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Bundles and conventions

Everything that crosses the exchange is one FHIR R4 Bundle of type collection, built to the NRCeS profiles for NHCX. The bundles in this reference are generic: any payer on the exchange takes them, private insurers and TPAs regulated by IRDAI as well as government schemes. Each chapter shows the generic bundle for one exchange in one direction, then what PMJAY changes and what PMJAY requires on top. The package's sample collection is read the same way: a provider's bundles are either examples written to this specification or captures from the sandbox run against the PMJAY payer, and a payer's are either the generic payer's or PMJAY's own. This chapter holds the rules every bundle obeys before any exchange is considered.

Rules​

1. Bundle type​

collection, not document and not transaction. Entries are resources placed directly, with no request or response elements. The open-protocol page describes claim objects as document bundles with a root Composition; the exchange accepts collection, and a Composition appears only at the head of an embedded clinical record.

2. Profiles​

Declare the NRCeS profile in meta.profile on every resource you send, for example https://nrces.in/ndhm/fhir/r4/StructureDefinition/Claim. Declare only profiles NRCeS publishes: there is no NRCeS QuestionnaireResponse profile, so a QuestionnaireResponse takes the base FHIR definition. Do not require a profile on what you receive: payer-generated resources often carry none.

3. References​

Resources in one bundle reference each other by urn:uuid:, with the same UUID as the entry's fullUrl. Absolute URLs are also accepted. Parse both.

4. Timestamps​

ISO 8601 with the Indian offset, +05:30. UTC fails validation. Read Bundle.timestamp for the send time; meta.lastUpdated can be stale.

5. Identifier types come from two systems​

PMJAY, ABHA, CLN, UTR, HPID and HPIN from NRCeS at https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-identifier-type-code. NPI for a hospital's HFR ID, NIIP for a payer's registry ID, NH for a plan, MB for a member number, and JHN, MD and MR from HL7 at http://terminology.hl7.org/CodeSystem/v2-0203. Take the system from the exchange you are building, not from the code.

6. The HFR ID inside the bundle​

Must equal the registry ID on the sender's participant record, whichever element carries it.

A Claim.item points at its diagnosis, procedure, care team and supporting information by sequence number, not by reference. Resolve through the sequence field, never by array position.

8. Documents arrive two ways​

A supporting-info entry carries the file inline in valueAttachment, or points with valueReference at a resource in the same bundle: a DocumentReference, or the Composition heading an embedded ABDM record. One document per entry, 2 MB each, 20 MB per claim or preauthorisation bundle. Plan responses run past 20 MB; size clients and proxies for 25 MB.

9. Category decides structured or not​

Supporting-info categories DIA, HDS, CD and INF take a reference to a structured record. POI, POA, DOB, DEF, FIR, ATT and MB take an attachment.

10. Encode attachments once​

Base64 the file once. On receipt, check the decoded bytes for a file signature before trusting them, because double-encoded attachments are in circulation and render as a blank page.

11. One Claim, three uses​

Claim.use is preauthorization, claim or predetermination, and nothing else changes. pre-auth and pre-det are not codes.

12. Codes and displays match the plan​

Character for character, including the plan's own misspellings. A payer rejects a package whose display differs from the plan's.

13. Match on the code, not the system​

The same package code appears under different systems in different exchanges. Match incoming codes on the code, and emit the system the exchange you are building expects.

Resources by exchange​

Each resource the bundles carry, its NRCeS profile, and the exchanges that use it.

Claim​

NRCeS profile: Claim.

ClaimResponse​

NRCeS profile: ClaimResponse.

Communication​

NRCeS profile: Communication.

CommunicationRequest​

NRCeS profile: CommunicationRequest.

Coverage​

NRCeS profile: Coverage.

CoverageEligibilityRequest​

NRCeS profile: CoverageEligibilityRequest.

CoverageEligibilityResponse​

NRCeS profile: CoverageEligibilityResponse.

InsurancePlan​

NRCeS profile: InsurancePlan.

Location​

NRCeS profile: Location.

Organization​

NRCeS profile: Organization.

Patient​

NRCeS profile: Patient.

PaymentNotice​

NRCeS profile: PaymentNotice.

PaymentReconciliation​

NRCeS profile: PaymentReconciliation.

Practitioner​

NRCeS profile: Practitioner.

PractitionerRole​

NRCeS profile: PractitionerRole.

Procedure​

NRCeS profile: Procedure.

Questionnaire​

QuestionnaireResponse​

Task​

NRCeS profile: Task.

Profiles in use​

The profiles the bundles declare in meta.profile, each linked to its published definition.

PMJAY​

The generic bundle above is what every payer takes, IRDAI-regulated insurers and TPAs included. PMJAY takes it with the changes and requirements below.

What PMJAY specifies​

  • Payer-generated bundles carry the case number as Bundle.identifier, under the payer's own host. The host arrives spelled both payer.pmjay.nha.gov.in and payer.pmajy.nha.gov.in; echo the spelling that arrived.
  • Payer-generated bundles tag every resource SUBSETTED from http://terminology.hl7.org/CodeSystem/v3-ObservationValue, "Resource encoded in summary mode". It marks a projection of the payer's record, not an error.
  • Identifier systems on the payer's side are NHA hosts such as https://hcx.pmjay.gov.in/v1/preauthorization and https://payer.nha.gov.in.
  • A preauthorisation with its embedded clinical records runs to around 30 entries, a claim to over 40, a query answer to nearly a hundred.

What PMJAY requires​

  • Element ids on every Claim bundle: the Claim its claim number, each item Item/n, each procedure Procedure/n, each supportingInfo SupportingInformation/n; 1 for Patient, Coverage and the provider Organization, 2 for the payer Organization. Refused with PAYR-1027 otherwise.
  • The Practitioner carries the HPR id typed HPIN under https://hpr.abdm.gov.in, beside HPID and the registration number typed MD. Refused with PAYR-1083 otherwise.
  • Items coded from the package master: item.category is the master's specialty code, and the ward tier rides as item.modifier with the master's stratification code.
  • Every supportingInfo carries a sequence, numbered from 1 with no gaps. Refused with PAYR-1019 otherwise.
  • Attachments as application/pdf, application/jpg, application/jpeg, application/png or application/fhir+json. Anything else is refused with PAYR-1008.
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