Claim query and answer
The payer asking for something before it adjudicates a claim. A private insurer asks through a communication; PMJAY asks in the claim response and takes the whole claim back as the answer.
The query
Sent on /v1/communication/request, workflow 27.
The bundle
| # | Resource | Profile |
|---|---|---|
| 1 | Task | Task |
| 2 | CommunicationRequest | CommunicationRequest |
| 3 | Claim | Claim |
| 4 | Patient | Patient |
| 5 | Organization (ins) | Organization |
| 6 | Organization (prov) | Organization |
| 7 | Practitioner | Practitioner |
| 8 | Coverage | Coverage |
Elements
1. Task
NRCeS profile: Task.
| Element | Example |
|---|---|
status | requested |
intent | order |
reasonCode.coding[] | additionalinfo Additional Information Request in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-reason-code |
code.coding[] | poll in http://terminology.hl7.org/CodeSystem/financialtaskcode |
description | Share the final bill breakup and the discharge summary. |
authoredOn | 2026-09-10T23:52:39+05:30 |
requester | reference urn:uuid:39cd4b51-bddd-5cc1-a65a-6fa4a2a83cb5, display Organization |
owner | reference urn:uuid:84d112ec-041c-57f8-986c-6619ccd8245e, display Organization |
input[].type.coding[] | include in http://terminology.hl7.org/CodeSystem/financialtaskinputtype |
input[].valueReference | reference urn:uuid:e6c95fe2-3bd5-5c9f-bf78-47959029cfe2, display CommunicationRequest |
2. CommunicationRequest
NRCeS profile: CommunicationRequest.
| Element | Example |
|---|---|
identifier[] | value NM-26-0SE00002K |
basedOn[] | reference urn:uuid:5c997608-ee6c-5496-9fdb-f8415e3eb8d5, display Claim-claim |
status | active |
category[].coding[] | alert in http://terminology.hl7.org/CodeSystem/communication-category |
priority | routine |
payload[] | contentString Share the final bill breakup and the discharge summary. |
authoredOn | 2026-09-10T23:52:39+05:30 |
requester | reference urn:uuid:39cd4b51-bddd-5cc1-a65a-6fa4a2a83cb5, display Organization |
recipient[] | reference urn:uuid:84d112ec-041c-57f8-986c-6619ccd8245e, display Organization |
sender | reference urn:uuid:39cd4b51-bddd-5cc1-a65a-6fa4a2a83cb5, display Organization |
reasonCode[] | text Share the final bill breakup and the discharge summary. |
reasonCode[].coding[] | additionalinfo Additional Information Request in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-reason-code |
The Claim, Patient, Organization, Practitioner, Coverage entries are shaped as in the chapters that introduce them.
The answer
Sent on /v1/communication/on_request, workflow 27, echoed.
The bundle
| # | Resource | Profile |
|---|---|---|
| 1 | Task | Task |
| 2 | Communication | Communication |
| 3 | CommunicationRequest | CommunicationRequest |
| 4 | Claim | Claim |
| 5 | Patient | Patient |
| 6 | Organization (prov) | Organization |
| 7 | Organization (pay) | Organization |
| 8 | Practitioner | Practitioner |
| 9 | Coverage | Coverage |
Elements
1. Task
NRCeS profile: Task.
| Element | Example |
|---|---|
status | completed |
intent | order |
code.coding[] | deliver in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-task-codes |
authoredOn | 2026-09-10T23:52:45+05:30 |
requester | reference https://nhcx.abdm.gov.in/provider, display Organization |
owner | reference https://nhcx.abdm.gov.in/payer, display Organization |
input[].type.coding[] | include in http://terminology.hl7.org/CodeSystem/financialtaskinputtype |
input[].valueReference | reference urn:uuid:6840ec3f-7126-4bfc-8a56-c2a2e9576d8d, display Communication |
reasonCode.coding[] | additionalinfo Additional Information Request in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-reason-code |
2. Communication
NRCeS profile: Communication.
