Reference table
Payers
A reference table of the payer types the platform bills, including self paying patients, insurers and schemes, with the traits of each.
A payer is the party responsible for a charge. The platform bills several kinds, from the patient paying directly to an insurer, a third-party administrator, or a government or corporate scheme, and each kind carries its own traits. This page is the reference table of payer types and the terms they hold.
Payer types
The platform recognises five payer types. Each settles a bill in its own way.
| Payer type | Who pays | How it settles |
|---|---|---|
| Self-pay | The patient | Pays directly, at the desk or online. |
| Insurer | A health insurer | Settles a cashless claim through pre-authorisation and a filed claim. |
| Administrator | A third-party administrator acting for insurers | Handles pre-authorisation and claims on an insurer's behalf. |
| Government scheme | A public health scheme | Settles at the scheme's published rates. |
| Corporate | An employer or corporate account | Settles against an agreed credit account. |
The traits a payer carries
Each payer in a site's registry carries the terms that shape a bill. A corporate account might carry a credit limit of INR 1,20,000, above which a new charge is held until the balance is cleared.
creditLimit integer | The unsettled balance a payer may carry before a charge is held. |
subLimits list | Per-category caps, such as a cap on room or on consumables. |
roomRentCap integer | A ceiling on the room rent the payer covers. |
balanceBilling boolean Required | Whether the patient may be billed for the balance a payer leaves. |
claimDeadline integer | The number of days within which a claim is filed. |
status string Required | Where the payer sits in its lifecycle, from draft to active to archived. |
Schemes
A scheme is a payer that settles under a defined public or contracted programme. The platform recognises the common Indian schemes and prices their care at the scheme's own rates.
| Scheme | Covers |
|---|---|
| PMJAY | The national public health assurance scheme. |
| CGHS | The central government health scheme. |
| ESIC | The employees' state insurance scheme. |
| ECHS | The ex-servicemen contributory health scheme. |
| State scheme | A state government health scheme. |
| Trust or embassy | A trust fund, or an international or embassy arrangement. |
Who pays for an admission
An admission carries one or more payer allocations, the record of who pays and in what order. Exactly one payer is primary at any moment. Self-pay sits as the residual, so a patient always has a responsible party even as insurers and schemes are added or removed. A change of payer re-splits the charges; the charges themselves stay on the books.
Self-pay is the residual
Every admission resolves to a responsible party. When an insurer or scheme covers part of a bill, self-pay carries the balance the payer leaves, so a bill always settles to someone.
The insurance path
An insured admission runs a claim from start to settlement. It opens with a pre-authorisation, gathers the coded clinical detail and the charged lines, submits to the payer, and closes on settlement. Where a payer settles short, the claim carries the shortfall into a dispute, an appeal or a write-off.
A reimbursement claim runs the other way. The patient pays in full, the hospital issues the documents, and the patient files for reimbursement.
Common questions
Who pays when a patient has no cover?
The patient pays directly, as a self-pay payer. Self-pay is also the residual on an insured admission, carrying whatever an insurer or scheme leaves.
Can an admission have more than one payer?
Yes. An admission carries one or more payer allocations, with exactly one primary at a time and self-pay as the residual.
Read how an insured admission moves through insurance claims.