Preauthorisation query and answer

When the payer wants more before it decides. A private insurer raises the query as a communication and takes the answer as one. PMJAY raises it as a ClaimResponse on the case's own thread and takes the answer as the whole preauthorisation, resubmitted.

The query

Sent on /v1/communication/request, workflow 24.

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 pre-operative X-ray and the clinical notes.`
`authoredOn`	`2026-09-10T23:51:47+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:4b35a6eb-3f99-5d0c-b0c8-5b2f049fdbde`, display `CommunicationRequest`

2. CommunicationRequest

NRCeS profile: CommunicationRequest.

Element	Example
`identifier[]`	value `NM-26-0SE00002I`
`basedOn[]`	reference `urn:uuid:c1a17d6e-c718-58de-8d3d-fd4c0607d729`, display `Claim-preauth`
`status`	`active`
`category[].coding[]`	`alert` in `http://terminology.hl7.org/CodeSystem/communication-category`
`priority`	`routine`
`payload[]`	contentString `Share the pre-operative X-ray and the clinical notes.`
`authoredOn`	`2026-09-10T23:51:47+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 pre-operative X-ray and the clinical notes.`
`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 24, 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`	`2026-09-10T23:51:53+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:3e398f2b-ab14-41e5-8939-d7746eea43de`, 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-26-0SE00002I`
`basedOn[]`	reference `urn:uuid:4b35a6eb-3f99-5d0c-b0c8-5b2f049fdbde`, display `CommunicationRequest`
`inResponseTo[]`	reference `urn:uuid:4b35a6eb-3f99-5d0c-b0c8-5b2f049fdbde`, display `CommunicationRequest`
`about[]`	reference `https://nhcx.abdm.gov.in/preauth/request`, display `Claim urn:uuid:c1a17d6e-c718-58de-8d3d-fd4c0607d729`
`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 `X-ray and clinical notes attached as asked.`
`payload[].contentAttachment`	contentType `application/pdf`, title `Proof of Identity (Aadhaar / Passport / Voter ID)`, creation `2026-09-10T23:51:40+05:30`
	contentType `application/pdf`, title `Medical Certificate / Doctor Referral`, creation `2026-09-10T23:51:40+05:30`
	contentType `application/pdf`, title `Radiology / X-Ray / CT / MRI Scan Reports`, creation `2026-09-10T23:51:40+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 preauthorisation. Sent on /v1/communication/request under 24.

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.

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-26-0SF000031`
`identifier[].type.coding[]`	`CLN` Claim number in `https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-identifier-type-code`
`status`	`active`
`use`	`preauthorization`
`patient`	reference `https://payer.nha.gov.in/preauthorization/v1/preauth/on_submit/claimresponse/pa…`
`created`	`2026-09-11T00:33:03+05:30`
`insurer`	reference `https://payer.nha.gov.in/preauthorization/v1/preauth/on_submit/claimresponse/or…`
`requestor`	reference `https://payer.nha.gov.in/preauthorization/v1/preauth/on_submit/claimresponse/or…`
`outcome`	`partial`
`disposition`	`query`
`preAuthRef`	`2026091110000817`
`payeeType.coding[]`	`provider` Provider in `http://terminology.hl7.org/CodeSystem/payeetype`
`item[]`	id `Item/Item/2`, itemSequence `2`
	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 `1500`
	value `1725`
	value `1800`
	and 1 more
`item[].adjudication[].reason.coding[]`	display `: Request acknowledged and accepted for further processing.`
	`Queried` Queried
	`Approved` Approved
`item[].adjudication[]`	value `0`
	value `100`
	value `1`
`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 `2070`
	value `1725`
	value `0`
	and 1 more
`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

1. Claim

NRCeS profile: Claim.

Element	Example
`identifier[]`	system `https://nhcx.abdm.gov.in`, value `NM-26-0SE00002N`
`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`	`preauthorization`
`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`	`2026-09-10T23:55:36+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 6 more
`supportingInfo[].category.coding[]`	`INV` Document Type - Investigation 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`
	`OTH` Other in `https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-supportinginfo-category`
	and 2 more
`supportingInfo[].code.coding[]`	`MAND0455` CXR PA view or CECT chest abdomen and pelvis in `https://nhcx.abdm.gov.in/document-code`
	`MAND0409` any investigations done in `https://nhcx.abdm.gov.in/document-code`
	`MAND0570` Planned line of management in `https://nhcx.abdm.gov.in/document-code`
	and 5 more
`supportingInfo[].valueAttachment`	contentType `application/pdf`, title `CXR PA view or CECT chest abdomen and pelvis`
	contentType `application/pdf`, title `any investigations done`
	contentType `application/pdf`, title `Planned line of management`
	and 1 more
`supportingInfo[].valueReference`	reference `https://nhcx.abdm.gov.in/questionnaireresponse/1`, display `Admission Details`
	reference `https://nhcx.abdm.gov.in/questionnaireresponse/2`, display `Authentication Consent`
`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`
`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`
`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/100020`
`status`	`completed`
`subject`	reference `https://nhcx.abdm.gov.in/patient`
`authored`	`2026-09-10T23:55:36+05:30`
`item[]`	linkId `100075`, text `Admission Date`
	linkId `100074`, text `Surgery/Treatment Start Date`
	linkId `100073`, text `Admission Type`
	and 1 more
`item[].answer[]`	valueDateTime `2026-09-10T18:25:00+05:30`
	valueString `PLANNED`
	valueString `Yes`

