| Step | Process | Proposed Timeline | Participants |
| 1 | Dispute is lodged | Day 0 | Complainant, HCX, Defendant |
| 2 | Parties in the dispute are informed. Parties
| Day 2 | |
| 3 | Discovery file is created with inputs from all parties involved | Day 5 | |
| 4 | Fast track (Faceless Only) Arbitration facilitate by empanelled arbitrators : (1st Level)
| Day 15 | Complainant, Defendant, Arbitrator |
Complainant/Defendant
Data Provider
| HCX role: HIE/HIO.HCX | 18 | 19 | In addition, participants like IRDAI (IGMS system - the existing dispute resolution platform) and insurance ombudsman and grievance redressal system in healthcare being co opted in subsequent phases. 20 | 21 | {% hint style="info" %} 22 | Each participant in the above list will be mapped with HCX participnt roels mentioned in the [Access Control ](broken-reference)section. 23 | {% endhint %} 24 | 25 | Followign sections provides details on the proposed process to follow in the dispute resolution. 26 | -------------------------------------------------------------------------------- /healthcare-operations-policies/guidelines-for-grievance-redressal/next-steps.md: -------------------------------------------------------------------------------- 1 | --- 2 | description: Envisioned next steps to a robust dispute resolution process for the ecosystem 3 | --- 4 | 5 | # Next steps 6 | 7 | An effective and comprehensive digital dispute resolution system is vital to the success of HCX. While this document refers to the first phase - commercial health insurance for in-patient procedures, the end goal is to resolve a majority of insurance claims related disputes before it reaches the legal system. Initiatives like integrating with various existing and emerging grievance resolution mechanisms in the insurance and healthcare ecosystem is important for HCX to achieve this vision. 8 | 9 | Keeping this in mind, the policy guidelines workign groups would keep working to evolve the guidelines based on ecosystem needs. It would mainly cover following aspects: 10 | 11 | 1. Further simplification and posiible automation of the process 12 | 2. Broadening of scope for other use cases - reimbursement, OPD, etc. 13 | 3. Integration of HCX scope into the larger ecosystem process like **insurance ombudsman and other upcoming grievance redressal system in healthcare** 14 | -------------------------------------------------------------------------------- /healthcare-operations-policies/guidelines-for-grievance-redressal/scope-of-disputes.md: -------------------------------------------------------------------------------- 1 | --- 2 | description: Envisioned list of disputes whose resolution can be facilitated by HCX 3 | --- 4 | 5 | # Scope of disputes 6 | 7 | Initially envisioned List of Disputes HCX can assist with: 8 | 9 || Dispute Category | Type of Dispute | Examples |
| Delays | TATs related disputes |
|
| Data Transmission Related | Disputes related to transmission failures (packet drop)Disputes related to transmission data mismatch between origination and receipt |
|
| Data Privacy | Disputes related to data privacy violation by an entity in the HCX ecosystem |
|
| Policy Related (E.g., Onboarding ) | Disputes related to the non compliance of HCX with respect to HCX policies | Examples
|
| Enforcement of Data Standards | Disputes related to members of the HCX ecosystem not adhering data transmission standards |
|
Envisioned onboarding process flow
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Typical OPD Cashless workflow
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