What Is Ayushman Card Pre-Authorization?

Pre-authorisation is the approval process used before certain PM-JAY treatment packages are provided. The empanelled hospital submits medical and beneficiary information to the authorised reviewing organisation.

The request may contain:

• Verified beneficiary information
• Hospital and speciality details
• Patient diagnosis
• Proposed procedure or treatment
• Selected PM-JAY package
• Clinical examination notes
• Laboratory reports
• Imaging or diagnostic reports
• Treating doctor’s recommendation
• Pre-Authorisation Request Form
• Other package-specific records

What Is an Ayushman Cashless Claim?

A cashless claim is the hospital’s request for payment under an approved PM-JAY treatment package. The eligible beneficiary receives covered care at the point of service without paying the approved package amount to the hospital.

Patient and Hospital Responsibilities

Complete PM-JAY Cashless Treatment Flow

Checks Before Hospital Admission

1. Confirm that the hospital is currently empanelled under PM-JAY.
2. Confirm that the exact branch is empanelled.
3. Confirm that the required speciality is available.
4. Ask whether the proposed treatment has an applicable package.
5. Carry the latest Ayushman Card or PM-JAY ID.
6. Carry an accepted photo identity document.
7. Carry prescriptions and medical reports.
8. Check whether the card’s eKYC is complete.
9. Ask the hospital about the pre-authorisation process.
10. Ask which charges are included in the package.
11. Do not sign a blank payment or consent form.

Find the Correct Empanelled Hospital

A hospital must be empanelled for the relevant clinical speciality. A hospital listed for one speciality may not be approved for every treatment.

1. Open the official PM-JAY hospital-search portal.
2. Select the state and district.
3. Select the required speciality where available.
4. Review the hospital name and address.
5. Call the exact hospital branch.
6. Confirm current PM-JAY empanelment.
7. Confirm the required doctor, facility and package.
8. Ask whether planned treatment requires an appointment.

Documents Required for Pre-Authorization

Beneficiary Registration at the Hospital

1. Visit the Ayushman help desk.
2. Ask for the Pradhan Mantri Arogya Mitra.
3. Show the Ayushman Card or PM-JAY ID.
4. Provide an accepted identity document.
5. Ask the representative to search the beneficiary.
6. Confirm the correct patient and family.
7. Complete OTP, face, fingerprint or another accepted verification.
8. Check the available card and eKYC status.
9. Ask the hospital to register the treatment case.
10. Keep any admission or transaction reference provided.

Medical Assessment and Diagnosis

The treating doctor must determine whether hospitalisation or a covered procedure is medically necessary.

The assessment may include:

• Patient history
• Physical examination
• Review of earlier reports
• Laboratory testing
• Imaging or diagnostic testing
• Specialist consultation
• Diagnosis
• Proposed treatment plan
• Reason for hospitalisation
• Selection of an appropriate package

How the Hospital Selects a Treatment Package

PM-JAY uses defined health-benefit packages. The hospital should select the package that matches the patient’s diagnosis, proposed treatment and its approved speciality.

The hospital should confirm:

• The package exists in the applicable system
• The hospital is empanelled for the speciality
• The patient meets the medical criteria
• The required reports are available
• The package is permitted for that hospital type
• No incompatible package is already active
• Sufficient family coverage is available
• Pre-authorisation is completed where required

What Is the Pre-Authorisation Request Form?

The Pre-Authorisation Request Form records the hospital’s proposed treatment and supporting clinical information. The treating doctor may need to review and sign the form before it is uploaded.

The form may contain:

• Patient and beneficiary details
• Hospital details
• Treating doctor’s information
• Diagnosis
• Proposed procedure
• Selected package
• Clinical findings
• Medical justification
• Attached investigation reports
• Doctor’s signature or confirmation

How the Hospital Submits Pre-Authorization

1. The hospital registers the verified beneficiary.
2. The doctor completes the diagnosis and treatment plan.
3. The hospital selects the applicable PM-JAY package.
4. Clinical reports and supporting records are collected.
5. The signed request form is prepared where required.
6. The hospital uploads the request through the transaction system.
7. A pre-authorisation reference is generated.
8. The authorised reviewer examines the request.
9. The hospital checks whether it is approved, queried or rejected.
10. The hospital informs the beneficiary about the next step.

