Health insurance information platform (hiip)
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The document discusses electronic claim objects to support India's health insurance sector. It proposes using standardized electronic objects based on FHIR resources to enable interoperable and automated claim processing. This would allow faster claims processing, reduced costs, and improved data for monitoring. The electronic objects would include minimum required coded data elements in a JSON format to represent claims, payments, and clinical summaries like discharge records.
![Book by Niti Aayog | Health Systems for new India: building blocks
E-OBJECTS BASED ON FHIR RESOURCES FOR DATA POINT LEVEL
INTEROPERABILITY: PROVIDER TO PAYER AND PROVIDER TO PROVIDER
ACCESS Health [Prof Dennis Streveler and Dr Pankaj Gupta] first wrote the concept of eObjects in NITI Aayog Theme papers, Health System for a NEW India: Building Blocks, Delhi, India, 2019.
CHAPTER 5 - Reimagining India’s Digital Health Landscape:
“Wiring” the Indian Health Sector
*Released Nov 2019
OPD Claims
• E-Prescription/ e-
encounter
• E-Referral
IPD Claims
• Coverage
Eligibility Request
& response
object
• Pre-authorization
Object &
Response
• Claim Request &
Response object
Provider
Payments
• Payment Notice
• Payment
Reconciliation
• E-Facility Object](https://image.slidesharecdn.com/healthinsuranceinformationplatformhiip-210419074214/85/Health-insurance-information-platform-hiip-7-320.jpg)
![IRDAI – NHA JOINT WORKING GROUP | IT INFRASTRUCTURE FOR
AUTOMATING HEALTH INSURANCE CLAIMS
Machine Readable
Health Claims Platform [HCP]
ACCESS Health Digital
through it’s
Social Entrepreneurship
Accelerator is
supporting Industry to
Innovate for
Adjudication
eobjects
ACCESS Health [Prof Dennis Streveler and Dr Pankaj Gupta] first wrote the concept of eObjects in NITI Aayog Theme papers, Health System for a NEW India: Building Blocks, Delhi, India, 2019.
*Released Sep 2019
HCP Tender has been
released](https://image.slidesharecdn.com/healthinsuranceinformationplatformhiip-210419074214/85/Health-insurance-information-platform-hiip-8-320.jpg)
![eClaim Objects
eDischarge Object
eBill
Sent for Claims
Adjudication
PROVIDER eObjects
ACCESS Health [Prof Dennis Streveler and Dr Pankaj Gupta] first wrote the concept of eObjects in NITI Aayog Theme papers, Health System for a NEW India: Building Blocks, Delhi, India, 2019.
ACCESS Health Digital through its Social Entrepreneurship
Accelerator is providing the MVPs and API design to help
HIS/EMR Industry to Innovate](https://image.slidesharecdn.com/healthinsuranceinformationplatformhiip-210419074214/85/Health-insurance-information-platform-hiip-9-320.jpg)
![What are E-Objects?
What is the need of standard
eobjects, when we already have a
standard claim forms by IRDA?
Standard Format
x No standard value sets
x Not machine-readable
Address
To and From
Policy Details
Package Details
Diagnosis
Details
Claim amount Details
NDHB and
MDDS
Compliant
E-object is like an
Envelope with machine
readable letter inside it
Standard Format
standard value sets
machine-readable
Interoperable
ACCESS Health [Prof Dennis Streveler and Dr Pankaj Gupta] first wrote the concept of eObjects in NITI Aayog Theme papers, Health System for a NEW India: Building Blocks, Delhi, India, 2019.
These eobjects will capture minimum required information which is essential for processing a claim
transaction submitted/requested by a provider or payer.](https://image.slidesharecdn.com/healthinsuranceinformationplatformhiip-210419074214/85/Health-insurance-information-platform-hiip-16-320.jpg)
Health insurance information platform (hiip)
- 1. Electronic Claim Objects- Supporting Infrastructure for Health Claim Platform-PMJAY 2.0 2
- 2. About ACCESS Health International 2 We have 8 Country offices across the globe. ACCESS Health International is a think tank and advisory group. We believe all people have right to access high quality, affordable healthcare Healthcare Delivery, Performan ce, Quality Health Finance, Health Policy, Research ACCESS Health Digital for Universal Health Coverage Health Insurance, States, Capacity Building Research Advocacy Advisory
- 3. About ACCESS Health Digital 3 DEPARTMENT OF DIGITAL HEALTH SOCIAL ENTRE PREURSHIP ACCELERATO R DIGITAL HEALTH CENTRE OF EXCELLENCE Research Advocacy Advisory ACCESS Health Digital works as a strategist for all digital health initiatives of Access Health in India. The key focus is to support and build a harmonized digital health ecosystem to achieve Universal Health Coverage in India by highlighting new ways for healthcare systems to leverage technological advancements to transform into digitally driven systems.
