PM-JAY claims checked by software: get your files ready

If your hospital or clinic is on the PM-JAY panel, someone at your claims desk spends hours uploading scans and answering queries. On 25 September, the National Health Authority (NHA) launched a framework for automatic adjudication of PM-JAY claims. Adjudication means deciding whether a claim is paid. More of that first look will now be done by software, so files that a machine cannot read will slow you down.

What was launched on 25 September

The launches came at Arogya Manthan 2026 in New Delhi, held to mark eight years of PM-JAY and five years of the Ayushman Bharat Digital Mission (ABDM). Two of them matter here.

• The auto-adjudication framework uses technology, data and analytics to process claims, with less dependence on manual review.
• The Secure Data Environment, built by NHA with support from IISc Bengaluru, lets approved bodies study de-identified PM-JAY and ABDM data, or run their analysis inside an isolated NHA system. Results are reviewed before release. This is for research and planning, not for your daily claims.

The launch reports do not give a start date or a list of packages. In April, NHA said PM-JAY handles nearly 50,000 claims a day across more than 1,900 packages, and that 15–20% were already decided automatically. Ask your State Health Agency which of your packages are covered, and from when.

What the software is likely to check

In May, NHA held the finale of a national hackathon on claim checking, with IISc and the IndiaAI Mission. The winning systems show what machine checks look for:

• Sorting each uploaded document by type and reading it with OCR (software that turns a scan into text), including poor scans in more than one language.
• Looking for hospital stamps and authorised signatures.
• Checking the case against the Standard Treatment Guidelines for that package.
• Matching X-ray, CT and MRI images with the radiology report and the claimed diagnosis.
• Spotting edited discharge summaries, altered bills and fake reports.

These were competition entries, not the final rulebook. But they show where the checks are heading.

Get your claim files ready

• Scan flat, straight and readable, one document per file. A phone photo of a folded page is the first thing a machine will fail on.
• Upload each file under the right document type. A discharge summary sitting in the wrong slot can look missing to software.
• Before scanning, check that every page that needs a stamp and signature has both.
• Make the patient name, age, dates and diagnosis match across the admission note, reports, discharge summary and bill. A mismatch between two documents is easy for software to catch.
• Where a package asks for imaging, check that the images and the radiology report say the same thing.
• Never edit a scanned file. If a document is wrong, get a fresh signed copy from the doctor.
• Read the Standard Treatment Guidelines for your ten most used packages and keep a one-page checklist for each at the claims desk.
• Log every query and rejection by reason. Fix the most common reason first.

How we can help

We build software for hospital back offices. We can set up a check at your claims desk that uses Vizhi, our vision model, to flag a blurred scan, a missing stamp or a file in the wrong slot before it is uploaded. If patient files must stay inside your building, Kaappu runs fully offline and logs every question asked. See our services for custom work like this, or talk to us about your claims desk.