PM-JAY Claims Processing: A Step-by-Step Guide for Hospitals

Claim processing is where most hospitals struggle with PM-JAY. A single documentation error can delay payment by weeks or result in outright rejection. Understanding the claims workflow end-to-end — and knowing where mistakes typically happen — is essential for maintaining healthy cash flow from Ayushman Bharat patients. This guide breaks down each step and shares practical tips to improve your claim approval rate.

The PM-JAY Claims Workflow: 6 Steps

Every PM-JAY claim follows a standardised workflow on the Transaction Management System (TMS). Here is the complete process:

Step 1: Patient Verification via BIS

The first step when a PM-JAY patient arrives is verifying their identity and eligibility through the Beneficiary Identification System (BIS). The verification is Aadhaar-based and can be completed using biometric authentication (fingerprint or iris scan) or OTP sent to the registered mobile number.

What you need at this stage:

•Patient's Aadhaar number or Ayushman Bharat Health Account (ABHA) ID
•Biometric device connected to the TMS workstation
•Active internet connection at the verification desk
•Designated Pradhan Mantri Arogya Mitra (PMAM) to handle the process

Upon successful verification, TMS displays the patient's eligibility status, remaining balance (out of Rs 5 lakh annual limit), and family details. If the patient is not eligible, the system will clearly indicate the reason.

Step 2: Pre-Authorization on TMS

After verification, the treating doctor determines the required procedure and the hospital raises a pre-authorization request on TMS. This is a critical step — errors here are the most common cause of claim rejection.

Pre-authorization request includes:

•Selected Health Benefit Package (HBP) code and name
•ICD-10 diagnosis code matching the selected package
•Estimated cost (must not exceed the package rate)
•Expected length of stay
•Clinical notes and supporting diagnostic reports (X-rays, blood tests, etc.)
•Treating doctor details and speciality

The pre-authorization is reviewed by the Insurance Company (IC) or State Health Agency (SHA). Approval typically happens within 30 minutes to 12 hours. For emergency cases, treatment can begin before pre-authorization, but the request must still be raised within 48 hours of admission.

Step 3: Treatment and Documentation

Once pre-authorization is approved, the hospital provides cashless treatment to the patient. During this phase, meticulous documentation is essential because every document will be required at the claim stage.

✓Maintain detailed treatment notes, including daily progress notes
✓Record all medications administered with batch numbers
✓Document all diagnostic tests and their results
✓Photograph surgical sites (pre-op and post-op) where applicable
✓Keep records of implants used with serial numbers and invoices
✓Ensure the treatment aligns with the approved HBP package

Step 4: Discharge Summary

At discharge, prepare a comprehensive discharge summary that will form the backbone of your claim. The discharge summary should include the admission diagnosis, treatment provided, procedures performed, medications prescribed at discharge, and follow-up instructions. The patient or their attendant must sign the discharge summary. Ensure the diagnosis and procedure codes on the discharge summary match exactly with what was entered during pre-authorization.

Step 5: Claim Submission on TMS

After discharge, the hospital submits the claim on TMS. This must be done within the stipulated time frame — typically within 7 days of discharge. Late submissions may result in automatic rejection.

Documents to upload with the claim:

•Signed discharge summary
•Treatment records and daily progress notes
•Diagnostic reports (lab results, imaging)
•Pre-operative and post-operative photographs (for surgical cases)
•Implant invoices and stickers (if applicable)
•Patient consent forms
•Aadhaar verification confirmation

Step 6: Claim Review and Payment

The submitted claim goes through a multi-level review process. The Insurance Company or SHA examines the clinical documents, verifies the treatment against the approved package, and checks for any discrepancies. If everything is in order, the claim is approved and payment is disbursed directly to the hospital's registered bank account. The standard payment timeline is 15 to 30 days from claim submission.

Claim Status	What It Means
Submitted	Claim uploaded on TMS, awaiting review
Under Review	Being examined by IC/SHA claims officer
Query Raised	Additional information or documents requested
Approved	Claim accepted, payment in process
Paid	Amount credited to hospital bank account
Rejected	Claim denied — reason provided in TMS
Partially Approved	Amount reduced from original claim

Common Claim Rejection Reasons

Understanding why claims get rejected helps you prevent these issues proactively. Here are the most frequent rejection reasons reported by hospitals:

Rejection Reason	How to Prevent It
Incomplete documentation	Use a checklist before submission. Ensure all required documents are uploaded in clear, legible scans.
ICD/procedure code mismatch	Verify that the diagnosis code on the discharge summary matches the pre-authorization exactly.
Claim amount exceeds package rate	Always bill within the approved HBP package rate. Do not add extra charges beyond what the package covers.
Late claim submission	Submit claims within 7 days of discharge. Set internal reminders to avoid missing the deadline.
Treatment not matching pre-authorization	If the treatment plan changes during hospitalisation, request a modification on TMS before proceeding.
Patient identity verification failure	Re-verify patient identity at discharge using the same Aadhaar-based method used at admission.
Duplicate claim submission	Check TMS for existing claims before raising a new one. Duplicates are automatically flagged and rejected.

Tips for Faster Claim Settlement

Based on feedback from hospitals with high claim approval rates, here are practical tips to speed up your settlements:

✓Designate a dedicated PM-JAY claims officer who handles all TMS submissions and follow-ups
✓Create standardised templates for discharge summaries that include all fields required by TMS
✓Scan and upload documents on the same day as discharge — do not let paperwork pile up
✓Respond to queries raised by IC/SHA within 24 hours to prevent claim escalation
✓Maintain a digital copy of every document alongside the TMS submission for audit readiness
✓Track all claims in a spreadsheet or management system with dates, amounts, and current status
✓Attend NHA training refreshers whenever offered — TMS features are updated regularly
✓Build a good relationship with your district-level IC/SHA representative for faster query resolution

How Zospital CRM Helps With PM-JAY Claims

While TMS is the official system for claim submission, Zospital CRM complements it by keeping your internal records organised and your workflow efficient. Here is how:

PM-JAY Badge on Patient Profiles

Instantly identify Ayushman Bharat beneficiaries in your patient list. The badge is visible across all views — appointments, visits, and billing.

Claim Type Tracking

Record each visit as PM-JAY, private insurance, or self-pay. Generate reports showing PM-JAY revenue, pending claims, and average settlement time.

Package Rate Quick Reference

Look up HBP package rates directly within Zospital while creating treatment plans. Ensure you are always within the approved amount before submitting to TMS.

Document Attachment

Attach discharge summaries, diagnostic reports, and claim receipts to patient records in Zospital. Maintain a complete audit trail without paper files.

Follow-Up Reminders

Set automated WhatsApp reminders for PM-JAY patients for post-discharge follow-ups. Improve patient outcomes and maintain compliance with treatment protocols.

Revenue Dashboard

Track PM-JAY payments alongside other revenue streams. See at a glance how much is pending, approved, or settled across all your PM-JAY claims.

Key Takeaways

•PM-JAY claims follow a 6-step process: BIS verification, pre-authorization, treatment, discharge, claim submission, and payment
•Most rejections are caused by documentation gaps and code mismatches — both are preventable
•Submit claims within 7 days of discharge and respond to queries within 24 hours
•A dedicated claims officer and standardised documentation templates significantly improve approval rates
•Use Zospital CRM alongside TMS to keep your internal records, patient tracking, and revenue reporting organised