Enhancing Claim Settlements under AB PM-JAY

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY), India’s flagship health insurance scheme, ensures financial protection for millions of beneficiaries by providing cashless and paperless access to healthcare services. Efficient and timely claim settlement is a cornerstone of its success, enabling seamless delivery of services and fostering trust among beneficiaries and healthcare providers.

Strengthening Claim Settlement Mechanisms

Under AB PM-JAY, claim settlements are managed by State Health Agencies under the respective state governments. To ensure prompt and efficient processing, the status of claim settlements is closely monitored, with regular review meetings conducted to evaluate progress.

To further enhance performance, the National Health Authority (NHA) has introduced revised health benefit packages, increasing the number of procedures to 1,961 and raising rates for 350 packages. Additionally, new packages have been added to ensure hospitals remain actively engaged in the scheme. This helps streamline claim settlement and ensures that it is completed within the defined turnaround time. Capacity-building initiatives, both virtual and physical, have also been implemented to empower hospitals and healthcare providers.

Ensuring Beneficiary Support and Grievance Redressal

A robust three-tier grievance redressal system has been established at the district, state, and national levels to address issues faced by beneficiaries. Beneficiaries can raise grievances through multiple channels, including the Centralized Grievance Redressal Management System (CGRMS), call centres, emails, and letters to State Health Agencies. Based on the nature of grievances, actions such as hospital coordination and beneficiary support are promptly undertaken.

To ensure better engagement with empanelled hospitals, a hospital-specific call centre (14413) has been set up to address their concerns in real-time. District Implementation Units (DIUs) also regularly visit hospitals to identify and resolve challenges faced by both beneficiaries and hospitals, ensuring that the scheme functions effectively on the ground.

Conclusion

AB PM-JAY continues to strengthen its claim settlement mechanisms and beneficiary support systems through constant monitoring, capacity-building efforts, and proactive grievance redressal measures. These initiatives aim to ensure the scheme remains efficient, transparent, and beneficial for all stakeholders, enhancing its overall impact on India’s healthcare landscape.

Disclaimer: This blog has been written exclusively for educational purposes. The securities mentioned are only examples and not recommendations. It is based on several secondary sources on the internet and is subject to changes. Please consult an expert before making related decisions.