- 4. • Private Health Insurance covers about 3% of India Population • Public Health insurance covers about 10-17% of India Population. • 80+% is Out of Pocket expenses. • Central Govt PMJAY is set to cover 40-50% of India Population. • In absolute numbers this market is 150 Million people, likely to go upto 500 Million people • There are 17+ Private Insurance companies that also do business in Health Insurance. • 4 Public Sector Companies also cover Health Insurance. • 4 Private Insurance companies whose core business in only Health Insurance. • TPA business has been servicing only the private health insurance i.e. 3% of India’s population. Now PMJAY is set to cover both public and private hospitals. Hence TPA business is ready for disruption; because the number of claims is set to go up by atleast 10 times; and the PMJAY is demanding claims in a standard format – The NDHB Health Standard! With the health insurance sector heading towards a boom, pm-jay is well positioned as the financial lever for digital health transformation in India..
- 5. ESIS (1948) & CGHS (1954) Mediclaim Policy by GIC (1986) UHIS YESHASVINI (2003) AAROGYASRI (2007) RSBY (2008) KALAIGNAR (2009) VAJPAYEE AROGYASHRI (2010) MAHATMA JOYTIBA PHULE (2012) UBDCD (2012) PM JAY (2018) BHAMASHAH (2014) BSKY (2018) Indian Public Health Insurance journey Approx 75 million people covered Approx 302 million people covered Approx 500 million people covered
- 6. 6 Identification Enrollment Policy Assignment Eligibility Verification Database Update Claim History Beneficiary Management Actuarial Science Policy Definition Policy Configuration Pricing & Risk Analysis Policy redesign Policy Management Claim submission Claim editing Administrative validation Clinical Validation Claim Denial Claim Query and req more info Claim Management Fraud trigger Management HEM integration Fraud classification Claim detail review Field medical audits Claim/fraud History Provider credibility scoring Fraud Management Fund Allocation Pri/sec Payer classification Provider Payment Payment reconciliation/ remittance Denial Management Fund Management Reporting to IRDA MIS config & Design Claim Analytics Dashboards Quality Care reporting Penalties & deviations Compliance & reporting Health Insurance Solution from systemic point of view On system Manual Absent Hybrid Scale Provider empanelment Payment settlement Provider system integration HEM database integration Payment Digital Contract Provider Management
- 7. Book by Niti Aayog | Health Systems for new India: building blocks E-OBJECTS BASED ON FHIR RESOURCES FOR DATA POINT LEVEL INTEROPERABILITY: PROVIDER TO PAYER AND PROVIDER TO PROVIDER ACCESS Health [Prof Dennis Streveler and Dr Pankaj Gupta] first wrote the concept of eObjects in NITI Aayog Theme papers, Health System for a NEW India: Building Blocks, Delhi, India, 2019. CHAPTER 5 - Reimagining India’s Digital Health Landscape: “Wiring” the Indian Health Sector *Released Nov 2019 OPD Claims • E-Prescription/ e- encounter • E-Referral IPD Claims • Coverage Eligibility Request & response object • Pre-authorization Object & Response • Claim Request & Response object Provider Payments • Payment Notice • Payment Reconciliation • E-Facility Object
- 8. IRDAI – NHA JOINT WORKING GROUP | IT INFRASTRUCTURE FOR AUTOMATING HEALTH INSURANCE CLAIMS Machine Readable Health Claims Platform [HCP] ACCESS Health Digital through it’s Social Entrepreneurship Accelerator is supporting Industry to Innovate for Adjudication eobjects ACCESS Health [Prof Dennis Streveler and Dr Pankaj Gupta] first wrote the concept of eObjects in NITI Aayog Theme papers, Health System for a NEW India: Building Blocks, Delhi, India, 2019. *Released Sep 2019 HCP Tender has been released
- 9. eClaim Objects eDischarge Object eBill Sent for Claims Adjudication PROVIDER eObjects ACCESS Health [Prof Dennis Streveler and Dr Pankaj Gupta] first wrote the concept of eObjects in NITI Aayog Theme papers, Health System for a NEW India: Building Blocks, Delhi, India, 2019. ACCESS Health Digital through its Social Entrepreneurship Accelerator is providing the MVPs and API design to help HIS/EMR Industry to Innovate
- 10. Health Claims Platform from NHA Adjudicate Claims Route to Insurer / TPA Health Claims Platform Hospital Submit using Open API Create a Health Claims platform that validates requests, routes to appropriate party, guarantees payment and gathers data for real time monitoring Create a market where Insurers / TPAs can choose software that will help them improve on adjudication and fraud waste and abuse prevention In Adjudication FWA prevention Standard e-claim, e-discharge Objects that can be used to initiate claims for PMJAY or any Payer Real time data for monitoring and evaluation Create a market where Hospitals can choose software that will help them process any insurance claim and get end to end visibility on claim status till payment. Hospitals have 3 choices -- Procure a specialized software, use free software from govt or modify their HIS system to support APIs