| Element | Example |
|---|---|
identifier[] | value NM-26-0SE00002K |
basedOn[] | reference urn:uuid:e6c95fe2-3bd5-5c9f-bf78-47959029cfe2, display CommunicationRequest |
inResponseTo[] | reference urn:uuid:e6c95fe2-3bd5-5c9f-bf78-47959029cfe2, display CommunicationRequest |
about[] | reference https://nhcx.abdm.gov.in/claim/request, display Claim urn:uuid:5c997608-ee6c-5496-9fdb-f8415e3eb8d5 |
status | completed |
category[].coding[] | notification in http://terminology.hl7.org/CodeSystem/communication-category |
priority | routine |
recipient[] | reference https://nhcx.abdm.gov.in/payer, display Organization |
sender | reference https://nhcx.abdm.gov.in/provider, display Organization |
payload[] | contentString Final bill and discharge summary attached. |
payload[].contentAttachment | contentType application/pdf, title Proof of Identity (Aadhaar / Passport / Voter ID), creation 2026-09-10T23:52:21+05:30 |
contentType application/pdf, title Medical Certificate / Doctor Referral, creation 2026-09-10T23:52:21+05:30 | |
contentType application/pdf, title Radiology / X-Ray / CT / MRI Scan Reports, creation 2026-09-10T23:52:21+05:30 | |
| and 6 more | |
payload[].extension[] | url <participant-defined>, valueString POI |
url <participant-defined>, valueString CER | |
url <participant-defined>, valueString RAD | |
| and 6 more |
The CommunicationRequest, Claim, Patient, Organization, Practitioner, Coverage entries are shaped as in the chapters that introduce them.
Rules
1. The generic query
A Task coded poll, reason additionalinfo, with an include input referencing a CommunicationRequest whose basedOn names the claim. Sent on /v1/communication/request under 27.
2. The generic answer
A Task coded deliver in ndhm-task-codes, completed, with an include input referencing a Communication whose basedOn names the request and whose payload carries the message and the documents. Posted on /v1/communication/on_request, echoing the correlation id and workflow id.
3. Keep attachments on their codes
When rebuilding a bundle to answer a query, key each attachment to its document code as you assemble it, and check the pairing before you send.
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 changes in the bundle
The query
PMJAY uses a different bundle for this step, headed by ClaimResponse rather than Task.
| # | Resource | Profile |
|---|---|---|
| 1 | ClaimResponse | none declared; NRCeS ClaimResponse |
| 2 | Patient | none declared; NRCeS Patient |
| 3 | Organization (pay) | none declared; NRCeS Organization |
| 4 | Organization (prov) | none declared; NRCeS Organization |
| 5 | Coverage | none declared; NRCeS Coverage |
1. ClaimResponse
NRCeS profile: ClaimResponse.
| Element | Example |
|---|---|
identifier[] | system https://hcx.pmjay.gov.in/v1/preauthorization, value NM-26-0SF00002T |
identifier[].type.coding[] | CLN Claim number in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-identifier-type-code |
status | active |
use | claim |
patient | reference https://payer.nha.gov.in/claim/v1/claim/on_submit/claimresponse/patient/PMJAY00… |
created | 2026-09-11T00:04:37+05:30 |
insurer | reference https://payer.nha.gov.in/claim/v1/claim/on_submit/claimresponse/organization/pa… |
requestor | reference https://payer.nha.gov.in/claim/v1/claim/on_submit/claimresponse/organization/pr… |
outcome | partial |
disposition | query |
payeeType.coding[] | provider Provider in http://terminology.hl7.org/CodeSystem/payeetype |
item[] | id Item/Item/1, itemSequence 1 |
item[].adjudication[].category.coding[] | submitted Submitted Amount in https://hl7.org/fhir/R4/valueset-adjudication.html |
eligible Eligible Amount in https://hl7.org/fhir/R4/valueset-adjudication.html | |
reason Reason for Adjudication in https://hl7.org/fhir/R4/valueset-adjudication.html | |
| and 3 more | |
item[].adjudication[].amount | value 1800 |
value 2070 | |
item[].adjudication[].reason.coding[] | display : null |
Queried Queried | |
item[].adjudication[] | value 100 |
value 0 | |
adjudication[].category.coding[] | status Status |
adjudication[].reason.coding[] | queried Queried |
total[].category.coding[] | benefit Benefit Amount in https://hl7.org/fhir/R4/valueset-adjudication.html |
submitted Submitted Amount in https://hl7.org/fhir/R4/valueset-adjudication.html | |
tax Tax in https://hl7.org/fhir/R4/valueset-adjudication.html | |
| and 2 more | |
total[].amount | value 0 |
value 1800 | |
value 2070 | |
total[] | id PMJAY0000X/PMJAY-T |
The Patient, Organization, Coverage entries are shaped as in the chapters that introduce them.
