Cashless claims in hospitals: why the case needs one record

A claim is a long conversation

In a hospital, a cashless claim is not one document. It is a sequence: eligibility check, pre-authorisation, enhancements as treatment changes, final authorisation at discharge, the claim file, queries from the insurer or the TPA, and finally settlement with deductions. Each step produces documents and messages, and the people involved sit in different departments.

When these live in email threads, portals and spreadsheets, the claim desk spends its day finding out where each case stands.

What the timelines say, and whom they bind

IRDAI's master circular on health insurance business of 29 May 2024 expects insurers to decide a cashless request within one hour and to give final authorisation at discharge within three hours of the hospital's request. A Ministry of Finance release of 26 March 2026 restated these timelines.

Two points matter for a hospital. The clock binds the insurer or TPA, not the hospital, and it is understood to start from a complete request. So the practical lever on the hospital side is to send complete requests quickly and to see at once when a request is waiting on a query. These timelines are an IRDAI rule on insurers; they do not describe CGHS, PM-JAY or ESI claims.

One case record

HospitalOS keeps eligibility, approvals, queries, documents and settlement on one case file, with an approval clock and an ageing view. The desk can see which cases have a query open, which are waiting for final authorisation, and which have been settled with a deduction that needs review.

• A document checklist per payer, so a missing discharge summary is caught before submission.
• A query log that records what was asked, who answered and when.
• An ageing view of open cases by payer.

Government schemes

Scheme patients bring their own systems. Under PM-JAY, the National Health Authority's Transaction Management System captures admission, pre-authorisation, discharge, claim and settlement. According to the CGHS office memorandum of 12 October 2025, revised CGHS rates came into force from 13 October 2025 and new cases were to be processed on TMS 2.0. A case record that holds the scheme reference next to the hospital's own documents helps the desk reconcile the two.

NHCX and ABDM: where we stand

The National Health Claims Exchange is a gateway under the Ayushman Bharat Digital Mission for standardised claim data between hospitals, insurers and patients, built on FHIR. As far as we can tell, hospital adoption is not mandatory at present. We design HospitalOS so that a hospital can move toward it later, and we do not claim certification or live integration today.

Alongside, not instead of

HospitalOS starts alongside the hospital information system the hospital already runs. Patients and bills can be imported one way, as agreed with that system's vendor. The aim is to give the claim desk a working view first, not to replace the core system.

This article is general information, not legal or tax advice. Rules and circulars change, so check the current text with your adviser before you rely on it.

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