Standards and FHIR

NHCX reuses the ABDM standards base and extends it for health claims. The standards base comes from the National Digital Health Blueprint and the ABDM FHIR Implementation Guide.

Standards base

NHCX uses open standards for data exchange and semantics.

Standard	Role in NHCX and ABDM
HL7 FHIR R4	Defines resources, profiles, bundles, and RESTful operations for health data exchange.
DICOM	Standardizes medical images from radiology, pathology, cardiology, and related domains.
SNOMED CT	Gives a structured clinical vocabulary for diagnoses, symptoms, procedures, substances, and devices.
LOINC	Identifies laboratory observations, panels, methods, components, and systems.
ICD-10	Classifies diseases for epidemiology, insurance, public health, and reports.

ABDM also defines health information types for clinical records. NHCX builds on that approach for claim records.

FHIR basics

Fast Healthcare Interoperability Resources (FHIR) is a health data exchange standard from HL7 International. FHIR connects small data units called resources. A resource can stand alone or combine with other resources.

FHIR has these traits:

• It uses common web formats such as JSON, XML, and RDF.
• It defines RESTful CRUD operations.
• It has about 150 resource types across entity, clinical, and financial categories.
• It supports extensions for local use cases.
• It binds resource elements to code systems and value sets.

FHIR interoperability models

FHIR supports 4 interoperability models.

Model	Purpose
REST	Exchange resources with standard HTTP operations.
Documents	Package a set of resources as one clinical or claim document.
Messaging	Send event-based resource messages between systems.
Services	Expose business operations as health data services.

Resources and bundles

A FHIR resource is a unit of exchange. It has an identity, metadata, structured elements, and optional human-readable text.

A bundle groups related resources for one purpose. For example, a claim bundle can include the claim, patient, provider, insurer, diagnosis, and procedure resources.

Resource part	Purpose
Identity and metadata	Identify the resource and help search or catalog it.
Human-readable text	Let a person view a summary.
Structured data	Carry identifiers, names, dates, codes, and references.
Extension	Add a defined local element when the base resource lacks it.
Terminology binding	Restrict a coded element to an approved value set.
Links	Refer to other resources in the same bundle or another source.

Profiles and value sets

A FHIR profile adapts a base resource for a use case. It defines required elements, optional elements, extra elements, value sets, and supported API features.

Profile rule	Definition
Required	The element must appear. FHIR cardinality uses values such as 1..1 or 1..*.
Must Support	A receiver must read the element when it appears. A sender can omit it when data is unavailable.
Optional	The element can appear when the use case needs it.
Value set	The element must use codes from an approved list.

The ABDM FHIR Implementation Guide Build 3.0.0 defines the base for ABDM. It includes 50 profiles, 7 clinical artifacts, 39 core profiles, 4 code systems, and 26 value sets.

NHCX profile requirements

NHCX profiles must fit Indian insurance workflows. They must also support PM-JAY and private insurance workflows.

Requirement	Description
Cycle-specific resources	Share the resources that match the claim cycle stage.
Easy validation	Keep structures practical for validation and payer process rules.
Generic insurance support	Cover public and private insurance workflows with one profile set.
Indian value sets	Define value sets for the Indian context.
Practical claim scenarios	Cover proof of presence, proof of identity, and other local claim needs.
ABDM reuse	Extend ABDM profiles and resources instead of a separate base.

FHIR resources for NHCX

The source lists these FHIR resources for NHCX claim exchange.

FHIR resource	Use in NHCX
InsurancePlan	Describes the insurance product, covered benefits, costs, and plan details.
Coverage	Represents the beneficiary coverage that supports an eligibility or claim flow.
CoverageEligibilityRequest	Asks the payer for coverage, benefit, and preauth requirement details.
CoverageEligibilityResponse	Returns eligibility, plan, benefit, and preauth requirement details.
Claim	Carries financial and clinical data from a provider to a payer.
ClaimResponse	Returns adjudication results or errors for a submitted claim.
PaymentNotice	Sends payment status and payment reference data.
PaymentReconciliation	Carries reconciliation details for payments.
Task	Tracks work or status for a claim-related action.

NHCX bundles

NHCX uses FHIR bundles for claim exchange. The source identifies 4 Health Claim Exchange profiles:

1. Claim Bundle
2. Claim Response Bundle
3. Coverage Eligibility Request Bundle
4. Coverage Eligibility Response Bundle

A claim bundle can use Bundle.type as collection. The first entry can be the Claim resource. Later entries can carry the patient, insurer, provider, procedure, and condition resources.

Bundle entry	Typical resource	Purpose
Entry 0	Claim	Carries the claim type, status, patient link, insurer link, diagnosis, and procedure links.
Entry 1	Patient	Identifies the beneficiary.
Entry 2	Organization	Identifies the insurer or another organization.
Entry 3	Practitioner	Identifies the provider or doctor.
Entry 4	Procedure	Codes a procedure with a terminology such as SNOMED CT.
Entry 5	Condition	Codes a diagnosis with a terminology such as SNOMED CT.

The claim use value can identify a claim, preauth request, or predetermination request. The source examples use values such as claim, pre-auth, and pre-det.

NHCX standard approach

NHCX uses a collaborative standard approach. It includes end users, public bodies, private bodies, NHA, IRDAI, and other national agencies.

The approach keeps FHIR, SNOMED CT, LOINC, ICD-10, and DICOM as relevant standards. It reuses community work and ABDM profiles where possible. NRCeS acts as the standards body and maintainer for ABDM value sets and NHCX profiles.