Getting empanelled under PMJAY (Ayushman Bharat) is how your nursing home or small hospital starts treating insured families cashless, with the government as the payer instead of the patient. For a lot of facilities in Bihar and eastern UP it is the single biggest lever on occupancy you have. But empanelment is not a one-time form — it is an operational commitment to registration, infrastructure, and above all records clean enough to survive a claim audit. Here is who qualifies, how the process runs, and what it asks of you once you are in.
Key Takeaways
- PMJAY covers eligible families up to ₹5 lakh per year for secondary and tertiary hospitalisation; empanelled facilities are paid at fixed Health Benefit Package (HBP) rates, not by the patient.
- You apply online through the National Health Authority / State Health Agency portal, after which a District Empanelment Committee reviews the file and inspects the premises.
- Most norms expect inpatient beds (often ten or more), qualified staff, a valid Clinical Establishments Act or nursing-home registration, and a working IT setup to file claims; aspirational districts get relaxed norms.
- Day-to-day claims run through the Transaction Management System (TMS): verify the beneficiary, raise a pre-authorisation, treat, then submit the claim with documents.
- Most rejected or delayed claims fail on paperwork — a missing discharge summary, mismatched identity, or notes that don't match the claimed package.
- Whether empanelment actually pays comes down to clean, retrievable inpatient records. That is an operations problem, not a policy one.
What PMJAY empanelment actually gives you
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) is a government health assurance scheme run by the National Health Authority. Eligible families get cover of up to ₹5 lakh per year for secondary and tertiary hospitalisation, cashless at any empanelled facility. The money comes from central and state governments, not patient premiums.
For a hospital, empanelment turns a population that often could not afford inpatient care into paying patients — with the government as payer. In states like Bihar and UP, where a large share of households are beneficiaries, that changes what a small hospital's ward can realistically run at. It also brings predictability: package rates are fixed, so you know what each procedure pays before you do it. The trade-off is process discipline. Claims are scrutinised, and weak documentation turns into rejections.
Who can get empanelled
Criteria are set by the NHA and your State Health Agency, and they scale with the level of care you offer. Broadly, expect requirements around:
- A minimum number of inpatient beds — often ten or more — with the supporting infrastructure.
- Qualified medical and nursing staff appropriate to the specialities you claim.
- Valid registration under the relevant law. Most facilities need to be registered under the Clinical Establishments Act or the state's nursing-home rules first.
- Basic equipment, infection control, and — for speciality packages — the matching department and specialist.
- A functional IT setup, because beneficiary verification and claims are online.
Relaxed norms exist for aspirational districts and the North East, which is how smaller facilities in underserved areas get in. And because PM-JAY pays higher package rates to accredited hospitals, pursuing NABH entry-level certification for a small hospital can raise what each empanelled case earns.
The empanelment process, step by step
Empanelment runs online through the NHA's Hospital Empanelment Module, usually reached from the PM-JAY provider portal.
- Register your hospital on the portal and create login credentials.
- Fill the detailed application — infrastructure, beds, staff, specialities, equipment and registrations.
- Upload supporting documents: registration certificates, staff qualifications, ownership or lease proof.
- Select the specialities and HBP packages you want to offer.
- A District Empanelment Committee reviews the file and conducts a physical inspection.
- On approval, you are empanelled and issued access to the transaction system.
The State Health Agency drives this in each state, so exact timelines and contacts differ between UP and Bihar. Choose your empanelment scope to match the procedures you actually perform — you can only claim packages inside the specialities you are empanelled for.
What it demands after you're in: TMS and claims
The day-to-day work happens in the Transaction Management System (TMS). The flow is consistent: verify the beneficiary's eligibility and identity, raise a pre-authorisation for the package, treat the patient, then submit the claim with the required documents for the State Health Agency or its insurer to adjudicate and pay.
This is where empanelment either pays or frustrates you. A claim is only as good as the record behind it, and the common failure points are boringly consistent.
| Why claims get rejected or delayed | The record that prevents it |
|---|---|
| Beneficiary identity mismatch | Verified identity tied to one patient UHID |
| Missing or weak discharge summary | Complete IPD notes and a discharge summary on file |
| Treatment doesn't match the package | Diagnosis, investigations and procedure logged against the case |
| Pre-authorisation not raised or documented | Pre-auth captured before treatment starts |
| Itemised bill can't be produced | A GST-ready bill linked to the same patient record |
None of this is exotic. It is the difference between a facility that assembles a clean claim in minutes and one that hunts across a register, a prescription pad and a billing book while the payment window slips.
Where Clinizy Care fits
Clinizy Care does not get you empanelled — no software does, and be wary of any that claims to. What it does is keep the trail a PMJAY claim is judged on. Because empanelled facilities admit patients, this is Care Plus territory (₹5,999/mo, up to 5 doctors, 10 staff and 30 beds): IPD and admission management, bed and ward management, discharge billing, and a single patient record where the consultation, prescription, investigations and GST-ready bill all sit under one UHID.
When the State Health Agency questions a claim, you export one consistent story instead of reconstructing it. It is offline-first, so a peak-OPD power cut doesn't stop admissions or billing — entries sync when the link returns. You can compare what each plan includes on the features page. If you run a pure OPD clinic with no beds, you probably don't need empanelment or this tier — Care Essentials at ₹1,999/mo is the honest starting point.