PM-JAY and your hospital: a practical guide to Ayushman Bharat empanelment

Pradhan Mantri Jan Arogya Yojana — PM-JAY — is the world's largest government health insurance scheme, covering over 55 crore beneficiaries across India. For hospitals, empanelment under PM-JAY means access to a massive patient pool, guaranteed government-backed payments, and the opportunity to serve the underserved.

But the empanelment process is not straightforward, the package rates require careful financial planning, and the claim submission process has pitfalls that can delay payments by months. This guide walks you through the entire journey — from eligibility to your first approved claim.

Who is eligible for empanelment

PM-JAY empanelment is open to both public and private hospitals. The basic eligibility criteria set by the National Health Authority (NHA) are:

Infrastructure requirements. The hospital must have a minimum of 10 beds for inpatient care. There must be adequate space for OPD, emergency services, and diagnostic facilities. Operation theatre facilities are required for hospitals offering surgical packages.

Manpower requirements. At least one qualified MBBS doctor available round the clock. Adequate nursing staff for the bed strength. A pharmacist and lab technician on staff.

Registration and licensing. The hospital must hold a valid Clinical Establishment licence under the Clinical Establishments Act 2010 (or the applicable state act). Registration under the local municipal body is also required.

ABDM compliance. As of 2026, NHA increasingly requires ABDM registration as a Health Information Provider (HIP) for new empanelments. While not yet mandatory for all states, having ABDM integration significantly strengthens your application and is expected to become a requirement by late 2026.

What disqualifies you. Single-specialty clinics without inpatient facilities are not eligible. Hospitals with a history of fraud or empanelment cancellation face a cooling-off period. Hospitals that do not meet fire safety and biomedical waste management norms are rejected.

The application process — step by step

Step 1: Register on the NHA empanelment portal

Visit pmjay.gov.in and navigate to the hospital empanelment section. Create an account with your hospital's details — name, address, registration number, bed strength, and specialties offered.

Step 2: Submit documentation

The documentation package includes:

• Clinical Establishment registration certificate
• Hospital photographs (exterior, OPD, wards, OT, lab, pharmacy)
• Equipment list with purchase invoices
• Staff list with qualification certificates for all clinical staff
• Fire safety certificate
• Biomedical waste management agreement
• PAN card and GST registration of the hospital entity
• Bank account details for claim settlement
• Land/building ownership or lease agreement

Tip from experienced applicants: The most common reason for application rejection is incomplete or unclear photographs. Take well-lit photos of every department with visible equipment. Assessors review these photos to verify infrastructure claims.

Step 3: District-level assessment

After document review, a district empanelment committee conducts a physical assessment of your hospital. An assessor visits to verify that the infrastructure, equipment, and manpower match your application. This visit is usually scheduled within 30-60 days of application submission, though delays are common in some districts.

What assessors actually look at: They check bed availability, verify doctor and nursing staff presence, inspect the OT (if applicable), confirm diagnostic capabilities, and review biomedical waste disposal arrangements. They also verify that the hospital is operational and treating patients — not a shell facility.

Step 4: Empanelment approval

If the assessment is satisfactory, the State Health Agency (SHA) approves empanelment. You receive a hospital empanelment ID and are listed on the PM-JAY portal as an empanelled facility. Patients can now search for your hospital on the PM-JAY app.

The entire process — from application to empanelment — takes 60-120 days in most states. Some states have longer backlogs.

Understanding package rates

PM-JAY operates on a package rate system — fixed rates for defined procedures. The hospital receives the package amount regardless of actual cost. This means profitability depends on managing your costs to stay within the package rate.

How package rates work

The NHA defines Health Benefit Packages (HBPs) — currently over 1,900 packages across 27 specialties. Each package specifies the procedure, the rate, the expected length of stay, and the implant costs (if applicable).

