PM-JAY — Pradhan Mantri Jan Arogya Yojana — is the health coverage component of Ayushman Bharat, India's flagship national health protection mission. Launched on 23 September 2018 by the Government of India, PM-JAY is administered by the National Health Authority (NHA) at the central level and implemented by State Health Agencies (SHAs) in each participating state.
PM-JAY provides health coverage of Rs 5 lakh per family per year for secondary and tertiary hospitalisation — covering a defined list of over 1,900 medical and surgical packages across 27 specialties. The coverage is cashless and paperless for the beneficiary — they present their Ayushman card (or are verified via eKYC), the hospital provides the treatment, and claims the package rate directly from the SHA or its empanelled insurer.
PM-JAY is among the largest government-funded health insurance programmes in the world by beneficiary count, covering approximately 500 million individuals (approximately 107 million families) in the bottom 40% of India's population. Beneficiary eligibility is determined by the Socio-Economic Caste Census (SECC) 2011 data, with additional categories added by some states through their state-level extensions. Beneficiaries pay no premium — the full cost is borne by the central and state governments in a 60:40 ratio (90:10 for northeastern and hill states).
Understanding who is eligible for PM-JAY is essential for verifying patient eligibility at the time of admission and avoiding claim rejection due to beneficiary ineligibility.
At the national level, eligibility is determined by SECC 2011 deprivation criteria for rural households and occupational criteria for urban households. Rural beneficiaries include households with no adult member between 16–59 years, households with disabled members, SC/ST households, landless agricultural labour families, and those living in one-room kutcha wall and kutcha roof houses. Urban beneficiaries include defined occupational categories including rag pickers, domestic workers, construction workers, street vendors, beggars, and sanitation workers.
The Rs 5 lakh coverage is a family floater — the entire limit is available to any or all members of the household family unit within a policy year. There is no cap on the number of family members. All pre-existing conditions are covered from day one of eligibility — there is no waiting period and no exclusion for pre-existing diseases.
Empanelled hospitals must verify beneficiary eligibility before providing PM-JAY covered treatment. Verification is done via: (1) Ayushman card QR code scan using the Ayushman Bharat app or hospital terminal, (2) eKYC verification using Aadhaar biometric authentication, or (3) manual verification through the NHA portal using Ration Card number or SECC database reference. The verification generates a transaction ID that must be referenced in the pre-authorisation request.
Many states have expanded PM-JAY coverage beyond the central SECC list using state funds. For example, Maharashtra's Mahatma Jyotiba Phule Jan Arogya Yojana (MJPJAY) extends coverage to additional categories, Rajasthan's Chiranjeevi Yojana offers universal coverage to all state residents, and Delhi and West Bengal have their own state health schemes. Empanelled hospitals must understand which beneficiary categories their state SHA includes and configure their HMS accordingly.
To treat PM-JAY beneficiaries and claim package reimbursements, a hospital must be formally empanelled by the State Health Agency. Empanelment is not automatic — it requires an application, inspection, and SHA approval.
Submit the hospital empanelment application through the NHA empanelment portal at pmjay.gov.in. The application requires: hospital registration certificate, Clinical Establishment Act registration (where applicable), list of clinical staff with qualifications and Medical Council registration numbers, infrastructure details (bed count, OT count, ICU, lab, pharmacy availability), and NABH accreditation certificate (if available — NABH accreditation provides preference in processing).
NHA defines minimum criteria: the hospital must have at least 10 beds (50 beds for empanelment as a specialty hospital), an in-house pharmacy, a clinical laboratory (own or contractual), and qualified specialist doctors for the specialties in which the hospital seeks empanelment. The hospital must have functional CCTV coverage of critical areas, a dedicated PM-JAY facilitation desk, and a trained Ayushman Mitra (designated PM-JAY coordinator) for beneficiary assistance.