The answer
PMJAY uses a different bundle for this step, headed by Claim rather than Task.
| # | Resource | Profile |
|---|---|---|
| 1 | Claim | Claim |
| 2 | Patient | Patient |
| 3 | Organization (prov) | Organization |
| 4 | Organization (pay) | Organization |
| 5 | Coverage | Coverage |
| 6 | Practitioner | Practitioner |
| 7 | Procedure | Procedure |
| 8 | QuestionnaireResponse | QuestionnaireResponse, which NRCeS does not publish; base FHIR QuestionnaireResponse |
| 9 | QuestionnaireResponse | QuestionnaireResponse, which NRCeS does not publish; base FHIR QuestionnaireResponse |
| 10 | QuestionnaireResponse | QuestionnaireResponse, which NRCeS does not publish; base FHIR QuestionnaireResponse |
| 11 | QuestionnaireResponse | QuestionnaireResponse, which NRCeS does not publish; base FHIR QuestionnaireResponse |
| 12 | QuestionnaireResponse | QuestionnaireResponse, which NRCeS does not publish; base FHIR QuestionnaireResponse |
| 13 | QuestionnaireResponse | QuestionnaireResponse, which NRCeS does not publish; base FHIR QuestionnaireResponse |
1. Claim
NRCeS profile: Claim.
| Element | Example |
|---|---|
identifier[] | system https://nhcx.abdm.gov.in, value NM-26-0SF00002T |
identifier[].type.coding[] | CLN Claim number in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-identifier-type-code |
status | active |
type.coding[] | 737481003 Inpatient care management (procedure) in http://snomed.info/sct |
use | claim |
patient | reference https://nhcx.abdm.gov.in/patient |
billablePeriod | start 2026-09-10T00:00:00+05:30, end 2026-09-10T00:00:00+05:30 |
created | 2026-09-11T00:04:45+05:30 |
insurer | reference https://nhcx.abdm.gov.in/payer |
provider | reference https://nhcx.abdm.gov.in/provider |
priority.coding[] | normal Normal in http://terminology.hl7.org/CodeSystem/processpriority |
careTeam[] | sequence 1 |
careTeam[].provider | reference https://nhcx.abdm.gov.in/practitioner |
careTeam[].role.coding[] | primary Primary provider in http://terminology.hl7.org/CodeSystem/claimcareteamrole |
careTeam[].qualification.coding[] | 394802001 General medicine in http://snomed.info/sct |
supportingInfo[] | id SupportingInformation/1, sequence 1 |
id SupportingInformation/2, sequence 2 | |
id SupportingInformation/3, sequence 3 | |
| and 24 more | |
supportingInfo[].category.coding[] | INV Document Type - Investigation in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-supportinginfo-category |
HDS Hospital discharge summary in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-supportinginfo-category | |
ONS Period, start or end dates of aspects of the Condition. (e.g. admission, discha… in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-supportinginfo-category | |
| and 4 more | |
supportingInfo[].code.coding[] | ODN Death Certificate in https://nhcx.abdm.gov.in/document-code |
ODN Clinical Note/Death Summary in https://nhcx.abdm.gov.in/document-code | |
ODN Mortality audit report in https://nhcx.abdm.gov.in/document-code | |
| and 17 more | |
supportingInfo[].valueAttachment | contentType application/pdf, title Death Certificate |
contentType application/pdf, title Clinical Note/Death Summary | |
contentType application/pdf, title Mortality audit report | |
| and 10 more | |
supportingInfo[].valueReference | reference https://nhcx.abdm.gov.in/questionnaireresponse/1, display Death |
reference https://nhcx.abdm.gov.in/questionnaireresponse/2, display Discharge Against Medical Advice (DAMA) | |
reference https://nhcx.abdm.gov.in/questionnaireresponse/3, display Discharge Consent | |
| and 3 more | |
diagnosis[] | sequence 1 |
diagnosis[].diagnosisCodeableConcept.coding[] | E11.9 Type 2 diabetes mellitus without complications in http://hl7.org/fhir/sid/icd-10 |
