Ayushman Bharat PM-JAY and KASP in Kerala: What Hospital Administrators Handle

In Kerala, Ayushman Bharat PM-JAY and KASP are not separate schemes competing for attention. They are converged into a single unified health assurance system managed by the State Health Agency (SHA). For hospital administrators, this convergence means one claim process, one beneficiary database, and one set of compliance rules. The core administrative burden falls on the hospital superintendent and the designated nodal officer, who are responsible for uploading claims, resolving rejections, and ensuring the hospital receives payment for every eligible procedure performed.

KEY TAKEAWAYS

• PM-JAY and KASP are converged in Kerala. All state schemes—RSBY, CHIS, SCHIS, and KBF—were merged with PM-JAY to form KASP, creating a single unified scheme.

• Hospital superintendents are accountable for claims. The Kerala government order explicitly states that superintendents must upload claims for all procedures and ensure payment is received.

• Rejected claims must be pursued. Superintendents must identify rejection reasons, rectify defects, and escalate unjust rejections to the District Grievance Redressal Committee.

• Ayushman Mitra is the frontline role. Empanelled hospitals must hire an Ayushman Mitra to manage the help desk, register beneficiaries, and handle pre-authorisation and discharge entries.

• Funds are audited and restricted. Claim revenues go into a separate bank account and cannot be used for original construction or branded drugs for individual patients.

What Is Ayushman Bharat PM-JAY?

Ayushman Bharat PM-JAY was launched by the Indian government back in 2018 as their flagship health assurance program. The idea behind this was to make sure every family gets health cover of up to ₹5 lakh a year for things like secondary and tertiary care hospital stays – all of this would be on a cashless basis and on a family floater policy no less, which means there’s no cap on how many people are covered under that 5 lakh. The scheme is focused on the lowest 40% of the population – and that’s determined by the Socio-Economic Caste Census of 2011.

The good news is that PM-JAY is a completely government funded scheme, with the Centre and States sharing the costs. Here in Kerala, theyve implemented it through the State Health Agency (SHA) using a trust model – which is a pretty standard setup.

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What Is KASP in Kerala?

You might have heard of Karunya Arogya Suraksha Padhathi – but KASP for short – which is actually the state of Kerala’s converged health scheme. Now, you see, they took all the different state health schemes and basically merged them with PM-JAY to create this one all-in-one scheme. That includes things like the Rashtriya Swasthya Bima Yojana (RSBY), Comprehensive Health Insurance Scheme (CHIS), Senior Comprehensive Health Insurance Scheme (SCHIS) and Karunya Benevolent Fund (KBF) .

Now when you put it all together, KASP gives you the same ₹5 lakh as PM-JAY but it also covers some other groups too. You see, Kerala is a bit of a trailblazer because they’re the first state to cover everyone with a 40% or more disability, and transgender people, no matter if they’re above the poverty line or below. Nice one, Kerala

KASP also has a bonus to it in that it has the Karunya Benevolent Fund (KBF) for people making less than ₹3 lakh a year, who aren’t eligible under KASP. The KBF kicks in when people have serious illnesses like cancer , haemophilia, kidney disease or heart disease and the government steps in to give them some much-needed financial aid.

Key Differences Between PM-JAY and KASP

Who Is Eligible for PM-JAY and KASP Benefits?

Eligibility for KASP is broader than PM-JAY alone. The following groups are covered:

• Families with a valid RSBY/CHIS card for 2018-2019

• Weaker sections identified by the Central Government as per SECC 2011

• Families that received a direct letter from the Central Government

• Persons with 40% or more disability and transgender persons (universal coverage)

• KBF: Families with annual income below ₹3 lakh not eligible under KASP

How Hospitals Enrol in PM-JAY and KASP

Hospital empanelment is managed through the National Health Authority’s Hospital Engagement Module (HEM). The process requires:

• Registration in the Health Facility Registry under Ayushman Bharat Digital Mission

• Creation of credentials through the User Management Portal (UMP)

• Submission of application through the HEM portal

• Desktop verification followed by physical inspection by the District Empanelment Committee (DEC)

Public hospitals with inpatient services are deemed empanelled. Private hospitals must undergo physical verification, including submission of original photographs and latitude-longitude details.

Hospitals holding NABH accreditation or PM-JAY certification for relevant specialties may be fast-tracked without physical verification. NABH-accredited hospitals also receive incentives: 10% over package rates for Entry Level NABH and 15% for Full NABH accreditation.

Role of Hospital Administrators in PM-JAY and KASP

The Kerala government order on KASP guidelines is explicit about administrative responsibilities. The superintendent of each government hospital is accountable for the entire claim management system.

Claim upload and monitoring. Superintendents must upload claims for all procedures performed for insured persons and ensure payment is received. They must also designate a nodal officer to closely monitor the claim management system in each hospital.