- 11. Electronic claim objects & PMJAY’s Health Claim Platform Provider TMS/ Enhanced HIS Payer TMS
- 12. PMJAY 2.0- Health Claim Platform Process Coverage Eligibility Check Coverage Eligibility Response Digital & automated provider-payer contract management Pre-authorization request Pre-authorization response Pre-authorization enhancement Claim/pre-auth information update (More info queries) Claim request Claim response Payment Notice Payment File creation Payment Reconcilation
- 13. Coverage Eligibility Check Claim/pre-auth information update (More info queries) Claim request Pre-authorization request Pre-authorization enhancement Coverage Eligibility Response Claim response Pre-authorization response Payment File creation Payment Reconciliation Payment Notice Provider Side processes Payer Side processes Same as existing New electronic process Color Coding Health Claim Platform Payer-Provider Digital Contract management E-facility Info (Provider Info) Policy/Package configuration using PML 2 1 3 5 4a 6 7 8 10 9 11 A request JSON object A response JSON object 4
- 14. NHCP - Process Flows using FHIR resource 4
- 16. What are E-Objects? What is the need of standard eobjects, when we already have a standard claim forms by IRDA? Standard Format x No standard value sets x Not machine-readable Address To and From Policy Details Package Details Diagnosis Details Claim amount Details NDHB and MDDS Compliant E-object is like an Envelope with machine readable letter inside it Standard Format standard value sets machine-readable Interoperable ACCESS Health [Prof Dennis Streveler and Dr Pankaj Gupta] first wrote the concept of eObjects in NITI Aayog Theme papers, Health System for a NEW India: Building Blocks, Delhi, India, 2019. These eobjects will capture minimum required information which is essential for processing a claim transaction submitted/requested by a provider or payer.
- 17. What is the structure of E-Objects? Header Detailed Body Header will contain Unique identification of all the parties involved in the transaction or episode and the routing information required by the health claim platform. Contains standard minimum required data elements that are required by a payer for auto-adjudication of claim. All the elements will carry structured coded data JSON Object Payer eObjects E-eligibility check & Response Object E-Preauthorization request & response Object E- claim request & response Object E-Payment Notice & E-payment reconciliation Object
- 18. Overview of E-Claim Object • Registries (Payer, Beneficiary, Facility, Doctor ) • Identifiers • API/Integrations with payer/provider system • Policy Mark-up Language • Rules engine- validations for mandatory information required and balance vs. requested amount Header (Information about the facility, beneficiary & payer) (IDs) Bill Summary defined by IRDA (Detailed if expanded) Pre-auth details and final treatment cost details Clinical Summary (Claim Relevant episode details) Disclaimer & Digital signature E-claim object field sample Claim ID Beneficiary ID Pre-Auth ID Patient UHID Pre-Auth Status Package Code Facility ID E-Discharge (Doc No.) Payer ID Claim Amount Health Plan ID/code Approved Amount Policy no. Package ID Provider identification Number Diagnosis Code
- 19. 19 Beneficiary Registry Identifiers ▪ Unique Identification (UID) G01.01 ▪ Beneficiary's Unique Health Identification Number (UHID) 05.002.0002 ▪ Beneficiary's Alternate Unique Identification (UID) Type, 05.002.0001 Demographics ▪ Full Name in English G01.02-02 ▪ Gender identification Code G01.03 ▪ Marital Status G01.03 ▪ Relation Type (Head of the family) G01.07-01 ▪ Relationship Code G01.08-01 ▪ Face Image record Header G01.09-00-01 ▪ Face Image Record data G01.09-00-02 ▪ Religion Code G01.14-01 ▪ Occupation Type Code G01.15-01 ▪ Date of Birth Type G01.16 ▪ Live Status G01.17 ▪ Premises Identifier (Master Code Directory: CD05.001) ▪ Relationship with Primary Insured, 05.002.0027 ▪ Patient Mobile Number, 05.003.0012 ▪ Email ID, G00.09 Health Insurance Details ▪ Insured Card ID 05.006.0003 ▪ Insurance Policy ID 05.006.0006 ▪ Health Insurance Coverage Begin Date 05.006.0031 ▪ Health Insurance Coverage End Date 05.006.0032 ▪ Source of Payment 05.006.0008 ▪ Insurance Policy Type 05.006.0004 ▪ Secondary Health Insurance Policy Indicator 05.006.0009 ▪ Secondary Health Insurance Policy ID 05.006.0010