diagnosis[].type[].coding[] | admitting Admitting Diagnosis in http://terminology.hl7.org/CodeSystem/ex-diagnosistype |
diagnosis[].onAdmission.coding[] | yes Yes in http://terminology.hl7.org/CodeSystem/ex-diagnosis-on-admission |
procedure[] | id Procedure/1, sequence 1, date 2026-09-10T00:00:00+05:30 |
procedure[].type[].coding[] | conservative Conservative in https://nhcx.abdm.gov.in/procedure-type |
procedure[].procedureReference | reference https://nhcx.abdm.gov.in/procedure/1, display Pleural Effusion (Pleural Effusion) |
insurance[] | sequence 1, focal true, preAuthRef 2026091110000795 |
insurance[].coverage | reference https://nhcx.abdm.gov.in/coverage |
item[] | id Item/1, sequence 1, factor 1, careTeamSequence 1, diagnosisSequence 1, procedureSequence 1, informationSequence 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 |
item[].productOrService.coding[] | MG0111A Pleural Effusion (Pleural Effusion) in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-procedure-code |
item[].servicedPeriod | start 2026-09-10, end 2026-09-10 |
item[].quantity | value 1 |
item[].unitPrice | value 1800, currency INR |
item[].net | value 1800, currency INR |
item[].category.coding[] | MG General Medicine in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-benefit-category |
item[].modifier[].coding[] | STRAT006a Routine Ward |
item[].programCode[].coding[] | AB-PMJAY Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-program-code |
total | value 1800, currency INR |
8. QuestionnaireResponse
| Element | Example |
|---|---|
questionnaire | https://payer.gov.in/policy/questionnaire/100025 |
status | completed |
subject | reference https://nhcx.abdm.gov.in/patient |
authored | 2026-09-11T00:04:45+05:30 |
item[] | linkId 100011, text Death Stage |
linkId 100098, text Death Date | |
linkId 100099, text Death Certificate | |
| and 2 more | |
item[].answer[] | valueString Before Surgery/Treatment |
valueDateTime 2026-09-10T18:34:00+05:30 | |
item[].answer[].valueAttachment | contentType application/pdf, title Death Certificate |
contentType application/pdf, title Clinical Note/Death Summary | |
contentType application/pdf, title Mortality audit report |
9. QuestionnaireResponse
| Element | Example |
|---|---|
questionnaire | https://payer.gov.in/policy/questionnaire/100137 |
status | completed |
subject | reference https://nhcx.abdm.gov.in/patient |
authored | 2026-09-11T00:04:45+05:30 |
item[] | linkId 103020, text DAMA Stage |
linkId 101403, text In Treatment Photo with Doctor/PMAM | |
linkId 100012, text Discharge Date | |
| and 3 more | |
item[].answer[] | valueString Before Surgery/Treatment |
valueDateTime 2026-09-10T18:34:00+05:30 | |
item[].answer[].valueAttachment | contentType application/pdf, title In Treatment Photo with Doctor/PMAM |
contentType application/pdf, title Upload Mangalkamana Patra | |
contentType application/pdf, title Feedback Form |
10. QuestionnaireResponse
| Element | Example |
|---|---|
questionnaire | https://payer.gov.in/policy/questionnaire/100466 |
status | completed |
subject | reference https://nhcx.abdm.gov.in/patient |
authored | 2026-09-11T00:04:45+05:30 |
item[] | linkId 135477, text Medical Superintendent Declaration Form (During Discharge) |
item[].answer[].valueAttachment | contentType application/pdf, title Medical Superintendent Declaration Form (During Discharge) |
11. QuestionnaireResponse
| Element | Example |
|---|---|
questionnaire | https://payer.gov.in/policy/questionnaire/100005 |
status | completed |
subject | reference https://nhcx.abdm.gov.in/patient |
authored | 2026-09-11T00:04:45+05:30 |
item[] | linkId 100097, text Post Treatment Photo with Doctor/PMAM |
linkId 100096, text Discharge Summary | |
