Preauthorisation request
The first bundle with clinical content. The provider asks the payer to approve a treatment before it is given. The spine is a Claim with use set to preauthorization.
Sent on /v1/preauth/submit, answered on /v1/preauth/on_submit, workflow 12 new, 121 resubmission.
The bundle
| # | Resource | Profile |
|---|---|---|
| 1 | Claim | Claim |
| 2 | Patient | Patient |
| 3 | Organization (prov) | Organization |
| 4 | Organization (pay) | Organization |
| 5 | Coverage | Coverage |
| 6 | Practitioner | Practitioner |
| 7 | Procedure | Procedure |
| 8 | QuestionnaireResponse | QuestionnaireResponse, which NRCeS does not publish; base FHIR QuestionnaireResponse |
Elements
Claim
NRCeS profile: Claim.
| Element | Example |
|---|---|
identifier[] | system https://nhcx.abdm.gov.in, value NM-26-0SE00002M |
identifier[].type.coding[] | CLN Claim number in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-identifier-type-code |
status | active |
type.coding[] | 737481003 Inpatient care management (procedure) in http://snomed.info/sct |
use | preauthorization |
patient | reference https://nhcx.abdm.gov.in/patient |
billablePeriod | start 2026-09-10T00:00:00+05:30, end 2026-09-10T00:00:00+05:30 |
created | 2026-09-10T23:53:57+05:30 |
insurer | reference https://nhcx.abdm.gov.in/payer |
provider | reference https://nhcx.abdm.gov.in/provider |
priority.coding[] | normal Normal in http://terminology.hl7.org/CodeSystem/processpriority |
careTeam[] | sequence 1 |
careTeam[].provider | reference https://nhcx.abdm.gov.in/practitioner |
careTeam[].role.coding[] | primary Primary provider in http://terminology.hl7.org/CodeSystem/claimcareteamrole |
careTeam[].qualification.coding[] | 394802001 General medicine in http://snomed.info/sct |
supportingInfo[] | id SupportingInformation/1, sequence 1 |
id SupportingInformation/2, sequence 2 | |
id SupportingInformation/3, sequence 3 | |
| and 8 more | |
supportingInfo[].category.coding[] | INV Document Type - Investigation in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-supportinginfo-category |
ONS Period, start or end dates of aspects of the Condition. (e.g. admission, discha… in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-supportinginfo-category | |
OTH Other in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-supportinginfo-category | |
| and 1 more | |
supportingInfo[].code.coding[] | POI Proof of Identity (Aadhaar / Passport / Voter ID) in https://nhcx.abdm.gov.in/document-code |
CER Medical Certificate / Doctor Referral in https://nhcx.abdm.gov.in/document-code | |
RAD Radiology / X-Ray / CT / MRI Scan Reports in https://nhcx.abdm.gov.in/document-code | |
| and 8 more | |
supportingInfo[].valueAttachment | contentType application/pdf, title Proof of Identity (Aadhaar / Passport / Voter ID) |
contentType application/pdf, title Medical Certificate / Doctor Referral | |
contentType application/pdf, title Radiology / X-Ray / CT / MRI Scan Reports | |
| and 5 more | |
supportingInfo[].valueReference | reference https://nhcx.abdm.gov.in/questionnaireresponse/1, display Total Knee Replacement (Unilateral), Standard Treatment Guidelines |
diagnosis[] | sequence 1 |
diagnosis[].diagnosisCodeableConcept.coding[] | E11.9 Type 2 diabetes mellitus without complications in http://hl7.org/fhir/sid/icd-10 |
diagnosis[].type[].coding[] | admitting Admitting Diagnosis in http://terminology.hl7.org/CodeSystem/ex-diagnosistype |
diagnosis[].onAdmission.coding[] | yes Yes in http://terminology.hl7.org/CodeSystem/ex-diagnosis-on-admission |
procedure[] | id Procedure/1, sequence 1, date 2026-09-10T00:00:00+05:30 |
procedure[].type[].coding[] | surgical Surgical in https://nhcx.abdm.gov.in/procedure-type |
procedure[].procedureReference | reference https://nhcx.abdm.gov.in/procedure/1, display Total Knee Replacement (Unilateral) |
insurance[] | sequence 1, focal true |
insurance[].coverage | reference https://nhcx.abdm.gov.in/coverage |
item[] | id Item/1, sequence 1, factor 1, careTeamSequence 1, diagnosisSequence 1, procedureSequence 1, informationSequence 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 |
item[].productOrService.coding[] | PROC-KNEE-01 Total Knee Replacement (Unilateral) in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-procedure-code |
item[].servicedPeriod | start 2026-09-10, end 2026-09-10 |
item[].quantity | value 1 |
item[].unitPrice | value 150000, currency INR |
item[].net | value 150000, currency INR |
item[].category.coding[] | Surgical Surgical in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-benefit-category |
total | value 150000, currency INR |
Patient
NRCeS profile: Patient.
