HCX Protocol
v0.8
v0.8
  • Summary
  • Context
  • Introduction to HCX
  • Approach
    • Design Principles
    • Key Specifications
    • Governance
  • Technical Specifications
    • Open Protocol
      • Registries
      • Claims Data Exchange (HCX) Protocol
        • Exchange Protocol
        • Message Structure
        • API Structure
        • Error Handling
      • Data Security and Privacy
        • Transport Security
        • Message Security and Integrity
        • API Security
      • Audit and Reporting
      • Notifications
        • Terminology
        • Categories
        • API specifications
        • List of key topics
        • Future considerations
      • Third party Information sharing
    • Digital Network Policies
  • Domain Specifications
    • Domain Data Models
      • Handling Attachments
      • Handling Processing Errors
    • Terminologies (Code sets or Metadata standards)
    • Domain Specific Languages (DSLs)
    • Implementation Guide
  • Business Policy Specifications
    • Access Control (Roles)
    • Guidelines for Participant Onboarding
    • Guidelines for Grievance Redressal
      • Scope of disputes
      • Involved participants
      • Guideline process for dispute resolution
      • Guidelines for leveraging FTA
      • Next steps
    • Guidelines for SLAs and ecosystem satisfaction
    • Guidelines for Operating charges
    • Guidelines for Beneficiary Authentication by Providers/Payors
    • Guidelines for Event audits
    • Reference Templates
      • HCX - Terms of use
      • Payer-Provider addendum
      • Payer-Policyholder addendum
    • Next steps
  • Contributing to the specifications
  • Future Roadmap
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  1. Business Policy Specifications
  2. Guidelines for Grievance Redressal

Involved participants

List of participants involved and their role in the above mentioned types of disputes

Participant Type

Role

Comments

Payors (Insurers)

Complainant/Defendant

HCX role: payer

Health Care Providers

Complainant/Defendant

HCX role: provider

Health Insurance Intermediaries - (Licensed) - E.g., Brokers & Corporate Agents

Complainant/Defendant

HCX role: <TBD>

Health Insurance Facilitators (No licence) - E.g., distributors, marketers, facilitators (Includes Master policy holders and institutions that provide coverage through group policies including self insurance schemes)

Complainant/Defendant

HCX role: member.isnp

Third Party Administrators

Complainant/Defendant

HCX role: agency.tpa

Arbitrators (Online Dispute Resolution Entities )

Fast track arbitration process

Multiple entities to be empanelled by the HCX operator (HCX role: To be decided)

HCX Switch Operator

Complainant/Defendant

Data Provider

HCX role: HIE/HIO.HCX

In addition, participants like IRDAI (IGMS system - the existing dispute resolution platform) and insurance ombudsman and grievance redressal system in healthcare being co opted in subsequent phases.

Each participant in the above list will be mapped with HCX participnt roels mentioned in the Access Control section.

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Last updated 2 years ago

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