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Summary: Swasth Alliance’s health claims data exchange platform

Technical and non-technical specifications involving data access, data sharing, grievance redressals, and more were proposed.

Swasth Alliance, a collaboration of 92 health, tech, and healthtech organisations such as iSPIRT, Boston Consulting Group, 1MG, Pharmeasy, etc. has released a set of specifications for its draft health claims data exchange (HCX).

Proposed under the Pradhan Mantri Digital Health Mission (PM-DHM), formerly known as the National Digital Health Mission, the HCX looks to facilitate the filing of requests and the disbursement of health insurance. The draft strategy for the PM-DHM, released in 2020, had mentioned the creation of a health claims platform as one of its objectives.

In its consultation paper, the Swasth Alliance has not just laid down technical specifications of the proposed HCX but also presented guidelines for governance and grievance redressal processes.

The full consultation paper can be viewed here. Stakeholders can submit their comments to the Alliance until October 8 at hcx@swasthapp.org.

Summary of the HCX specifications

Who can participate in the exchange?

  1. Provider: This would be the health service provider such as a hospital.
  2. Payor: This would be the insurance service provider.
  3. Agency: A third-party administrator acting on behalf of the payor.
  4. Regulator: Regulatory bodies like the Insurance Regulatory and Development Authority and the Insurance Information Bureau of India will be a part of the exchange.
  5. Research bodies: This would include research groups.
  6. E-commerce participants: E-commerce platforms facilitating insurance adoption like PolicyBazaar.
  7. Scheme sponsors: Scheme owners of specific programmes, e.g. NHA for Ayushman Bharat
  8. Other HCXs: Other health claims exchanges could be involved and interact with each other in the following circumstances:
  • When a provider is onboarded in a gateway instance but the payor for that health policy scheme is registered in another gateway instance.
  • If a beneficiary enrolled in a health policy scheme took treatment in a network hospital in another state and that hospital is onboarded in a different gateway instance than the payor.
  • For top-up cases, the providers and payors are registered in different gateway instances, and in such scenarios primary insurance is handled by one payor in one gateway instance but the secondary insurance is handled by another payor registered in a different gateway instance.

How will data be shared under the exchange?

  • The paper says that all data being shared on the exchange will be end-to-end encrypted. The messages being shared would also be modeled according to JWE tokens.
  • However, the payload in the messages will be based on data standards developed by Health Level Seven (HL7), a not-for-profit.
  • Multiple functions will take place through Application Program Interfaces (APIs), such as the proposed Aadhaar-based KYC to authenticate claims beneficiaries, access to participants’ registry, and so on.
  • Some information like the type of payload will be shared with the HCX as ‘protected headers’ to help the HCX identify senders and receivers of a message, perform integrity checks, audits, and routing functions.
  • The HCX will retain some non-encrypted information (such as header, sender, and recipient details) related to each event (like a claims request, a pre-authentication request, or a payment notification) as part of the audit logs.

Source: Swasth Alliance

How will data be accessed by each participant?

According to the consultation paper, participants will have access to the data through the following ways:

1. Provider, Payor, Agency/Third Party administrator, scheme sponsor: Will be able to send and receive requests to check the eligibility of an insurance claim, pre-auth requests i.e the first insurance claims forms, claims request, and insurance payments. They will also be able to acknowledge payments they have received and search for pre-auth and insurance claims requests.

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2. Regulator: Will only be allowed to search for claims

3. Research bodies: Will be able to send and receive eligibility checks, and will get access to anonymised and aggregated data on pre-auths, and claims.

4. E-commerce participants: Will be able to access anonymised data of pre-auths and claims, but subject to consent. They will also be able to send and receive eligibility requests.

5. Other HCXs: Will not get access to the actual payload or the non-encrypted information being sent.

Grievance redressal guidelines:

The paper proposes forming a working group to finalise a grievance redressal policy after public consultation. It further lays down pointers for a model grievance redressal which includes caveats about creating nodal governing bodies, mechanisms for grievance redressal of different types, mechanisms with allowance for re-opening, escalation of grievances, informing participants about changes, etc.

Governance framework:

The paper proposes a governance framework with three bodies, this framework has been specified only for the exchanges’ pilot period-

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i) Governance council for specifications will be created comprising representatives from insurance companies, third-party administrators, healthcare service providers, public bodies, academic bodies, etc. They will formulate topic-specific working groups.

ii) Working groups will be made to propose new specifications or enhancements. These specifications will be evaluated, further developed, and peer-reviewed on ‘implementability’ following which a public consultation paper will be released.

iii) Independent ethics and conflicts committee would function as an appellate authority for the Swasth Alliance’s work. All the documents, minutes of meetings, and deliberations by the three bodies will be made public.

Proposal for iSPIRT to govern HCX after pilot: The paper says that after a year of finalising the specifications, the iSPIRT Foundation would govern the health claims exchange. This would involve developing additional specifications, Application Program Interfaces, protocols related to multiple gateways, multi-party dispute resolution, frauds, etc. iSPIRT would also create a governance body, with Swasth as one of the members, to supervise the creation of specifications.

Suggested sandbox approach to HCX

The paper suggests a sandbox approach to finally operationalising the health claims exchange. This will take place in the following stages:

  1. The participants will submit an online application to join the HCX sandbox.
  2. Once their details are verified, they will be given the credentials to integrate their software with the HCX sandbox.
  3. Here they will be expected to complete a set of functional and security tests/flows, which include security testing by STQC or CERT-IN.
  4. The results of these tests will have to be submitted to the HCX operator, who upon successful review, will issue a certificate that can be used to integrate with the production environment of HCX operators – this is the stage before going live on the exchange.
  5. To onboard the production environment, participants will have to be authenticated through their registration with Healthcare Facilities’ Registry, or if they are not on the HFR through authentication by the Insurance Regulatory and Development Authority (IRDAI) or any such other body, or by filling a detailed application form on company registration, contact number, etc.
  6. Applicants will have to share their functional and security testing certificates from the sandbox for a final round of approval by the HCX’s internal team.
  7. If they are approved, they will be issued a participant ID along with production access secret credentials.
  8. After this, the participant and their app can go live. At this stage, the paper recommends that the participant conduct staff training and a pilot before going live.
  9. A participant could also be deboarded from the HCX – voluntarily, through a request by the regulator, or because of bad behaviour such as hacking, slowing down of the HCX system, etc.

National Digital Health Mission and health claims exchange

The paper self-admittedly borrows from recommendations laid down by a Joint Working Group of the NHA and IRDAI in 2019; the chairman of the working group, Kiran Anandampillai was also involved in the creation of Swasth Alliance’s proposed HCX specifications. The Joint Working Group recommended the creation of a health claims platform, key design principles for such a platform, the creation of standard e-claim forms, a format for such forms, and more. The committee was formed to define roadmaps related to digitising health claims processing, disbursement, and collating them for analysis.

Before this, in 2018, the NITI Aayog’s proposal of a National Health Stack also listed a health claims platform among its key components to facilitate health insurance coverage under the government’s National Health Protection Scheme (NHPS) and private insurance schemes.

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Written By

I cover health and education technology for MediaNama. Reach me at anushka@medianama.com

MediaNama’s mission is to help build a digital ecosystem which is open, fair, global and competitive.

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