Life Line Nursing Home HMIS
Sections 21–23 & 52

Government and insurance cases get their own workflow

An Ayushman patient is not a self-paying patient with a different tag. PM-JAY has its own transaction lifecycle, its own document requirements and its own failure modes. So does a TPA insurance claim. Both are built as first-class workflows, not as payment categories.

Section 21 · Insurance

Insurance & TPA claim management

From policy capture and pre-authorization through query management to settlement — including the outcomes nobody likes to plan for: rejection and short payment.

  • Insurance company
  • TPA
  • Policy number
  • Member ID
  • Coverage details
  • Pre-authorization
  • Approval amount
  • Requested amount
  • Approved amount
  • Documents
  • Claim submission
  • Query management
  • Claim status
  • Settlement
  • Rejection
  • Short payment
Section 22 · Ayushman Bharat

The PM-JAY case, end to end

The official PM-JAY hospital transaction workflow runs from beneficiary identification through pre-authorization, treatment and discharge to claim processing. The module follows that sequence, so the desk always knows which stage a case is stuck at.

  1. 1

    Beneficiary

  2. 2

    Verification

  3. 3

    Package

  4. 4

    Pre-auth

  5. 5

    Approval

  6. 6

    Treatment

  7. 7

    Discharge

  8. 8

    Claim

  9. 9

    Settlement

Beneficiary identification

6 features

  • Ayushman beneficiary verification workflow
  • Beneficiary ID / details
  • Family / member information
  • Identity documentation
  • Eligibility / status
  • Patient verification status

Package management

8 features

  • Procedure / package master
  • Package code
  • Package description
  • Package rate
  • Applicable category
  • Procedure mapping
  • Package inclusions / exclusions
  • Configurable government rate updates

Pre-authorization

13 features

  • Case creation
  • Diagnosis
  • Proposed treatment
  • Package selection
  • Required documents
  • Doctor information
  • Investigation reports
  • Upload facility
  • Pre-auth request status
  • Approval
  • Query
  • Rejection
  • Resubmission

Treatment tracking

8 features

  • Approved package
  • Treatment / procedure
  • Medicines
  • Investigations
  • Consumables
  • Doctor notes
  • Nursing notes
  • Clinical documentation

Discharge

7 features

  • Discharge checklist
  • Final diagnosis
  • Procedure
  • Discharge summary
  • Required documents
  • Doctor approval
  • Beneficiary discharge

Claim

10 features

  • Claim preparation
  • Required documents
  • Claim submission tracking
  • Query
  • Query response
  • Resubmission
  • Approved amount
  • Rejected amount
  • Settlement
  • Claim history

What this module does not assume

Live PM-JAY transaction and API functionality depends on the nursing home’s current empanelment, state and NHA requirements, authorised credentials, and the official integration mechanisms available to the facility. Storing an Ayushman card number does not by itself confer PM-JAY eligibility or claim access — the software is built so that the desk workflow is ready the moment those approvals are in place.

Section 23 · ABDM

Designed to become ABDM-compatible

ABDM promotes interoperability between health systems while the medical records themselves stay with the provider — they are not centrally stored by ABDM. Building to ABDM-compatible data structures now means the integration is a connection later, not a rewrite.

ABDM flow

  1. Patient
  2. ABHA
  3. Consent
  4. Health record
  5. Digital record
  6. Secure sharing

Registries worth planning for

Life Line can also consider HFR (Health Facility Registry) registration as part of ABDM adoption, and doctor profiles can be structured for future HPR (Healthcare Professionals Registry) mapping.

Potential ABHA / ABDM features

  • ABHA number
  • ABHA address
  • Patient consent
  • Health record linking
  • Digital health record generation
  • Prescription record
  • Lab report
  • Discharge summary
  • Health record discovery / sharing
  • Consent management
  • ABDM-compatible data structures
  • HFR / HPR mapping where applicable
Section 52 · High-level flows

The four routes a case can take

Whichever path a patient arrives on, it resolves to the same record and the same billing engine.

OPD 7 stages
  1. Patient
  2. Registration
  3. Doctor
  4. Prescription
  5. Investigation
  6. Billing
  7. Follow-up
IPD 10 stages
  1. Patient
  2. Admission
  3. Bed
  4. Doctor
  5. Nursing
  6. Investigation
  7. Pharmacy
  8. Treatment
  9. Billing
  10. Discharge
Ayushman 9 stages
  1. Beneficiary
  2. Verification
  3. Package
  4. Pre-auth
  5. Approval
  6. Treatment
  7. Discharge
  8. Claim
  9. Settlement
ABDM 6 stages
  1. Patient
  2. ABHA
  3. Consent
  4. Health record
  5. Digital record
  6. Secure sharing

Tell us where Life Line stands today

Current PM-JAY empanelment status, the TPAs and insurers you already work with, whether the facility is registered in HFR, and whether your doctors have HPR registration — these answers shape how much of Phase 3 is a connection versus a build.

Share your current status