| Element | Example |
|---|---|
identifier[] | value MRAV1985001 |
value 91-1234-1234-1234 | |
identifier[].type.coding[] | PMJAY Pradhan Mantri Jan Aarogya Yojana (PMJAY) ID in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-identifier-type-code |
ABHA Ayushman Bharat Health Account (ABHA) ID in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-identifier-type-code | |
MB Member Number in http://terminology.hl7.org/CodeSystem/v2-0203 | |
name[] | text <patient name> |
telecom[] | system phone, value 9876543210 |
gender | male |
birthDate | 1985-06-15 |
Organization (prov)
NRCeS profile: Organization.
| Element | Example |
|---|---|
identifier[] | system https://nhcx.abdm.gov.in, value IN1910000151 |
identifier[].type.coding[] | NPI National provider identifier in http://terminology.hl7.org/CodeSystem/v2-0203 |
type[].coding[] | prov Healthcare Provider in http://terminology.hl7.org/CodeSystem/organization-type |
name | KyroCare Multispeciality Hospital |
Organization (pay)
NRCeS profile: Organization.
| Element | Example |
|---|---|
identifier[] | system https://nhcx.abdm.gov.in, value 1000004805 |
identifier[].type.coding[] | NIIP National Insurance Payor Identifier (Payor) in http://terminology.hl7.org/CodeSystem/v2-0203 |
type[].coding[] | pay Payer in http://terminology.hl7.org/CodeSystem/organization-type |
name | Sandbox Payer |
Coverage
NRCeS profile: Coverage.
| Element | Example |
|---|---|
identifier[] | value POL7UMU001 |
identifier[].type.coding[] | NH National Health Plan Identifier in http://terminology.hl7.org/CodeSystem/v2-0203 |
status | active |
type.coding[] | HIP health insurance plan policy in http://terminology.hl7.org/CodeSystem/v3-ActCode |
subscriber | reference https://nhcx.abdm.gov.in/patient |
subscriberId | MRAV1985001 |
beneficiary | reference https://nhcx.abdm.gov.in/patient |
relationship.coding[] | self in http://terminology.hl7.org/CodeSystem/subscriber-relationship |
payor[] | reference https://nhcx.abdm.gov.in/payer |
Practitioner
NRCeS profile: Practitioner.
| Element | Example |
|---|---|
identifier[] | system https://nhcx.abdm.gov.in, value 71-8422-5818-7201 |
system https://hpr.abdm.gov.in, value 71-8422-5818-7201 | |
identifier[].type.coding[] | HPID Healthcare Professional ID (HPID) in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-identifier-type-code |
HPIN Health Practitioner ID issued by NDHM in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-identifier-type-code | |
name[] | text Dr. Ananya Rao |
qualification[].code.coding[] | MD Doctor of Medicine in http://terminology.hl7.org/CodeSystem/v2-0360 |
Procedure
NRCeS profile: Procedure.
| Element | Example |
|---|---|
status | preparation |
code | text Total Knee Replacement (Unilateral) |
code.coding[] | 71388002 Procedure (procedure) in http://snomed.info/sct |
subject | reference https://nhcx.abdm.gov.in/patient |
performedDateTime | 2026-09-10T00:00:00+05:30 |
QuestionnaireResponse
| Element | Example |
|---|---|
questionnaire | <participant-defined> |
status | completed |
subject | reference https://nhcx.abdm.gov.in/patient |
authored | 2026-09-10T23:53:57+05:30 |
item[] | linkId PROC-KNEE-01/stg/1, text Duration of symptoms and the conservative treatment tried (months of physiother… |
linkId PROC-KNEE-01/stg/2, text Kellgren-Lawrence grade of osteoarthritis on the standing X-ray | |
linkId PROC-KNEE-01/stg/3, text Range of motion and deformity of the knee (flexion contracture, varus/valgus) | |
| and 2 more | |
item[].answer[] | valueString Recorded. |
Rules
The case number
Claim.identifier, typed CLN, carries the provider's case number. Every later message on the case, the payer's included, names it.
One focal insurance
Exactly one Claim.insurance[] entry carries focal: true.
