Health Claims Exchange Protocol
Open-source, community driven protocol for decentralised Health Claims data Exchange - the first step to a Digitised Health Benefits Ecosystem
Our Vision
Our Vision
To create an open, community-driven, trusted protocol that will revolutionize the health benefits sector by enabling seamless data exchange among policyholders, payers, health service providers, third-party administrators, regulators, observers, and other stakeholders. By promoting transparency, efficiency, and collaboration, we aim to enhance the insurance experience, streamline claims processing, facilitate innovation, enhance risk assessment and pricing, enhance health benefits coverage, and ultimately provide greater value to policyholders. Together, we aim to achieve a future where data exchange becomes the foundation for a customer-centric, digitally-driven health benefits ecosystem.
Overview
The health benefits ecosystem, including the insurance industry, plays a crucial role in protecting individuals and businesses against financial risks. However, current non-digital and non-standardised processes pose several challenges to the stakeholders.
Key ecosystem challenges:
Policyholders
- Cumbersome claims experience
- Delays and frustration
- Limited access to real-time information
- Poor insurance adoption
Regulators
- Balancing between consumer protection, fair market practices, and industry growth
- Ensuring regulatory compliance
- Enhancing regulatory innovation
- Monitoring performance
Payers/TPAs
- Rising incurred claims ratios (ICRs)
- Manual adjudication and limited fraud analytics
- Delayed product innovation
- Poor customer satisfaction
Healthcare Providers
- Difficulties in managing claims
- Poor patient experience
- Delayed payments
- Inefficient use of resources
Health Claims Exchange (HCX) Protocol
To address these challenges and unlock the full potential of the health benefits ecosystem, the Health Claims Data Exchange (HCX) Protocol offers a transformative solution. This protocol revolutionizes how data and information are exchanged, bringing together policyholders, payers, health service providers, and regulators on a unified network. Salient features of the HCX protocol are:
- Set of specifications consisting of APIs, data models, reference architecture, and domain-specific standards that enable the creation of decentralised networks
- The layered design allows the independent evolution of health benefit use cases
- It leverages digital technologies and an open network for seamless data exchange
- It is being developed as a digital public good, in an unprecedented, transparent, and collaborative process anchored by 120+ volunteers from the healthcare, health-tech, and health payer ecosystem
Benefits of HCX Protocol
Improved Policyholder Experience
Enhanced Transperancy
Accurate Risk Assesment and Pricing
Efficient Claims Processing
Potential for Innovative Products
Improved Policymaking and Regulatory Compliance
We encourage diverse stakeholders including payers, policyholders, health service providers, and regulators to join our growing community. Together, we can shape the future of insurance claims processing, foster innovation, and deliver greater value to policyholders. Read the documentation or Join our vibrant community to stay informed, work together, and help shape the future of the Claims Exchange Protocol.
Background
The journey of the HCX protocol began with a passionate community of 50+ volunteers comprising stakeholders from across the healthcare ecosystem. This diverse group included payers, hospitals, third-party administrators (TPAs), insurance technology players, and think tanks. The inspiration behind HCX came from the recommendations of the IRDAI-NHA (Insurance Regulatory and Development Authority of India-National Health Authority) Joint Working Group, which emphasized the creation and adoption of a Health Claims Exchange. Spearheaded by Swasth, the development of HCX was initiated as a dedicated platform for health claims use cases, to establish a transparent, collaborative, and open effort.
Since its inception, the HCX community has grown rapidly and now boasts a strength of over 120 dedicated individuals. This dynamic and diverse community is continuously working towards enhancing domain knowledge and refining policy specifications for the health sector. Through active collaboration and knowledge sharing, this community strives to develop best practices, establish robust standards, and promote innovation in health claims processing.