Pre-Authorization Status Meanings

What If a Pre-Authorization Query Is Raised?

A query means the reviewer needs more information before making a final decision.

The query may ask for:

• Clearer diagnostic reports
• Additional laboratory tests
• Imaging reports or images
• Doctor’s clinical justification
• Correct package selection
• Updated beneficiary information
• Signed forms
• Previous treatment records
• Clarification of medical necessity

1. Ask the hospital what information was requested.
2. Provide available genuine medical records.
3. Ask the treating doctor to complete the clinical response.
4. Ensure the hospital uploads the response.
5. Ask for the resubmission status.
6. Do not pay an agent to remove or bypass the query.

What Happens After Pre-Authorization Approval?

After approval, the hospital should explain the authorised package and proceed according to the medical plan.

Ask the hospital:

• Which package was approved?
• Which procedure or treatment is authorised?
• What is included in the package?
• Is an implant or device included?
• Is ICU or another level of care approved?
• Are any medically necessary tests pending?
• Is any separate payment being requested?
• What is the expected treatment schedule?

What If Pre-Authorization Is Rejected?

Ask the Arogya Mitra or treating doctor for the exact rejection reason. Do not accept only a general statement that the Ayushman Card is not working.

Possible reasons include:

• The diagnosis does not match the selected package
• Medical necessity was not sufficiently documented
• Required reports were missing
• The hospital lacks the approved speciality
• The package is not available for that hospital type
• The beneficiary could not be verified
• Family coverage is insufficient
• A duplicate or conflicting package exists
• The requested treatment is excluded or unsupported
• The submitted information was incorrect

1. Request the rejection reason or reference.
2. Ask whether the package was selected correctly.
3. Ask whether additional medical evidence can resolve the issue.
4. Ask whether the hospital can correct and resubmit the request.
5. Ask whether another applicable package exists.
6. Seek a second opinion when medically appropriate.
7. Search for another empanelled specialist hospital where necessary.
8. Register a grievance when a valid process is improperly denied.

What Is a Package Enhancement Request?

During treatment, the patient’s condition may change or the approved package may need an authorised enhancement. The hospital may submit an enhancement request where the official workflow permits it.

An enhancement request may require:

• Updated clinical condition
• Reason the original authorisation is insufficient
• New investigation reports
• Updated treatment plan
• Doctor’s justification
• Requested additional package or amount
• Confirmation of available family coverage

Pre-Authorization During Emergency Hospitalization

In an emergency, the patient should receive immediate medical assessment. The hospital’s Ayushman team should begin beneficiary verification and package processing as quickly as the situation allows.

1. Inform staff that the patient may be a PM-JAY beneficiary.
2. Provide any available Ayushman Card or PM-JAY ID.
3. Provide an available government photo ID.
4. Ask an attendant to contact the Ayushman help desk.
5. Ask the hospital to verify the beneficiary.
6. Ask whether an emergency package applies.
7. Keep records of any initial payment.
8. Collect receipts and itemised details.
9. Do not delay urgent treatment solely because an OTP is unavailable.

Treatment After Package Approval

The hospital should provide the approved care according to clinical requirements and PM-JAY package conditions.

During treatment:

• Ask what procedure has been approved
• Ask which doctor is responsible for treatment
• Ask about major risks and alternatives
• Read medical-consent forms before signing
• Report unexpected payment demands
• Keep copies or photographs of payment receipts
• Ask about medicines and implants used
• Ask the Arogya Mitra when an enhancement is required

What May Be Included in an Approved Package?

