Introduction

The National Health Claims Exchange (NHCX) is a national gateway for health insurance claims in India. It routes claim requests and responses between health sector participants. It gives payers, providers, beneficiaries, regulators, and observers one exchange protocol.

NHCX uses standard APIs and FHIR payloads for claim data. The exchange works like a secure message gateway. It sends each request to the correct destination with consistency, privacy, security, and durability.

Objectives

NHCX has 4 main objectives:

• Reduce receivable cycles for providers.
• Increase cashless claim acceptance at smaller hospitals too.
• Support insurance innovation, auto-adjudication, and fraud control.
• Standardize the claims process for more trust and transparency.

Actors

Actor	Role in NHCX
Payer	A payer receives requests, applies claim rules, and returns claim responses.
Provider	A provider sends eligibility, preauth, predetermination, and claim requests.
Beneficiary	A beneficiary receives care and uses the insurance benefit.
Regulator	A regulator can use exchange data for oversight and compliance.
Observer	An observer can use authorized data for audit or analytics.

Key use cases

Use case	Primary sender	Purpose
Onboarding	Provider or payer	Register a participant on NHCX and enable request routes.
Coverage eligibility	Provider	Check if a beneficiary has valid coverage or a valid package.
Preauth	Provider	Request approval before care or before a package starts.
Predetermination	Provider	Ask the payer for claim adjudication before final submission.
Claim submission	Provider	Submit a claim for payer adjudication and response.
Payment notice	Payer	Send payment status, bank reference data, and UTR data.
Communication request	Payer	Ask the provider for claim remarks or extra information.
Reprocess request	Provider	Ask the payer to reprocess a rejected or partly paid claim.

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