Insurance plan request

One Task asking a payer for the plan behind a policy. There is no patient and no clinical content, because the plan belongs to the policy and the hospital, not to an admission. Sent once per policy and cached.

Sent on /v1/insuranceplan/request, answered on /v1/insuranceplan/on_request.

The bundle​

Elements​

1. Task​

NRCeS profile: Task.

Rules​

1. The Task code system​

poll under http://terminology.hl7.org/CodeSystem/financialtaskcode, not the older https://nhcx.abdm.gov.in/api.

2. Intent​

order. Some element tables say original-order; the bundle sends order.

3. Inputs​

valueString, typed policyNumber and providerId under ndhm-task-input-type-code. At least one; both narrow the answer to the packages this hospital is empanelled for.

4. No case yet​

No case exists, so the bundle carries no case number. The callback is the only link between request and answer.

5. Task codes differ by system across the exchange​

poll, cancel, reprocess, release and status in financialtaskcode; deliver in ndhm-task-codes; approve in http://hl7.org/fhir/CodeSystem/task-code. Switch on system and code together.

6. When to send it​

Once per policy, not per patient. Refresh on a policychange communication and on your own schedule.

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 PMJAY bundle has the same resources, elements and systems as the generic one.

What PMJAY specifies​

• policyNumber is the beneficiary's own policy code from the policy lookup, of the form PMJAY/<state>/S/G.
• providerId is the hospital's HFR ID, the same value as on its participant record.

What PMJAY requires​

• A policy the hospital is not empanelled under is refused with PAYR-1401.
• Refresh weekly per the FRD, or every fifteen days per the scenario sheet, and at once on renewal, amendment or a policychange communication.

Use cases, APIs and data elements​

B2 Request insurance plan (provider)​

A Task with code poll, keyed on policy number and provider id. The answer is the policy as a benefit structure: packages, rates, documents, questionnaires.

Request headers

Data elements

NRCeS profiles: Task.

D1 Fetch the insurance plan (pmjay)​

Keyed on provider id, policy code and participant id. The answer is the scheme configuration for this hospital: specialities, packages, rates, Claim-Condition flags, mandatory documents and questionnaires. Over twenty megabytes; store it queryable, version it, refresh weekly and on any policychange communication.

Request headers

Data elements

NRCeS profiles: Task.