-hour discharge authorization mandate; penalty for breach; Cashless Everywhere directive; standardised definitions irdai.gov.in/health-dept
Primary Lok Sabha Written Reply — Finance Minister Nirmala Sitharaman Parliament of India Dec 1, 2025 86.88% pre-auths processed within 1 hour (Aug 2024–May 2025); 96.69% discharge auths within 3 hours; compliance data post-Master Circular AngelOne (reporting Lok Sabha data)
Primary New India Assurance — Customer Information Sheet (Mediclaim Policy) New India Assurance Co. Ltd. Jan 2020 TPA cashless process; 24-hour intimation rule; claim registration procedure newindia.co.in (PDF)
Primary New India Assurance — Intermediary Information New India Assurance Co. Ltd. Current TPA role in NIA cashless: TPA issues ID cards, pre-auth letter, tracks discharge, submits to NIA for final payment; UTR and settlement flow newindia.co.in/intermediary
Primary New India Assurance — Premier Mediclaim Policy New India Assurance Co. Ltd. Current TPA cashless arrangement; denial ≠ treatment denial; 72-hour advance notice for TPA facilitation services newindia.co.in
🏥

2. Hospital Official Sources

Type Source / Title Publisher Date Used For URL
Official Insurance & TPA Helpdesk — Cashless Treatment FAQ Manipal Hospitals Current Manipal pre-auth process: 24-hour emergency rule, planned admission advance notice, document list, insurer coordination steps, denial and reimbursement path manipalhospitals.com/insurance-tpa-helpdesk
Official Insurance and TPA Services Aditya Birla Memorial Hospital Current Pre-auth form submitted to TPA via email; TPA sends approval or query; 10am–6pm counter hours; document list required for cashless; hospital not responsible for TPA denial adityabirlahospital.com/insurance-and-tpa
Official Empanelled Insurance & TPA — Cashless Process Smita Memorial Hospital Current Authorization letter (AL) receipt process; AL amount check; 48-hour emergency intimation; portal upload workflow; no AL within 24 hrs → patient deposit required smitahospital.com/empanelled-insurance-tpa
Secondary Case Study on TPA in Apollo Hospital, Ahmedabad SlideShare (academic case study, 2022) Sep 2022 TPA desk function at Apollo; list of 27 empanelled TPAs; pre-auth document checklist; admission and discharge process; study objective: understanding reasons for delay slideshare.net
🛡️

3. Insurer Official Sources

Type Source / Title Publisher Date Used For URL
Official Claims — Cashless Procedure Star Health & Allied Insurance Current In-house claims processing (no TPA); 14,000+ network hospitals; 96%+ cashless final approvals within 3 hours; ₹25 Cr settled daily; cashless claim procedure steps starhealth.in/claims
Official Cashless Health Insurance Star Health & Allied Insurance Current Pre-auth form submission for planned and emergency; 90% of cashless claims approved under 2 hours; 7-day post-discharge document submission deadline starhealth.in/health-insurance/cashless-health-insurance
Official How Initial Approval Works in Health Insurance Star Health & Allied Insurance Current Pre-auth definition; 3–5 day advance submission for planned; 24-hour window for emergency starhealth.in/answers
Official New Cashless Pre-Authorisation Form (PDF) Star Health & Allied Insurance Current Official pre-auth form fields and structure; required clinical and policy information starhealth.in (PDF)
Official How Cashless Treatment on Insurance Works — Step-by-Step Guide Niva Bupa Health Insurance Current 30-minute pre-auth processing commitment (subject to complete documents); cashless step-by-step; non-payable items; discharge process nivabupa.com
Official Insurance Claim — Cashless Process Niva Bupa Health Insurance Current Official cashless steps: 48-hour advance; identity verification; pre-auth form submitted by network hospital; 30-minute confirmation by SMS/email; non-payable items; discharge sign-off transactions.nivabupa.com/claims
Official ManipalCigna ProHealth Insurance — Request for Cashless Hospitalisation Form (PDF) ManipalCigna Health Insurance (now Manipal Cigna) Mar 2025 Official cashless pre-auth form fields; document list (discharge summary, cash memos, diagnostic reports, surgeon certificate); 7-day post-discharge document submission window manipalcigna.com (PDF)
Official FAQs — Customer Support (Claims) ManipalCigna Health Insurance Current Planned vs emergency cashless process; 48-hour advance notice for planned; authorisation letter sent to registered email and TPA desk manipalcigna.com/faqs/claims
🔄

