Communication

The payer's asynchronous channel to the provider: a turnaround alert, a grievance, a policy or wallet change, or a request for documents. The provider acknowledges within thirty seconds, whether or not the issue is resolved.

The request​

Sent on /v1/communication/request.

The bundle​

Elements​

1. Task​

NRCeS profile: Task.

2. CommunicationRequest​

NRCeS profile: CommunicationRequest.

The Claim, Patient, Organization, Practitioner, Coverage entries are shaped as in the chapters that introduce them.

A notification​

Sent on /v1/communication/request, workflow N02.

The bundle​

Elements​

1. Task​

NRCeS profile: Task.

2. CommunicationRequest​

NRCeS profile: CommunicationRequest.

The Organization entries are shaped as in the chapters that introduce them.

The acknowledgement​

Sent on /v1/communication/on_request.

The bundle​

Elements​

1. Task​

NRCeS profile: Task.

2. Communication​

NRCeS profile: Communication.

The CommunicationRequest, Claim, Patient, Organization, Practitioner, Coverage entries are shaped as in the chapters that introduce them.

Rules​

1. The push pattern​

Task.code poll with an input of type include referencing the resource being delivered, a CommunicationRequest from the payer. intent is order on a request and proposal on a notification. Resolve the reference and read its type.

2. Switch on the reason​

Task.reasonCode from ndhm-reason-code: tatquery, grievance, walletupdate, policychange, additionalinfo, claimArbitration. Accept the misspelling claimArbitartion on receipt.

3. Notifications​

A notification carries its reason under the communication-category system, such as information, and a CommunicationRequest with category notification and the message in payload.

4. Category, priority, topic​

category alert, reminder, notification, instruction or questionnaire; priority routine, urgent, asap or stat; topic progress-update for anything about a live case.

5. completed is the event​

Task.status and Communication.status read completed when the message is delivered. Do not close a case on them.

6. The acknowledgement​

A Task coded deliver, completed, whose include input references a Communication with basedOn naming the request. Same correlation id. Take each organisation's role from Organization.type, not from the identifier type.

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​

PMJAY sends this exchange in the generic shape.

What PMJAY specifies​

• PMJAY does not use this channel for queries. A PMJAY CommunicationRequest is a notification: a turnaround alert, a grievance, a wallet or policy change, or an arbitration intimation.

What PMJAY requires​

• Acknowledge within thirty seconds with the same Task bundle and Task.status completed, and leave the case's status alone.

Use cases, APIs and data elements​

C6 Raise a communication (payer)​

A message about a case, typed by its reason code: additionalinfo, tatquery for a turnaround breach, grievance, walletupdate, policychange, claimArbitration. A generic or IRDAI payer raises its document queries here, as a CommunicationRequest task bundle carrying 24, 241 or 27, and takes the answer as a Communication task bundle on on_request echoing the correlation id and workflow id. PMJAY does not use it for queries; its query is the ClaimResponse on the case's own thread.

Request headers

Workflow codes

Data elements

NRCeS profiles: CommunicationRequest, Task.

B4 Respond to a communication (provider)​

Acknowledge or answer a message the payer sent about a case. A generic or IRDAI payer raises its query here, as a CommunicationRequest task bundle carrying 24, 241 or 27; the answer is a Communication task bundle on on_request that echoes the request's correlation id and workflow id. The payer's reason code says what kind of message it was.

Request headers

Workflow codes

Data elements

NRCeS profiles: Communication.