Summary*
Current protocol status and enhancements from previous version
Inspired by the recommendations of the Joint Working Group of NHA and IRDAI (2019), Health Claims Data Exchange (HCX) is an ambitious open source project that aims to define interoperable protocol specifications to enable a multi-party exchange of health claims information.
The HCX switches can be thought of as routing switches or email gateways that facilitate communication with the desired level of consistency, security, privacy, and durability. However, unlike the internet or email, this protocol is defined for a specialised use case of exchanging health claims (or benefits) related information between relevant actors - payors, providers, beneficiaries, regulators, observers, etc.
Version Information
Version - 0.9 | Release date - December, 2023 | Published documentation link | Github link | Protocol website
Important Note: The version of the HCX Protocol documentation currently published is a draft and is subject to revisions and updates as we engage in the public consultation process. The sections that have significant changes since previous version (v0.8) are marked with asterisk "*" at the end of the title (also visible in the menu tree).
Please be aware that this version is comprehensive and self-contained, making it . Furthermore, there are no identified backward compatibility breaking changes from the previous version.
We value your feedback and encourage you to participate in shaping the final version of the protocol. Your insights and contributions are essential to ensure the protocol's effectiveness and alignment with ecosystem needs.
To provide feedback or suggestions: Please use information provided in "Contributing to the protocol" reach out or contribute to the protocol.
of changes (Change Log):
Relocated the design principles and proposed governance approach from the specification documentation to the HCX protocol website.
Introduced additional methods for managing attachments using Document Management Systems (DMS) in handling attachment section.
Updates to the user registry schema definitions for multi-tenancy, allowing for distinct user roles within a tenant.
Included QR Code specifications section to provide standard structure for Participant and Policy QR codes
Restructured Open Protocol section as follows
"Notifications" and "Third Party Information Sharing" sections, that were directly under Open Protocol, are now divided into Message Flows and API specifications sections.
Restructured Claims Data Exchange Protocol section as follows
Renamed "Exchange Protocol" sub-section to "Message Flows" and restructured to include all message flows covered in the protocol under their respective sections as follows
Primary Message Flow - Base flow for the claim process
Additional Message Flows - Flows that help achieve variations/enhancements in the claim process - Redirect, Forward, Relay, Intra-Cycle Communication (supporting information, beneficiary consent and payment account information), Third party Information sharing
Notifications - Notification flow to help enhance participant and user experinece of the main claim process
Renamed "API Structure" section "API Specifications" and restructured the section to separate out various kind of APIs (Registry, Primary Message Flow, Operational APIs, Notification) into their own sub-sections.
API specifications section of earlier "Notifications" and "Third Party Information Sharing" sections has been subsumed here as sub sections as part of the point 4.2.2 above.
Enhanced API security section to facilitate participants to use per participant, per user API keys for better security and audit-ability.
Introduced Use Cases section to list various use cases ( IPD and OPD : Cashless/Reimbursement), their mapping with the HCX protocol and implementation considerations for listed use cases.
In the process of mapping cashless and reimbursement use cases, both for Inpatient (IPD) and Outpatient (OPD) treatments, the following protocol enhancements have been incorporated:
Additional participant roles are added to enable appropriate access control levels.
Defined Access Groups to simplify access mapping to roles.
Guidelines for Participant onboarding:
Restructured the section into multiple subpages for enhancing the readability
Include recommendations on BSP verification
Enhanced recommendations for "Non ABDM enrolled Providers with no ROHINI id" to encompass verification through both public and private payers.
Recommended Communication request/response flow for seeking patients consent verification token when submitting reimbursement claims through a TSP/ISNP platform.
Following valueset have been enhanced in the Implementation Guide
Communication Reason Codes - Enhanced to facilitate the sharing of patient consent and account information in reimbursement claims.
Claim Supporting Info Codes - Added new codes for bills/receipts associated with a claim, covering items such as medicines, lab tests, medical services, and more.
Claim Denial Codes - Introduced codes to address claim denials resulting from policyholder consent declines or missing consent in reimbursement claims.
Added description to the "Future Focus areas" section.
Previous Versions
The following table provides a summary of the existing specification versions and links to the respective documentation.
The 0.8 version of HCX specifications has been developed based on inputs and feedback from the HCX community and in accordance with the planned roadmap. This version includes several key enhancements:
Notifications capability which allows for the sharing of important updates regarding the network, participants, and workflows with various entities.
Information Fetch API has been introduced to facilitate the sharing of information with authorised third parties.
API security enhancements have been made, which will allow for the generation of password-based API tokens.
Based on the business policy working group's recommendations, following enhancements have been made in the business policy specifications: improvements in onboarding and grievance redressal, as well as the inclusion of guidelines on SLAs, participant satisfaction, and operating charges.
Access control roles have been redefined to support the specification improvements and new use cases.
After consulting with NRCES, the FHIR community, and the HCX community, this version of specification incorporates a significant simplification by changing the bundle type from "document" to "collection." This new structure effectively reduces the overhead associated with the "document" bundle type and supports cycle-specific constraints on the bundles, making the integration process much more straightforward for integrators.
Some of the significant advantages of using the "collection" bundle type include simplifying programming for bundle parsing and verification, eliminating extraneous details such as the signature, and reducing the payload size.
In summary, this new bundle type significantly streamlines the integration process and reduces unnecessary complexities, ultimately improving the overall experience for all parties involved.
Based on feedback from various ecosystem players on the baseline version and rigorous feasibility analysis with the NHA team on the adoption of the specifications in public scheme use cases, this version includes the following key enhancements over the baseline version:
Multi-party processing support through REDIRECT and FORWARD constructs
Initial support for digital encoding of policies using InsurancePlan FHIR profile
New APIs to support pre-determination cycle
Introduction of communication APIs to support additional information exchange during various claim cycles - pre-determination, pre-auth, or claims.
Introduction of status API to support fetching of the status of a submitted request
Search API definition deferred to future version to allow further deliberation
Simplification of Protocol Headers - identifiers and status
Standardisation of protocol errors
Restructuring, examples, and language modifications to enhance readability
Base version of specifications. It was built by 60+ volunteers from across the healthcare ecosystem (including Insurers, Hospitals, TPAs, Insurance Technology players and Think tanks) as a part of a transparent, collaborative and open effort during July 2020-September 2021 and launched for public consultation on September 08, 2021. You can find the launch details and list of volunteers here.
The next sections provides description of the key terms used in the HCX protocol.
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