4. TPA Official Sources

Type Source / Title Publisher Date Used For URL
Official Medi Assist TPA — Main Site Medi Assist India TPA Pvt. Ltd. Current 28,500+ provider partnerships; 10M+ claims received annually; 348M+ lives serviced; 125 offices; 32 insurance partners; 21+ years; WhatsApp chatbot channel mediassisttpa.in
Official Hospital FAQ — Cashless Claim Process Medi Assist India TPA Pvt. Ltd. Current Cashless vs reimbursement types; e-card usage; pre-auth form submission by hospital; real-time tracking via MediBuddy/MAven app; Medi Assist sends approval to hospital mediassisttpa.in/faq
Official All You Need to Know About Cashless Claims Medi Assist Blog Nov 2024 Pre-authorization definition; eCashless process; 72-hour planned intimation; emergency within 48 hours; network hospital requirement blog.mediassist.in/cashless-claims-guide
Official Online Claim Submission FAQs Medi Assist Blog Nov 2024 Online portal submission; passcode-based provisional pre-auth; hospital receives request and confirms availability; document upload process blog.mediassist.in/online-claim-submission-faqs
Official eCashless Portal Medi Assist India TPA Pvt. Ltd. Current Patient-side eCashless request flow; secure passcode; hospital receives request; documents required at admission m.mediassist.in/submitecashless.aspx
Official Health Insurance Ready Reckoner (PDF) Medi Assist India TPA Pvt. Ltd. Current Full cashless vs reimbursement workflow; pre-auth request within 72 hours (planned) or 24 hours (emergency); up to 3 hours for status check; original document courier within 30 days portal.mediassist.in (PDF)
🔗

5. NHCX — National Health Claims Exchange

Type Source / Title Publisher Date Used For URL
Primary National Health Claims Exchange — Wikipedia Wikipedia (citing NHA and Financial Express) 2024 NHCX developed by NHA; platform went live June 2024; first claim processed; aims to unify 50 insurance providers; FHIR-based interoperability en.wikipedia.org/wiki/National_Health_Claims_Exchange
Secondary National Health Claims Exchange (NHCX): Health Claims Reform India InsurTech Summit Jul 2025 34 insurers and TPAs live on NHCX as of July 2024 (government data); FHIR standards; single API framework; TAT measurement design; underwriting and actuarial implications; adoption without mandate indiainsurtechsummit.com
Secondary National Health Claims Exchange — Current Affairs Overview Vajiramandravi Apr 2025 3-hour cashless settlement mandate; 12 insurers + 1 TPA integrated; centralised portal reduces hospital multi-portal burden; ABDM integration vajiramandravi.com
Industry National Health Claims Exchange (Report PDF) NatHealth (Healthcare Federation of India) Jun 2025 IRDAI standardisation of claim forms; DPDP data protection alignment; technical and operational integration challenges; NHCX governance nathealthindia.org (PDF)
Secondary NHCX — National Health Claim Exchange Overview Emorphis Health Aug 2024 FHIR-based interoperability; ABDM alignment; efficiency and transparency goals; payer/provider/beneficiary ecosystem emorphis.health/blogs/nhcx-healthcare-insurance
Secondary About National Health Claims Exchange IAS Gyan (Current Affairs) Jun 2024 Finance Ministry + IRDAI joint supervision; standardised steps for all stakeholders; current TPA card and portal fragmentation problem described iasgyan.in
Secondary National Health Claims Exchange — Substack Overview Substack Sep 2024 NHA + IRDAI collaboration; open Health Claims Data Exchange Specifications; industry feedback process; Bima Sugam context substack.com/home/post/p-149357755
📊

