PMJAY | Pradhan Mantri Jan Arogya YojanaThe World’s largest health scheme, is on NHCX
Pradhan Mantri Jan Arogya Yojana gives eligible families cashless secondary and tertiary treatment at empanelled hospitals.
PMJAY sits on NHCX like any other payer - same cover, same cashless treatment, raised and settled through the exchange
- ₹5 lakh per family, per yearCover for secondary and tertiary hospitalisation for every eligible family, with no premium to pay at the point of care.About the cover
- Cashless at the hospitalAn empanelled hospital treats and discharges the patient, then raises the claim over NHCX instead of a payer-specific portal.How a claim travels
- Run by NHA with the statesThe National Health Authority runs PM-JAY and the exchange nationally; each State Health Agency runs the scheme in its own state.Read the specification
PMJAY Benefits
Cover a family can use
Up to ₹5 lakh per family per year for secondary and tertiary hospitalisation, with no premium to pay at the point of care.
Cashless at the hospital
An eligible patient is treated and discharged without paying the hospital; the claim is settled between the hospital and the scheme afterwards.
Run by NHA with the states
The National Health Authority runs PM-JAY nationally, and each State Health Agency runs it in its own state, with its own empanelment and its own claim processing.
State: MAHARASHTRAHover the card to flip it
Three things a hospital does differently
The scheme is the same and so is the cover. What changes is where the claim is raised, how the patient is proved to be the beneficiary, and what happens to a claim that arrives clean.
The claim is composed in the software the hospital already runs, from the diagnosis, procedure and bill lines it already holds. No second data entry, no staff switching systems to submit what has just been recorded.
The patient is authenticated against their Ayushman record at the hospital, so who was treated is settled at the point of care rather than queried weeks later against a paper trail.
A claim that arrives coded, complete and validated can be priced against the scheme’s rules as it lands, so the straightforward majority settle first and human review is spent on the cases that need it.
How a scheme claim travels
The same four moves every claim makes, with the standards doing the work in between. Nothing here is particular to one hospital’s software or one state’s claim system.
What each side gets
For hospitals
One integration, not one per payer: the same bundle format serves PM-JAY, state schemes and private insurers.
Claims validated before they leave, so incomplete ones are caught at the desk instead of coming back as queries weeks later.
A readable trail for every claim, which is what a disputed settlement actually turns on.
Connecting a PM-JAY hospital or payer
Integration is the same for a scheme claim as for any other: read the specification, build a bundle that validates, rehearse the whole flow against the sandbox, then apply for the environment you need.