Dr. Harish Kumar Health claims and medical audit

A health-insurance claim, audited line by line, with the rule behind every rupee

Six worked examples of how Indian health-insurance claims are audited, on synthetic cases, with the rule and its source behind every rupee.

The six worksheets

  1. 1. Final bill audit: Audit a hospital bill line by line: room-rent cap, proportionate deduction, Annexure I items, co-pay and sum-insured cap, with the three-hour discharge timer.
  2. 2. PED, waiting period and moratorium: Check a pre-existing condition against the 36-month look-back, the waiting periods and the 60-month moratorium, and draft a note for the claims committee.
  3. 3. Reimbursement risk signals: Score a reimbursement file on eleven stated signals, each with its points and evidence, to decide how closely a desk should look. Signals for review, not findings.
  4. 4. Package and implant price caps: Settle an admission on a package: charges already inside the package, implant price ceilings with their dates, and what is held for documents.
  5. 5. AYUSH inpatient compliance: Check an AYUSH inpatient admission against the facility criteria, the minimum stay and the records, then settle each bill line by category on a sample case.
  6. 6. NHCX claim bundle checks: Paste a sample FHIR claim bundle and see what is missing or inconsistent before it goes to the National Health Claims Exchange (NHCX). Synthetic data only.

Also on the site

  • Claim lifecycle: Follow an Indian health-insurance claim from admission to payment: the IRDAI turn-around time (TAT) limits, why claims run late, and what a policyholder can do.
  • Dashboard: A year of synthetic health claims run through the worksheets: deductions, authorisation times and risk bands, with filters and charts. All figures are invented.
  • Illustrated guide: the whole site and each worksheet as one picture.
  • Method and limits: how the rules are sourced, tested and labelled.

Every case on this site is synthetic. These are working drafts and illustrations, not a claim decision or legal advice. The interactive worksheets need JavaScript; nothing is sent anywhere.