6. Industry Statistics & Research

Type Source / Title Publisher Date Used For URL
News Health Insurance Claim Rejections Up 19.10% in FY24: IRDAI Report Business Standard Dec 27, 2024 11% health claims denied; 6% pending; ₹26,000 Cr disallowed and repudiated; 19.10% YoY increase in rejections; public vs private insurer settlement ratio disparity business-standard.com
News Health Insurers Take 20–46 Days to Settle Patients' Claims: Report Business Standard (citing SecureNow Insurance Broker study) Apr 17, 2022 Reimbursement claim settlement: 20–46 days average from intimation; maternity claims: 7–108 days; patients prompt in intimating within 1 week business-standard.com
Secondary What is TPA in Health Insurance — Role, Benefits, and Drawbacks Ditto Insurance (citing IRDAI Annual Report 2024–25) Feb 2026 69% of 2.25 crore claims processed by TPAs (IRDAI 2024–25); in-house vs TPA processing breakdown joinditto.in/articles/health-insurance/what-is-tpa
Secondary What is TPA in Health Insurance 2025 — Benefits and Role Explained Fincover 2025 TPA market overview; ~17 active IRDAI-licensed TPAs after recent mergers; 75%+ urban policyholders using cashless (FY 2024–25) fincover.com
News IRDAI Mandates Cashless Claim Within an Hour Policybazaar Jun 2024 IRDAI Master Circular directive: 1-hour TAT for cashless authorization; 100% cashless across all hospitals target; dedicated hospital help desks by July 31, 2024 policybazaar.com
Secondary Cashless Health Insurance Claim Authorisation in 2025: IRDAI Rules and Data AngelOne Dec 2025 Lok Sabha compliance data: 86.88% within 1 hour; 96.69% discharge within 3 hours; 0.77% took over 8 hours; Bima Bharosa portal integration angelone.in
Secondary How Long Does Cashless Health Insurance Claim Authorisation Take in 2025? Upstox Dec 2025 Verbatim IRDAI Master Circular language on 1-hour pre-auth and 3-hour discharge; insurer liability for delay costs; Bima Bharosa CMS integration upstox.com
Secondary Niva Bupa Health Insurance Claim Guide NYVO May 2026 Niva Bupa cashless workflow: 48-hour advance intimation; 1-hour response mandate per IRDAI Master Circular 2024; 3-hour discharge authorization; Cashless Everywhere hospitals nyvo.in/resources/claims/niva-bupa-claim-guide
Secondary IRDAI Annual Report 2024–25 Highlights Algate Insurance (summary) Mar 2026 3.26 crore claims processed; 8% repudiation rate; 2,57,790 grievances received; claims account for 69% of general insurance complaints algatesinsurance.in
News Cashless No More: Niva Bupa Customers to Pay at Max Hospitals Business Standard Sep 2, 2025 Real-world example of insurer–hospital tariff dispute causing cashless suspension; illustrates structural tension between hospital billing rates and insurer-approved tariffs business-standard.com
Process Map Scope & Limitations

This process map is compiled for informational purposes by CaladriusHealth.AI. All regulatory figures are drawn from IRDAI's published annual reports and official circulars. Process workflow descriptions for hospitals and payers represent a normalised composite of publicly documented industry practice — they are not based on primary interviews with the named organisations and should not be attributed to those organisations as confirmed internal procedures.

Named hospitals (Apollo, Fortis, Manipal, Narayana, Max) and payers (Star Health, Niva Bupa, New India Assurance, Medi Assist, ICICI Lombard) are referenced as representative entities within India's health insurance ecosystem. Internal system names, proprietary tool references, and specific operational thresholds not confirmed in public sources have been removed from this document. Readers requiring confirmed operational details from specific organisations should engage those organisations directly.

CaladriusHealth.AI is building on the ABDM ecosystem and is currently undergoing ABDM certification and security assessment, with NHCX integration in progress. This document does not constitute legal, regulatory, or clinical advice.