Following application submission, the State Health Agency (or its designated inspection agency) conducts a physical inspection of the facility. Inspectors verify infrastructure against the submitted documents, assess clinical capability, and confirm PM-JAY operational readiness (facilitation desk, Ayushman Mitra availability, HMS capable of TMS portal access). NABH-accredited facilities may be exempted from certain inspection requirements.
Upon inspection approval, the SHA issues an empanelment agreement. The hospital signs the agreement, which governs the rates (NHA package rates), payment timelines, penalty clauses for fraud or quality failures, and operational obligations. After signing, the hospital is activated on the TMS (Transaction Management System) portal and can begin treating PM-JAY beneficiaries and submitting claims.
PM-JAY billing is fundamentally different from fee-for-service billing. Understanding this difference is critical for accurate revenue projection and operational planning for empanelled hospitals.
NHA defines over 1,900 treatment packages across 27 clinical specialties. Each package has a fixed government-defined rate that represents full payment for that treatment episode. Package rates are all-inclusive: they cover bed charges (general ward), nursing care, physician fees, surgeon's fees, anaesthesia fees, OT charges, all investigations (pre-operative and post-operative) related to the package, all medications administered during the hospitalisation, and discharge medications for up to 15 days following discharge. Hospitals cannot charge PM-JAY beneficiaries any amount over the package rate — doing so is a violation of the empanelment agreement and subject to penalty.
To illustrate the scale of packages: Coronary Artery Bypass Graft (CABG) — NHA rate Rs 1,50,000 to Rs 2,10,000 depending on complexity. Total Knee Replacement — Rs 80,000 per knee. Cataract surgery with IOL — Rs 6,500 to Rs 8,000. Normal delivery — Rs 9,000. Appendicectomy (laparoscopic) — Rs 16,000. Chemotherapy cycle — Rs 15,000 to Rs 50,000 depending on the protocol. Package rates are reviewed and revised periodically by NHA — ensure your HMS always has the current rate schedule.
Only one package may be claimed per hospitalisation episode, except in defined circumstances where NHA permits concurrent package billing (e.g., when a patient undergoes two distinct surgical procedures in the same admission). Package selection must be based on the primary clinical reason for admission. Billing a higher-value package than the treatment actually provided is fraudulent upcoding — one of the most seriously penalised violations in PM-JAY.
Pre-authorisation (prior approval from the SHA or its insurance partner) is required for all planned PM-JAY hospitalisations. For emergency admissions, post-facto authorisation must be obtained within 24 hours of admission.
All PM-JAY claims are submitted through the NHA Transaction Management System (TMS) portal. The claim must be submitted within 15 days of the patient's discharge date.
A complete PM-JAY claim submission includes: the completed claim form in TMS (pulling data from the pre-auth record), discharge summary (structured, signed by the treating doctor), investigation reports referenced in the discharge summary, operative notes (for surgical packages), anaesthesia record (for procedures requiring general anaesthesia), implant stickers and invoices (for procedures involving implants — knees, cardiac valves, stents), signed beneficiary consent forms, and the beneficiary identity verification record from eKYC or Aadhaar authentication.
NHA guidelines mandate that clean claims (complete documentation, no queries) must be processed and paid within 15 working days of submission. State-level payment timelines vary — some states have current payment cycles of 30–45 days for clean claims, while a few states have outstanding backlogs. Track claim submission dates and payment receipt dates in your HMS to monitor state-specific payment performance and identify systematic delays that warrant escalation.
The TMS portal provides real-time claim status — submitted, under review, approved for payment, pending additional information (query raised), or rejected. Your HMS should integrate TMS claim status into the hospital's revenue cycle dashboard so billing staff can see all outstanding PM-JAY claims, identify pending queries, and track payment receipts without logging into TMS separately for each claim.
When the SHA raises a query on a claim (requesting additional documentation or clarification), the hospital must respond within the specified timeframe — typically 7 working days. Queries that are not responded to within the deadline result in claim closure (rejection). The response must be submitted through TMS with the requested documents attached as scanned files.