Example package rates (2026): - Normal delivery: Rs 9,000 - C-section: Rs 18,000 - Cataract surgery: Rs 30,000 - Knee replacement (unilateral): Rs 1,50,000 - Coronary artery bypass graft (CABG): Rs 2,40,000 - Appendectomy: Rs 35,000

The financial reality: Package rates are set below private market rates. An appendectomy that you would bill at Rs 60,000-80,000 to a paying patient is reimbursed at Rs 35,000 under PM-JAY. The hospital needs to manage costs — shorter stays, efficient OT utilisation, lean consumable usage — to make PM-JAY patients financially viable.

The strategic calculation: While individual PM-JAY patients may generate lower margins than private patients, the volume compensates. A hospital that empanels under PM-JAY in an area with a large beneficiary population can fill beds that would otherwise remain empty. Empty beds generate zero revenue; PM-JAY beds generate positive revenue, even if the margin is thinner.

Claim submission: the process that determines your cash flow

Getting empanelled is step one. Getting paid is step two — and this is where many hospitals struggle.

The claim workflow

1. Beneficiary verification. When a PM-JAY patient arrives, verify their eligibility using the PM-JAY TMS (Transaction Management System) portal or app. The patient's Ayushman card or ABHA ID is validated against the NHA database.

2. Pre-authorisation. For procedures requiring pre-authorisation, submit the request through the TMS with clinical details and supporting documents. Pre-authorisation approval typically takes 24-72 hours. Emergency cases have a relaxed timeline.

3. Treatment and documentation. Treat the patient. Document everything — admission notes, investigation reports, operative notes (if surgical), daily progress notes, and discharge summary. This documentation is critical for claim approval.

4. Claim submission. Within the prescribed timeline after discharge (varies by state, typically 7-15 days), submit the claim through the TMS with all supporting documents.

5. Claim processing. The Insurance Company or State Health Agency reviews the claim. They verify that the treatment matches the pre-authorisation, the documentation is complete, and the charges align with the package rate.

6. Payment. Approved claims are settled within 15-30 days via direct bank transfer. In practice, payment timelines vary by state — some states pay within 15 days, others take 60-90 days.

Common claim rejection reasons

Incorrect package code. The treatment performed does not match the package code submitted. NHA updates package codes periodically, and hospitals using outdated code lists face rejections. Always verify the latest HBP version before submitting.

Incomplete documentation. Missing discharge summaries, unsigned operative notes, or absent investigation reports. Every piece of clinical documentation should be complete and uploaded with the claim.

Pre-authorisation mismatch. The procedure performed differs from what was pre-authorised without obtaining a revised approval. If the treatment plan changes during hospitalisation, update the pre-authorisation before proceeding.

Beneficiary eligibility issues. The patient's Ayushman card details do not match NHA records, or the patient's family has exhausted their Rs 5 lakh annual coverage limit.

Late submission. Claims submitted after the prescribed deadline are automatically rejected in most states. This is one of the easiest problems to prevent — submit claims within 48-72 hours of discharge, not on the last day.

Practical tips from empanelled hospitals

Designate a PM-JAY coordinator. Do not split PM-JAY work across multiple staff members. One dedicated person who handles beneficiary verification, pre-authorisation, documentation collection, and claim submission dramatically reduces errors and rejections.

Verify eligibility before admission, not after. Admitting a patient, performing a procedure, and then discovering they are not eligible or their coverage is exhausted leaves you with an unpaid bill and no recourse.

Maintain a claim tracker. Track every claim — submission date, status, approval or rejection, payment date. This helps you identify patterns in rejections and follow up on delayed payments systematically.

Build relationships with your SHA. The State Health Agency is your primary point of contact for empanelment issues, claim disputes, and policy clarifications. Having a working relationship with the SHA team helps resolve issues faster than formal complaint channels.

Keep your digital infrastructure current. The NHA TMS portal is updated regularly. Ensure your computers, internet connection, and software can handle the portal requirements. A hospital that cannot access the TMS portal due to technical issues will face claim submission delays.

PM-JAY empanelment is a strategic decision, not just an administrative one. It brings volume, community goodwill, and government recognition — but it requires operational discipline to manage package-rate economics and claim processes efficiently. Hospitals that treat PM-JAY as a serious business line, rather than an afterthought, consistently achieve better financial outcomes from the programme.