Package inclusions depend on the treatment and current Health Benefit Package rules. Covered components may include:

• Medical examination and consultation
• Registration connected with the approved hospitalisation
• General-ward accommodation where applicable
• Nursing services
• Doctor, surgeon and anaesthesia fees
• Operation-theatre charges
• Applicable ICU or high-dependency care
• Medicines and consumables
• Diagnostic and laboratory investigations
• Applicable implants or devices
• Patient food during hospitalisation
• Covered complications during treatment
• Applicable pre-hospitalisation expenses
• Applicable post-hospitalisation follow-up care

What If the Hospital Demands Extra Payment?

Ask whether the payment relates to an excluded service, voluntary upgrade or a covered item already included in the approved package.

1. Ask which package was approved.
2. Ask which items are included.
3. Ask for the reason for the additional charge.
4. Ask for an itemised written estimate or bill.
5. Ask the Arogya Mitra to explain the charge.
6. Do not pay an employee privately.
7. Collect a receipt for every payment.
8. Keep prescriptions and purchase bills.
9. Register a grievance when a covered item is improperly charged.

Ayushman Hospital Discharge Process

Once the treating doctor considers the patient fit for discharge, the hospital records the treatment and discharge information in the transaction system.

1. The doctor confirms that discharge is medically appropriate.
2. The hospital prepares the discharge summary.
3. Treatment and procedure details are recorded.
4. Implant or device information is recorded where applicable.
5. Discharge medicines and instructions are prepared.
6. Follow-up requirements are explained.
7. The hospital completes the applicable transaction steps.
8. The beneficiary collects all records and personal documents.
9. The hospital prepares the claim-supporting documents.

Documents to Collect at Discharge

• Discharge summary
• Final diagnosis
• Procedure or surgery details
• Medicine list
• Laboratory and imaging reports
• Implant or device information
• Follow-up date
• Diet and activity instructions
• Warning signs and emergency contact instructions
• Payment receipts for any amount paid
• Pre-authorisation or transaction reference where available
• All original identity documents

Post-Hospitalization Care

PM-JAY packages may include applicable post-hospitalisation follow-up, medicines or diagnostics for the same treatment episode, subject to the approved package.

Before leaving, ask:

• Which follow-up services are included?
• For how long are included services available?
• Which medicines will be supplied?
• Are dressing changes included?
• Are follow-up tests included?
• Must follow-up occur at the same hospital?
• What should be done if complications develop?

How the Hospital Submits the Cashless Claim

After treatment and discharge, the empanelled hospital submits the provider claim through the official transaction system.

The hospital may upload:

• Beneficiary-verification record
• Approved pre-authorisation
• Admission information
• Treatment and procedure notes
• Investigation reports
• Operation notes where applicable
• Implant or device details
• Discharge summary
• Required photographs or clinical evidence
• Other package-specific claim documents

What If the Hospital Claim Receives a Query or Rejection?

A claim query or rejection usually concerns the provider’s submitted documents, package compliance or treatment record.

Possible reasons include:

• Missing discharge documents
• Incomplete clinical records
• Mismatch between approved and claimed package
• Missing operation notes
• Incomplete implant information
• Incorrect admission or discharge dates
• Duplicate claim
• Package-rule violation
• Insufficient evidence of treatment

Who Receives the Claim Settlement?

Once an eligible hospital claim is approved, payment is processed for the empanelled healthcare provider according to the state’s implementation model and scheme rules.

How Can a Beneficiary Check Pre-Authorization or Claim Status?

A beneficiary may not have access to the hospital’s complete internal claim-processing screen. The practical approach is to ask the hospital’s Ayushman help desk for the current transaction status and reference.

1. Ask the Arogya Mitra for the pre-authorisation reference.
2. Ask whether the request is submitted, queried, approved or rejected.
3. Ask what additional document is required when a query is raised.
4. Ask which package was finally approved.
5. At discharge, ask whether the treatment transaction was completed.
6. Keep the discharge and transaction references.
7. Call 14555 when the hospital does not provide a clear explanation.
8. Register a grievance when necessary.

