PMJAY Integration Overview

PMJAY hospitals can run the PMJAY claim flow inside an ABDM-enabled HMIS. The HMIS sends claims to the payer through NHCX. This model removes duplicate entry across HMIS and TMS.

Why the flow changes

The current PMJAY flow depends on the TMS 2.0 Provider System. Hospitals still keep clinical and financial data in their own HMIS. This creates 2 records for the same PMJAY case.

Current issue	Effect on a hospital
Duplicate entry	Staff enter the same data in HMIS and TMS.
Weak data exchange	Systems cannot reuse beneficiary, clinical, and claim data.
Single-system dependency	Portal limits affect user access and claim work.
Low flexibility	Hospitals cannot adapt PMJAY work to local processes.

Target model

The target model lets the hospital use one HMIS for the PMJAY case. The HMIS records clinical data, billing data, and claim data once. NHCX routes the claim transaction to the payer.

flowchart LR
Hospital[Hospital HMIS] --> NHCX[NHCX]
NHCX --> Payer[PMJAY payer system]
Payer --> NHCX
NHCX --> Hospital

Hospital benefits

Benefit	Result
Embedded PMJAY flow	Staff use the HMIS for registration, preauthorisation, claim, and payment.
Structured data	The HMIS can auto-fill forms and reduce manual errors.
Better audit records	Clinical, bill, claim, and payment records stay in the hospital system.
Simpler user access	Staff train on one hospital system instead of 2 systems.
Higher scale	High-volume hospitals avoid portal limits and downtime.

Sandbox journey

PMJAY-specific requirements

Requirement	What the HMIS must do
InsurancePlan response	Use it as the source for packages, costs, STGs, documents, and claim rules.
Biometric authentication	Perform beneficiary authentication at registration, preauthorisation, and discharge.
Structured data exchange	Send supporting health records as ABDM Health Information Types.
Query flow	Do not use the Communication API for PMJAY claim queries. Use the correct preauth or claim workflow ID.

Normal NHCX flow vs PMJAY flow

NHCX step	PMJAY HMIS note
Get InsurancePlan	Same API. Use the provider-specific PMJAY plan.
Get policy	Same API. Confirm the beneficiary policy.
Coverage eligibility check	Same API. Use the correct purpose.
Preauthorisation	Perform biometric authentication before submission.
Communication Request	Do not use it for PMJAY claim queries.
Claim submission	Same API. Include discharge details in the claim.
Payment Notice	Same API. Acknowledge the payment notice.
Status check	Same API pattern. Track the correlation ID.