Items
Each item links to the care team, diagnosis and procedure by sequence. net is unitPrice times quantity; do not compute with factor. Claim.total equals the sum of the item nets.
Documents
The mandatory document codes are the ones the auth-requirements answer returned. Send each code and display exactly as given.
The STG answers
Each package's STG questionnaire is answered as a QuestionnaireResponse in the bundle, with the linkIds the plan gives.
Claim.type
SNOMED 737481003, Inpatient care management. Payers echo it, some under the ndhm-claim-type ValueSet URL.
References to records
A valueReference may point at the Composition heading an embedded record rather than at a DocumentReference. Follow the reference, then walk the record.
PMJAY
The generic bundle above is what every payer takes, IRDAI-regulated insurers and TPAs included. PMJAY takes it with the changes and requirements below.
What changes in the bundle
Resources
- PMJAY adds 1
QuestionnaireResponse.
Elements PMJAY adds
| Element | Example |
|---|---|
Claim.item[].modifier[].coding[] | STRAT006a Routine Ward |
Claim.item[].programCode[].coding[] | AB-PMJAY Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in https://nrces.in/ndhm/fhir/r4/CodeSystem/ndhm-program-code |
QuestionnaireResponse.item[].answer[].valueAttachment | contentType application/pdf, title Medical Superintendent Declaration Form (During Admission) |
What PMJAY specifies
item.programCodecarriesAB-PMJAYunderndhm-program-code.item.modifiercarries the ward tier from the master's stratification codes, anditem.categorythe master's specialty code.- The Authentication Consent answer is a second
QuestionnaireResponsebeside the STG answers, with its attachments asvalueAttachmentand its dates asvalueDateTime. - Document codes are the
MANDcodes the auth-requirements answer returned.
What PMJAY requires
- The biometric user token on the request, or the plan's Authentication Consent questionnaire answered as a
QuestionnaireResponse. Refused withPAYR-1256otherwise. - The STG questionnaire answered for every package that needs one. Refused with
PAYR-1254otherwise. - Not more than one day before admission, with the registration and admission dates as supporting information.
- One live preauthorisation per beneficiary per hospital. Refused with
PAYR-1238while another is open. LM100is not allowed on a preauthorisation. Refused withPAYR-1270.- Auto-approval only when this is the first preauthorisation on the case and every package carries
ApprovalNotRequiredY.
Use cases, APIs and data elements
B3 Submit pre-authorisation (provider)
Permission to treat. A resubmission, an enhancement and a query answer all reuse the same bundle with a new correlation id and the original reference; only the workflow code tells them apart. The acknowledgement on 20 brings the payer's own case number, and the desk files everything under it.
| API | /v1/preauth/submit apis/03-preauth/v1-preauth-submit.bru |
| Callback | /v1/preauth/on_submit apis/03-preauth/v1-preauth-on-submit.bru |
| Workflow | 12 new, 121 resubmission, 13 enhancement; under PMJAY 19 answers a query and 131 an enhancement query |
| Carries JWE | yes |
| Focal resource | Claim |
Request headers
| Header | Example value |
|---|---|
x-hcx-sender_code | 1000004446@hcx |
x-hcx-recipient_code | 1518@hcx |
x-hcx-api_call_id | {{$guid}} |
x-hcx-request_id | {{$guid}} |
x-hcx-correlation_id | {{$guid}} |
x-hcx-workflow_id | 12 |
x-hcx-timestamp | {{$isoTimestamp}} |
x-hcx-status | request.initiated |
x-hcx-ben-abha-id | 91711234567890 |
x-hcx-use_case | New |
Workflow codes
| Code | Name | Authored by | x-hcx-status | Means |
|---|---|---|---|---|
12 | Preauth Request Initiated | provider | request.initiated | New preauth submission |