When Is Family Coverage Used?

The approved hospitalisation transaction is recorded against the applicable family or beneficiary coverage. The amount is treatment utilisation, not a cash withdrawal.

• Approved package utilisation may reduce available family coverage
• Earlier treatment by another member may affect remaining coverage
• Package utilisation is recorded through the official system
• Rejected or cancelled transactions should be reviewed carefully
• Unused coverage cannot be withdrawn as cash

Pre-Authorization for Treatment in Another State

National portability allows an eligible beneficiary to seek treatment at an empanelled hospital outside the home state. The destination hospital verifies the beneficiary and submits the applicable package request.

Before travelling:

• Confirm the hospital’s current empanelment
• Confirm the required speciality
• Carry the latest Ayushman Card
• Carry complete medical records
• Ask whether the package is available for portability
• Ask whether pre-authorisation is required

Pre-Authorization for Senior Citizens Aged 70 Plus

A senior citizen with an approved Ayushman Vay Vandana Card must still complete hospital verification and the applicable treatment-package process.

• Confirm that the senior’s card is generated
• Carry an accepted photo identity document
• Carry previous reports and medicine information
• Confirm the required hospital speciality
• Ask which package is proposed
• Ask whether an enhancement or special approval is required
• Collect the discharge and follow-up records

What If the Hospital Refuses to Submit Pre-Authorization?

Ask for a clear reason. The hospital may have a genuine speciality, package, verification or medical issue, but it should explain the problem.

Ask whether:

• The hospital is currently empanelled
• The required speciality is active
• The beneficiary was successfully verified
• The selected package is available
• The doctor considers hospitalisation medically necessary
• Required reports are missing
• The package is restricted to another hospital type
• Family coverage is available
• A previous transaction is blocking the request

1. Ask for the Arogya Mitra or hospital nodal officer.
2. Request the exact reason for non-submission.
3. Ask whether another package can be considered.
4. Ask whether missing reports can be completed.
5. Request a written explanation or reference.
6. Search for another appropriate empanelled hospital.
7. Register a grievance when a valid process is improperly refused.

Pre-Authorization or Cashless Claim Complaint

Register a complaint when an empanelled hospital demands an unofficial approval fee, refuses to explain a rejection, charges for covered items or asks the beneficiary to pay because of a provider-claim dispute.

Keep the following information ready:

• Beneficiary’s full name
• Ayushman Card or PM-JAY ID
• State and district
• Hospital name and exact branch
• Date of admission or attempted admission
• Treatment and speciality
• Proposed package name where known
• Pre-authorisation reference
• Current approval or rejection status
• Exact hospital explanation
• Payment receipts and bills
• Medical reports and discharge documents

Pre-Authorization and Claim Fraud Warning

• Do not pay an agent to approve pre-authorisation
• Do not pay a private fee to answer a medical query
• Do not sign a blank pre-authorisation form
• Do not use another person’s Ayushman Card
• Do not submit false medical reports
• Do not agree to a procedure that was not explained
• Do not share an OTP with an unknown caller
• Do not share an ATM PIN, UPI PIN, CVV or banking password
• Do not believe promises of direct ₹5 lakh payment
• Do not pay to increase the official family coverage
• Do not allow an unknown person to control your phone remotely
• Do not leave original identity documents permanently with the hospital
• Do not pay cash without a receipt

Frequently Asked Questions

Final Words

Ayushman Card pre-authorisation is handled by the empanelled hospital after beneficiary verification and medical assessment. The hospital selects an applicable package, uploads the required clinical information and responds to any query raised by the reviewer.

After approval, the hospital provides treatment according to the authorised package. At discharge, the beneficiary should collect the complete discharge summary, reports, medicine instructions and receipts. The hospital then submits its provider claim through the official system.

Never pay an unofficial approval or claim fee. Ask for the exact package, pre-authorisation status and written explanation for any extra charge or rejection. Use the official helpline and grievance portal when a valid cashless-treatment process is improperly denied.