Rejection management. When claims are rejected, superintendents must find the reason, rectify defects, and pursue the claim through the District Grievance Redressal Committee if the rejection is unjust. The order states that “not pursuing all channels to obtain a valid claim will not be accepted” .

Financial accounting. Receipts from insurance reimbursements must be deposited in a separate bank account operated by the Superintendent/RMO and the Lay Secretary or another administrative officer. These funds are not to be deposited in HMC/HDC/HDS accounts.

Fund utilisation. KASP funds can be used for purchasing generic drugs from the essential drug list when KMSCL supplies are short, purchasing new equipment, extending AMC, carrying out maintenance, and hiring technical personnel. Original construction is explicitly prohibited. All purchases must follow proper procedures and are subject to audit.

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Patient Registration and Beneficiary Verification

The Ayushman Mitra (AM) is the frontline role for beneficiary management. Empanelled hospitals must hire an Ayushman Mitra to manage the help desk exclusively for KASP.

The Ayushman Mitra’s responsibilities include:

• Receiving beneficiaries and guiding them through the scheme process

• Registering unregistered members of already-enrolled families through the Beneficiary Identification System (BIS)

• Checking the beneficiary family’s balance cover amount

• Taking pre-authorisation as required

• Entering package details and discharge summary in the KASP software

The SHA has instructed hospitals to assign a dedicated counter for BIS registration, especially in Medical Colleges and District Hospitals, to avoid delays for beneficiaries.

Pre-Authorisation and Health Insurance Claims Processing

The claim process follows a defined workflow. For planned procedures, pre-authorisation is required before admission. The Ayushman Mitra enters the package details and patient information into the system based on the doctor’s advice.

At discharge, the Ayushman Mitra enters all relevant details and the discharge summary into the KASP software. The claim is then processed by the Third Party Administrator/Implementation Support Agency (TPA/ISA) appointed by the SHA.

The TPA/ISA is responsible for servicing legitimate claims within allocated timeframes and coordinating grievance redressal. Monitoring of the TPA/ISA includes claims management processes and grievance redressal performance.

Required Documents and Hospital Records Management

Claims require complete documentation. The discharge summary must capture presenting features, investigations, line of treatment given during stay, and line of treatment advised at discharge. If these details are missing, the claim may be rejected.

Other required documents include investigation reports signed by the doctor or pathologist with registration number, post-operative photos showing the scar in surgical cases, OT notes detailing surgical steps, pre- and post-operative X-rays where applicable, and verification of length of stay against the discharge summary.

Hospitals must maintain records of claim approvals, partial approvals, rejections, and amounts received. The Kerala order requires close monitoring of total eligible claims, eligible amount, number of claims approved fully and partially, and reasons for rejection.

Common Challenges in PM-JAY and KASP Claim Processing

Rejections for incomplete documentation. Claims are rejected when mandatory documents are missing or discharge summaries lack required details.

Delayed payments. The TPA/ISA is bound by service level agreements, but delays can occur. Hospitals must track pending claims and follow up through grievance channels.

Beneficiary registration gaps. If a family member is not registered in BIS, the Ayushman Mitra must register them before treatment can proceed.

Fraud investigations. The SHA conducts field audits and verification to detect fraudulent claims. Hospitals found engaging in malpractices face show-cause notices and potential de-empanelment.

Best Practices for Managing PM-JAY and KASP in Hospitals

Designate a dedicated nodal officer. The superintendent should appoint a nodal officer exclusively for claim management, as required by the Kerala order.

Train Ayushman Mitra staff thoroughly. The counter staff must be proficient in BIS registration, pre-authorisation, and discharge entry to avoid delays.

Maintain a rejection log. Track every rejection with its reason and the corrective action taken. Review patterns monthly to identify systemic issues.

Audit documentation before submission. Verify that discharge summaries, investigation reports, and OT notes contain all required details before uploading claims.

Use KASP funds correctly. Purchase only generic drugs from the essential list, follow approval procedures for non-essential drugs, and maintain separate accounting.

Pursue rejected claims. Escalate unjust rejections to the District Grievance Redressal Committee and follow up to the State level if necessary.

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CONCLUSION

For hospital administrators in Kerala, PM-JAY and KASP are not abstract government schemes. They are operational realities that require daily attention. The superintendent is accountable for claim uploads, rejection management, fund utilisation, and audit compliance. The Ayushman Mitra is the frontline role that determines whether beneficiaries receive timely care.

The convergence of schemes into KASP simplifies the beneficiary experience but concentrates the administrative burden on hospital leadership. Success requires dedicated staff, disciplined documentation, persistent follow-up on rejections, and strict adherence to fund utilisation rules. Hospitals that master these processes receive timely payments and serve their communities effectively. Those that do not face rejected claims, audit findings, and frustrated patients.