Understanding rejection patterns allows hospitals to design intake and clinical documentation workflows that prevent these errors before the claim is submitted.
While PM-JAY is a centrally sponsored scheme, states implement it with significant variations. Hospitals operating in multiple states must understand the specific rules of each state's SHA.
Both states operate Aarogyasri health schemes that predate PM-JAY and have their own package lists and rates, which in some categories exceed NHA's national rates. Aarogyasri packages are administered through the Aarogyasri Health Care Trust (Telangana) and Dr. YSR Aarogyasri (Andhra Pradesh). Hospitals empanelled under Aarogyasri must use the respective state portal for pre-auth and claims — not the NHA TMS — for state scheme patients.
Tamil Nadu operates the Chief Minister's Comprehensive Health Insurance Scheme (CMCHIS) alongside PM-JAY. CMCHIS has its own package list, rates, and claim submission portal. Private hospitals empanelled under both schemes must correctly identify which scheme applies to each patient and route claims through the appropriate system. Tamil Nadu's state scheme has historically had broader coverage categories than central PM-JAY.
Rajasthan's Chiranjeevi Yojana offers universal health coverage to all residents of Rajasthan — not limited to SECC beneficiaries. This significantly expands the beneficiary pool compared to central PM-JAY. Chiranjeevi operates through its own portal and package rate schedule under the State Health Assurance Agency (SHAA), Rajasthan.
Maharashtra's Mahatma Jyotiba Phule Jan Arogya Yojana (MJPJAY) is converged with PM-JAY and extends state coverage to farmers, journalists, and other additional categories. Maharashtra has its own package rate schedule for some specialties that supplements NHA's rates. MJPJAY claims for state-eligible patients (beyond the central SECC list) must be routed through the state SHA portal.
A PM-JAY-ready hospital management system reduces manual TMS portal work, ensures documentation completeness, and integrates PM-JAY workflows into the hospital's standard clinical processes.
PM-JAY (Pradhan Mantri Jan Arogya Yojana) is India's national government-funded health protection scheme providing cashless hospitalisation coverage of Rs 5 lakh per family per year for secondary and tertiary inpatient care. Launched in September 2018 and administered by the National Health Authority (NHA), it covers over 500 million individuals in the bottom 40% of India's population as identified by SECC 2011 data. Coverage begins from the first day of eligibility — there are no waiting periods and no pre-existing condition exclusions.
Hospitals apply online through the NHA empanelment portal at pmjay.gov.in, submitting facility registration documents, clinical staff credentials, and infrastructure details. The State Health Agency (SHA) reviews the application and conducts a physical inspection. Minimum requirements include at least 10 beds, in-house pharmacy and lab, a dedicated PM-JAY facilitation desk, and a trained Ayushman Mitra coordinator. NABH-accredited facilities receive processing preference. After inspection approval, the hospital signs an empanelment agreement and is activated on the TMS portal.
PM-JAY billing is strictly package-based, not fee-for-service. NHA defines over 1,900 pre-priced packages covering medical and surgical treatments across 27 specialties. The package rate is all-inclusive — bed, nursing, doctors' fees, investigations, medications, OT, and anaesthesia are all covered within the single package amount. Hospitals receive the package rate as full payment and cannot charge the beneficiary any additional amount. This fundamentally changes the hospital's revenue cycle from line-item billing to episode-based billing.
PM-JAY claims require: structured discharge summary signed by the treating consultant (with ICD-10 diagnosis code and pre-auth reference number), pre-authorisation approval printout from TMS, beneficiary eKYC or Aadhaar verification record, investigation reports supporting the diagnosis and package, operative notes for surgical packages, anaesthesia record for GA procedures, implant stickers and purchase invoices for implant-involving procedures, and signed patient consent forms. All documents must be submitted via the TMS portal within 15 days of the discharge date.
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