linkId 101799, text Discharge Stage | |
| and 4 more | |
item[].answer[].valueAttachment | contentType application/pdf, title Post Treatment Photo with Doctor/PMAM |
contentType application/pdf, title Discharge Summary | |
contentType application/pdf, title Feedback Form | |
item[].answer[] | valueString After Surgery/Treatment |
valueDateTime 2026-09-10T18:34:00+05:30 | |
valueString Yes |
12. QuestionnaireResponse
| Element | Example |
|---|---|
questionnaire | https://payer.gov.in/policy/questionnaire/100022 |
status | completed |
subject | reference https://nhcx.abdm.gov.in/patient |
authored | 2026-09-11T00:04:45+05:30 |
item[] | linkId 100088, text Hospital Bill |
linkId 15201, text Justification Letter | |
linkId 103013, text Bill Date | |
| and 4 more | |
item[].answer[].valueAttachment | contentType application/pdf, title Hospital Bill |
contentType application/pdf, title Justification Letter | |
contentType application/pdf, title Any other document | |
item[].answer[] | valueDateTime 2026-09-10T18:34:00+05:30 |
valueString Recorded. |
13. QuestionnaireResponse
| Element | Example |
|---|---|
questionnaire | https://payer.gov.in/policy/questionnaire/100136 |
status | completed |
subject | reference https://nhcx.abdm.gov.in/patient |
authored | 2026-09-11T00:04:45+05:30 |
item[] | linkId 100115, text LAMA Stage |
linkId 101403, text In Treatment Photo with Doctor/PMAM | |
linkId 100101, text Surgery/Treatment Date | |
| and 2 more | |
item[].answer[] | valueString Before Surgery/Treatment |
valueDateTime 2026-09-10T18:34:00+05:30 | |
valueString Yes | |
item[].answer[].valueAttachment | contentType application/pdf, title In Treatment Photo with Doctor/PMAM |
The Patient, Organization, Coverage, Practitioner, Procedure entries are shaped as in the chapters that introduce them.
What PMJAY specifies
- The query is a
ClaimResponsewithoutcomepartialand reasonqueriedon 27, the question as free text in the item adjudication. - The answer is a fresh submit of the whole claim, on the same claim number, under 161.
What PMJAY requires
- Answer on 161. A claim query answered on 151, 19 or 16 is refused with
PAYR-1321. - The full bundle, rebuilt from your stored submission, never a delta.
Use cases, APIs and data elements
D10 Answer a claim query (pmjay)
As D7, on the claim endpoint: the query is a ClaimResponse on 27, the answer a fresh submit on 161. The sandbox refuses 151, 19 and 16 with PAYR-1321. The final adjudication then arrives with outcome complete and, often, a deductible adjudication naming why the eligible amount is less than the claimed one.
| API | /v1/claim/submit apis/05-claim/v1-claim-submit.bru |
| Callback | /v1/claim/on_submit apis/05-claim/v1-claim-on-submit.bru |
| Workflow | 161 |
| Carries JWE | yes |
| Focal resource | Claim |
| Simulator console | /builder?family=claim&usecase=query-answer |
Request headers
| Header | Example value |
|---|---|
x-hcx-sender_code | 1000004446@hcx |
x-hcx-recipient_code | 1518@hcx |
x-hcx-api_call_id | {{$guid}} |
x-hcx-request_id | {{$guid}} |
x-hcx-correlation_id | {{$guid}} |
x-hcx-workflow_id | 161 |
x-hcx-timestamp | {{$isoTimestamp}} |
x-hcx-status | request.initiated |
x-hcx-ben-abha-id | 91711234567890 |
x-hcx-use_case | New |
Workflow codes
| Code | Name | Authored by | x-hcx-status | Means |
|---|---|---|---|---|
161 | Claim Doc Query Response | status sheet only | response.complete |
Data elements
| Element | Label | Group | Type | Card. | FHIR path | Example | Notes |
|---|---|---|---|---|---|---|---|
claimNumber | Claim Number | Case | string | 1..1 | Claim.identifier[0].value | CL26AA2600001 | |
workflowId | Workflow Code | Header | string | 1..1 | Header.x-hcx-workflow_id | 161 |
NRCeS profiles: Claim.