121 | Preauth Request Resubmitted | provider | request.initiated | Resubmission after query/rejection |
13 | Enhancement Request Initiated | provider | request.initiated | Enhancement (additional amount) request |
19 | Preauth Query Response Submitted | provider | response.complete | Response to payer's query on preauth |
131 | Enhancement Query Response Submitted | provider | response.partial, response.error, response.complete | Response to enhancement query |
Data elements
| Element | Label | Group | Type | Card. | FHIR path | Example | Notes |
|---|---|---|---|---|---|---|---|
claimNumber | Pre-auth Case Number | Case | string | 1..1 | Claim.identifier[0].value | PA20260226001 | also at Bundle.id |
use | Claim Use | Case | code | 1..1 | Claim.use | preauthorization | |
preAuthRef | Approval Reference (if enhancement) | Case | string | 0..1 | Claim.insurance[0].preAuthRef[0] | APPR-2026-HP-00891 | |
patientName | Patient Full Name | Beneficiary | string | 1..1 | Patient.name[0].text | Ramesh Chandra Sharma | |
memberId | Scheme / Insurer Member ID | Beneficiary | string | 1..1 | Patient.identifier[type=PMJAY].value | PMJAY-HP-2024-998811 | also at Coverage.subscriberId |
abhaNumber | ABHA Number | Beneficiary | string | 0..1 | Patient.identifier[type=ABHA].value | 91234567890123 | |
gender | Gender | Beneficiary | code | 1..1 | Patient.gender | male | code system http://hl7.org/fhir/administrative-gender |
birthDate | Date of Birth | Beneficiary | date | 1..1 | Patient.birthDate | 1982-06-15 | |
patientPhone | Mobile Phone | Beneficiary | string | 0..1 | Patient.telecom[system=phone].value | 9876543210 | |
policyNumber | Policy Number | Coverage | string | 1..1 | Coverage.identifier[0].value | PMJAY/HP/S/G | |
facilityId | Hospital Facility ID (HFR/NPI) | Provider | string | 1..1 | Organization[type=prov].identifier[system=https://facility.abdm.gov.in].value | IN1910000151 | |
providerName | Hospital Name | Provider | string | 1..1 | Organization[type=prov].name | Apex Multispeciality Hospital | |
payerId | Payer Identifier (NIIP) | Payer | string | 1..1 | Organization[type=pay].identifier[system=https://irdai.gov.in].value | 1000003538 | |
payerName | Payer Name | Payer | string | 1..1 | Organization[type=pay].name | National Health Authority - PMJAY | |
practitionerId | Practitioner ID (HPID/HPIN) | Practitioner | string | 1..1 | Practitioner.identifier[system=https://hpr.abdm.gov.in].value | 21-8899-4455-6677 | |
practitionerName | Doctor Name | Practitioner | string | 1..1 | Practitioner.name[0].text | Dr. Arvind Kumar | |
admissionDate | Admission Date | Stay | dateTime | 1..1 | Claim.billablePeriod.start | 2026-02-26T10:00:00+05:30 | |
dischargeDate | Discharge Date | Stay | dateTime | 1..1 | Claim.billablePeriod.end | 2026-03-02T14:30:00+05:30 | |
careSetting | Care Setting | Stay | code | 1..1 | Claim.type.coding[0].code | institutional | code system http://terminology.hl7.org/CodeSystem/claim-type |
primaryDiagnosisCode | Primary Diagnosis (ICD-10) | Clinical | string | 1..1 | Claim.diagnosis[0].diagnosisCodeableConcept.coding[0].code | A97.0 | code system http://hl7.org/fhir/sid/icd-10 |
procedureCode | Package / Procedure Code | Clinical | string | 1..1 | Claim.procedure[0].procedureCodeableConcept.coding[0].code | MG004A | |
estimatedTotal | Estimated Package Amount | Billing | decimal | 1..1 | Claim.total.value | 15500.00 |
NRCeS profiles: Claim, Patient, Coverage, Organization, Practitioner.
D4 Submit pre-authorisation (pmjay)
Not more than one day before admission, with the biometric token or the consent response, the documents the auth-requirements answer asked for, the STG questionnaire for each package, and the registration and admission dates as supporting info. Auto-approved only if it is the first pre-authorisation for the case and every package allows it.
