Use Cases

NHCX routes claim data between payers and providers. Each use case uses the exchange to validate, route, and return claim information.

Detailed use cases

Use case	Sender	Receiver	Description
Onboarding providers and payers	Provider or payer	NHCX	NHCX onboards providers and payers. It validates each participant and routes requests to target applications.
Check coverage eligibility	Provider	Payer	A provider checks beneficiary eligibility through NHCX. The payer returns coverage, package, or procedure eligibility.
Preauth request submission	Provider	Payer	A provider submits a preauth request for a beneficiary through NHCX. The payer stores the request details. The payer returns adjudication details through the on_submit callback.
Predetermination request submission	Provider	Payer	A provider submits a predetermination request for a claim through NHCX. The payer stores the request details. The payer returns auto-adjudication details for the policy and beneficiary history through the on_submit callback.
Claim request submission	Provider	Payer	A provider submits a claim request for a beneficiary through NHCX. The payer stores the request details. The payer returns adjudication details through the on_submit callback.
Payment notice	Payer	Provider	A payer sends the payment status for a claim. The notice includes bank reference numbers, scroll status, and UTR numbers.
Communication request submission	Payer	Provider	A payer sends claim remarks to the provider through NHCX. The provider stores the communication details. The provider returns the information that the payer needs for the claim.
Reprocess request	Provider	Payer	A provider asks the payer to reprocess a claim. Use this flow when a claim has a partial payment or rejection.

Flow groups

Flow group	Use cases	Main outcome
Access	Onboarding, coverage eligibility	Participants can join the exchange and verify a benefit.
Approval	Preauth, predetermination	The payer can approve or estimate a claim before final claim submission.
Claim	Claim request submission, communication request, reprocess request	The payer and provider can complete claim adjudication.
Payment	Payment notice	The provider receives payment status and bank reference data.