Digital claims, from eligibility to settlement.

The problem it is trying to solve

A hospital dealing with a dozen payers today deals with a dozen processes: different portals, different formats, different documentation demands, different people to chase. The cost is not the software license. It is the staff time, and the working capital tied up in claims nobody can find.

NHCX standardizes the exchange. Claims move in a common format, status is queryable, and the same submission works across payers who are on the exchange. That is a genuine operational improvement and it is worth understanding precisely, because it is also routinely oversold.

The lifecycle, stage by stage

Six stages, and the hospital’s work is concentrated in two of them.

Eligibility

Confirming the patient is covered and for what. Faster through the exchange than a phone call, but only as good as the data the payer holds.

Pre-authorization

The treatment plan and estimated cost, submitted before treatment where the policy requires it. This is where most delay happens and most rejections originate.

Treatment and documentation

Your clinical record has to support the claim. A claim fails on documentation far more often than on eligibility.

Claim submission

The itemized bill, clinical documents and discharge summary, mapped to standard codes.

Adjudication

The payer decides. Queries come back through the same channel rather than by phone, which is the real change.

Settlement and reconciliation

Payment against submitted claims, matched automatically rather than by spreadsheet.

What actually changes for your billing desk

Less portal-hopping, and a status you can look up rather than chase. Queries arrive as structured messages instead of phone calls, and reconciliation stops being a monthly spreadsheet exercise.

What does not change: the payer still decides, the policy still governs, and a claim with poor documentation still fails. If your rejections today are mostly documentation, a gateway will not fix them. It will only tell you faster.

PMJAY is a scheme, not a technology

Ayushman Bharat PMJAY is a government health insurance scheme with defined packages and rates. NHCX is the pipe through which claims can travel. They are frequently spoken about as one thing and they are not.

A hospital empanelled under PMJAY has scheme obligations, including package rates, treatment protocols and documentation, that exist whether or not the claim travels through a modern exchange.

Prerequisites, in the order they bite

Most of these are ABDM prerequisites, which is not a coincidence.

Facility registration

You need an identity in the Health Facility Registry before anything can be attributed to you.

Registered professionals

Clinical documents supporting a claim are signed by someone, and the exchange cares who.

Coded services

Your service catalog has to map to standard codes. This is unglamorous data work and it is where projects stall.

Documentation discipline

A discharge summary that a payer accepts is a clinical-record problem before it is an integration problem.

Our position

Nirogix does not have claims integration today. There is no insurance module, no pre-authorization workflow and no NHCX connectivity in the product. It is scheduled in the phase that adds the connected and regulated capabilities, alongside WhatsApp and telemedicine.

A hospital whose primary pain is cashless claims should not buy Nirogix this quarter, and we would rather say so on a web page than at the end of a procurement process.