- 20. June 16, 2019 Presentation Title Here 20 Payer Registry • Payer Identification No./Insurance company code, 05.007.0013 • Payer Type- Public/Private • Payer/Insurance Company Name 05.007.0012 • Payer Registered Address • Payer Mobile number • Payer email • Bank Account Number 05.001.0013 • Bank Name 05.001.0009 • Bank Branch Name 05.001.0012 • Mode of Payment 05.001.0014 • Indian Financial System Code (IFSC) 05.001.0010 • Magnetic Ink Character Recognition (MICR) Code 05.001.0011 • Authorized Signatory • Tax Deduction Account Number (TAN) 05.001.0008. Plan /scheme Master ▪ Health Plan Type 05.006.0005 ▪ Health Plan Code ▪ Health Plan Name
- 21. Illustration | FHIR resource mapping with e-claim metadata Data Element MDDS Code FHIR mapped Primary package code 05.007.0020 Claim.item.productOrService Primary package amount 05.007.0021 Claim.item.unitPrice Bed Days (Total Amount) Claim.item.category- Claim.item.net if this is total amount Bed Type code (Breakup of the bucket) 05.008.0017 Claim.item.detail.category or claim.item.detail.subdetail.category Bed Type cost Claim.item.unitPrice Bed Days (Number) 05.007.0022 Claim.item.quantity ICU Days (Total Amount) Claim.item.net if this is total amount Bed Days (Number) Claim.item.quantity Lab Charges Claim.item.net if this is total amount LOINC code Claim.item.productOrService Quantity of Service 05.007.0022 Claim.item.quantity Total Bill Amount 05.007.0024 Claim.total
- 22. Separating Claims Data Flow from Clinical Data flow Personal Health Records Hospital (Provide r) National Health Claims Platform Insurer / TPA (Payer) eClaim document PHR Episode ID PHR Consent Discharge summary Diagnostic reports Case Sheets OT Notes ... Access Clinical info using consent Recommendation: NHA and IRDAI should support the National Digital Health Mission by requiring providers to share personal data via PHR for all insured cases. This approach will helps build up the longitudinal health records for patients treated under insurance
- 23. E-Discharge Summary Object Header Relevant clinical history ( Co- morbidities or secondary diagnosis) In-hospital treatment details (services) Discharge Details Sample fields Patient UHID Package Code Discharge object ID LOIN code Unique Facility Identification Number Referring Physician ID Treating Doctor Identification No. Referral Object ID Health Condition Code Discharge Date Procedure code Admission Date Note: E-discharge object/attachment could be used until PHR is available
- 24. Electronic Claim Objects- Advantages Operational Technology Structured, coded, Machine-readable data Interoperable using FHIR Resource 4 based Faster & cost-effective Claim Processing Metadata standards for semantic interoperability Common structure and meaning across the health insurance industry Open API specification for the industry to innovate the health claim cycle management Freedom to choose applications for Claim submission/processing for Providers and payers Highly secure, encrypted health claim information Freedom to choose application for Claim processing Light weight JSON based container that supports syntactic and semantic interoperability Minimum required information to process claim without looking at the attachment Machine readable data that can be utilized by AI for fraud profiling and support dynamic rule engine for proactive fraud management
- 25. PROVIDER PERSPECTIVE Faster Turnaround Time, Faster Payments, Hassel free Paperless ATM style eClaims Hospital Admin Official Faster Payments, Practice is Growing, More Referrals Specialist Doctor in Hospital How many Stents and CABG were done for Faridabad District Residents and What Type of Screenings Do We Need To Do? State Health Official What's the Average Cardiac Disease Burden of Aspirational District Residents and What Type of Screenings Do We Need To Do? Central Govt Health Official STATE HEALTH PERSPECTIVE
- 26. INSURANCE PERSPECTIVE How do we handle Tsunami of Claims, Reduce Disease Burden and check the Fire of Frauds Insurance Officials 80% Hassel free Paper less eClaims Auto Adjudication, Robotic Process Automation, Less chances of Frauds Insurance Officials Blue Cross Blue Shield North Carolina has implemented RPA to extend the functionality of its auto adjudication platform and was able to save $11 million and reduce claims processing staff from 425 to about 300 people in just 18 months. Claim requiring human intervention costs approximately $4.00 to process, while an auto- adjudicated claim costs approximately $1.00. With a population 1/4th of India, about 3 billion healthcare claims are filed each year in USA.
- 27. PATIENTS PERSPECTIVE My Mother Has Just Been Hospitalized and I Don’t Have Access To her BP Medication Name Which the ER Physician is Asking For. Earlier Had to search for Empaneled Hospital. Too much of paperwork for admission, pre-auth... A Common Citizen More Empaneled Hospitals, More Specialist Options, Preferred Treatment given by Hospitals, Medical Records in Digilocker A Common Citizen
- 28. THANKS! Dr Pankaj Gupta Head – ACCESS Health Digital [email protected] Twitter: @pankajguptadr, @accesshdigital LinkedIn: drpankajgupta, accesshdigital