9. QuestionnaireResponse

Element	Example
`questionnaire`	`https://payer.gov.in/policy/questionnaire/100024`
`status`	`completed`
`subject`	reference `https://nhcx.abdm.gov.in/patient`
`authored`	`2026-09-10T23:55:36+05:30`
`item[]`	linkId `100093`, text `Medical Superintendent Declaration Form (During Admission)`
	linkId `100095`, text `Remarks`
`item[].answer[].valueAttachment`	contentType `application/pdf`, title `Medical Superintendent Declaration Form (During Admission)`
`item[].answer[]`	valueString `Recorded.`

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

What PMJAY specifies

The query arrives on /v1/preauth/on_submit under 24: a ClaimResponse with outcome partial and reason queried.
The question is free text in item.adjudication where the category is reason, in reason.coding.display. On a live case it grows into a log, split by | into turns and by ~ into user, timestamp, type, comment and desk. Tolerate a single segment, treat the literal null as empty, and never put | or ~ in anything you send back.
The log is cumulative. The answer you sent reappears in it on the next response, which is the only sign it was read.
The answer is the whole preauthorisation bundle again on /v1/preauth/submit under 19, on the same case number, with the reply text in item.productOrService.text.

What PMJAY requires

Answer on 19, never on a new 12, which opens a second case.
Put the query remarks under supportingInfo category NMI, code CQD, as a valueString.
Supporting-info dates in +05:30.

Use cases, APIs and data elements

D7 Answer a pre-authorisation query (pmjay)

The query arrived as a ClaimResponse on 24, on the case's own thread, with the question in the item adjudication, not on the communication API. Answer with a fresh submit of the same bundle shape on this code, never as a new 12, which opens a second case.


API	`/v1/preauth/submit` `apis/03-preauth/v1-preauth-submit.bru`
Callback	`/v1/preauth/on_submit` `apis/03-preauth/v1-preauth-on-submit.bru`
Workflow	19
Carries JWE	yes
Focal resource	`Claim`
Simulator console	`/builder?family=preauth&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`	`{{$guid}}`
`x-hcx-workflow_id`	`19`
`x-hcx-timestamp`	`{{$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
`19`	Preauth Query Response Submitted	provider	`response.complete`	Response to payer's query on preauth

Data elements

Element	Label	Group	Type	Card.	FHIR path	Example
`claimNumber`	Case Number	Case	`string`	`1..1`	`Claim.identifier[0].value`	`VB26AA2600001`
`workflowId`	Workflow Code	Header	`string`	`1..1`	`Header.x-hcx-workflow_id`	`19`
`nmiDocument`	Need More Info (NMI) Document	Documents	`base64Binary`	`1..1`	`Claim.supportingInfo[category=NMI].valueAttachment.data`	`JVBERi0xLjQK...`

NRCeS profiles: Claim.

The query​

The bundle​

Elements​

1. Task​

2. CommunicationRequest​

The answer​

The bundle​

Elements​

1. Task​

2. Communication​

Rules​

1. The generic query​

2. The generic answer​

PMJAY​

What changes in the bundle​

The query​

1. ClaimResponse​

The answer​

1. Claim​

8. QuestionnaireResponse​

9. QuestionnaireResponse​

What PMJAY specifies​

What PMJAY requires​

Use cases, APIs and data elements​

D7 Answer a pre-authorisation query (pmjay)​

The query

The bundle

Elements

1. Task

2. CommunicationRequest

The answer

The bundle

Elements

1. Task

2. Communication

Rules

1. The generic query

2. The generic answer

PMJAY

What changes in the bundle

The query

1. ClaimResponse

The answer

1. Claim

8. QuestionnaireResponse

9. QuestionnaireResponse

What PMJAY specifies

What PMJAY requires

Use cases, APIs and data elements

D7 Answer a pre-authorisation query (pmjay)