| API | /v1/preauth/submit apis/03-preauth/v1-preauth-submit.bru |
| Callback | /v1/preauth/on_submit apis/03-preauth/v1-preauth-on-submit.bru |
| Workflow | 12 |
| Carries JWE | yes |
| Focal resource | Claim |
| Simulator console | /builder?family=preauth&usecase=initiate |
Request headers
| Header | Example value |
|---|---|
x-hcx-sender_code | 1000004446@hcx |
x-hcx-recipient_code | 1518@hcx |
x-hcx-api_call_id | {{$guid}} |
x-hcx-request_id | {{$guid}} |
x-hcx-correlation_id | {{$guid}} |
x-hcx-workflow_id | 12 |
x-hcx-timestamp | {{$isoTimestamp}} |
x-hcx-status | request.initiated |
x-hcx-ben-abha-id | 91711234567890 |
x-hcx-use_case | New |
Workflow codes
| Code | Name | Authored by | x-hcx-status | Means |
|---|---|---|---|---|
12 | Preauth Request Initiated | provider | request.initiated | New preauth submission |
Data elements
| Element | Label | Group | Type | Card. | FHIR path | Example | Notes |
|---|---|---|---|---|---|---|---|
claimNumber | PMJAY Case Number | Case | string | 1..1 | Claim.identifier[0].value | VB26AA2600001 | |
patientName | Patient Full Name | Beneficiary | string | 1..1 | Patient.name[0].text | Ramesh Chandra Sharma | |
memberId | Scheme / Insurer Member ID | Beneficiary | string | 1..1 | Patient.identifier[type=PMJAY].value | PMJAY-HP-2024-998811 | also at Coverage.subscriberId |
abhaNumber | ABHA Number | Beneficiary | string | 0..1 | Patient.identifier[type=ABHA].value | 91234567890123 | |
gender | Gender | Beneficiary | code | 1..1 | Patient.gender | male | code system http://hl7.org/fhir/administrative-gender |
birthDate | Date of Birth | Beneficiary | date | 1..1 | Patient.birthDate | 1982-06-15 | |
patientPhone | Mobile Phone | Beneficiary | string | 0..1 | Patient.telecom[system=phone].value | 9876543210 | |
facilityId | Hospital Facility ID (HFR/NPI) | Provider | string | 1..1 | Organization[type=prov].identifier[system=https://facility.abdm.gov.in].value | IN1910000151 | |
providerName | Hospital Name | Provider | string | 1..1 | Organization[type=prov].name | Apex Multispeciality Hospital | |
payerId | Payer Identifier (NIIP) | Payer | string | 1..1 | Organization[type=pay].identifier[system=https://irdai.gov.in].value | 1000003538 | |
payerName | Payer Name | Payer | string | 1..1 | Organization[type=pay].name | National Health Authority - PMJAY | |
practitionerId | Practitioner ID (HPID/HPIN) | Practitioner | string | 1..1 | Practitioner.identifier[system=https://hpr.abdm.gov.in].value | 21-8899-4455-6677 | |
practitionerName | Doctor Name | Practitioner | string | 1..1 | Practitioner.name[0].text | Dr. Arvind Kumar | |
primaryDiagnosisCode | Primary Diagnosis (ICD-10) | Clinical | string | 1..1 | Claim.diagnosis[0].diagnosisCodeableConcept.coding[0].code | A97.0 | code system http://hl7.org/fhir/sid/icd-10 |
procedureCode | Package / Procedure Code | Clinical | string | 1..1 | Claim.procedure[0].procedureCodeableConcept.coding[0].code | MG004A | |
patientPhoto | Patient Photo on Bed (POI) | Documents | base64Binary | 1..1 | Claim.supportingInfo[category=POI].valueAttachment.data | JVBERi0xLjQK... |
NRCeS profiles: Claim, Patient, Organization, Practitioner.
D5 Resubmit pre-authorisation (pmjay)
Revises an approved or rejected case for a different amount or package. Nullifies every earlier instance; the payer treats it as the new base request.
| API | /v1/preauth/submit apis/03-preauth/v1-preauth-submit.bru |
| Callback | /v1/preauth/on_submit apis/03-preauth/v1-preauth-on-submit.bru |
| Workflow | 121 |
| Carries JWE | yes |
| Focal resource | Claim |
| Simulator console | /builder?family=preauth&usecase=resubmit |
Request headers
| Header | Example value |
|---|---|
x-hcx-sender_code | 1000004446@hcx |
x-hcx-recipient_code | 1518@hcx |
x-hcx-api_call_id | {{$guid}} |
x-hcx-request_id | {{$guid}} |
x-hcx-correlation_id | {{$guid}} |
x-hcx-workflow_id | 121 |
x-hcx-timestamp | {{$isoTimestamp}} |
x-hcx-status | request.initiated |
x-hcx-ben-abha-id | 91711234567890 |
x-hcx-use_case | Resubmit |
Workflow codes
| Code | Name | Authored by | x-hcx-status | Means |
|---|---|---|---|---|
121 | Preauth Request Resubmitted | provider | request.initiated | Resubmission after query/rejection |
Data elements
| Element | Label | Group | Type | Card. | FHIR path | Example | Notes |
|---|---|---|---|---|---|---|---|
claimNumber | Existing Case Number | Case | string | 1..1 | Claim.identifier[0].value | VB26AA2600001 | |
workflowId | Workflow Code | Header | string | 1..1 | Header.x-hcx-workflow_id | 121 |
NRCeS profiles: Claim.