Ayushman Bharat empanelment opens your clinic or hospital to crores of insured patients under the world's largest public health assurance scheme, and for many tier-2 and tier-3 facilities in Uttar Pradesh and Bihar it is the single biggest growth opportunity available. This guide explains the PM-JAY scheme, who qualifies for empanelment, how HBP packages and rates work, the step-by-step application, and how claims flow through the Transaction Management System, so you can decide whether and how to get empanelled.
What PM-JAY Actually Is
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, PM-JAY, is a government health assurance scheme run by the National Health Authority (NHA). It provides eligible families health cover of up to 5 lakh rupees per family per year for secondary and tertiary hospitalisation, cashless at any empanelled hospital across India.
The scheme is funded by central and state governments, not by patient premiums. For the patient, treatment at an empanelled facility is cashless and paperless. For the provider, the scheme reimburses treatment at pre-agreed package rates after a claim is filed and approved.
Why Empanelment Matters for UP and Bihar
In states like Uttar Pradesh and Bihar, a very large share of households are PM-JAY beneficiaries. For a nursing home in Gorakhpur or a small hospital in Muzaffarpur, empanelment converts a population that previously could not afford inpatient care into paying patients, with the government as the payer.
It also brings predictability. Package rates are fixed, so you know what each procedure pays. The trade-off is that you must follow the scheme's processes precisely, because claims are scrutinised and poor documentation leads to rejections.
Who Can Get Empanelled
Empanelment criteria are set by the NHA and the State Health Agency, and they vary by the level of care a facility offers. Broadly, a hospital must meet minimum requirements covering:
- A minimum number of inpatient beds, often ten or more, with supporting infrastructure.
- Qualified medical and nursing staff appropriate to the specialities offered.
- Registration under the relevant law, such as the Clinical Establishments Act or the state nursing home registration.
- Basic equipment, infection control, and for specialised packages, the relevant department and specialist.
- A functional IT setup to file claims online.
Special relaxed norms exist for hospitals in aspirational districts and the North East, which helps smaller facilities in underserved areas get in.
HBP Packages and Rates
Treatments under PM-JAY are organised into the Health Benefit Packages (HBP). Each package has a code, a defined scope, and a fixed rate. The package master is revised periodically, with HBP 2022 being a major revision that updated rates and added procedures.
| Element | What it means for you |
|---|---|
| Package code | The specific procedure or treatment you bill against |
| Package rate | The fixed reimbursement amount, all-inclusive |
| Specialty | Medical, surgical, or speciality grouping |
| Pre-auth | Some packages need approval before treatment |
You can only claim for packages that match the specialities you are empanelled for, so choose your empanelment scope to match the procedures you actually perform.
The Empanelment Application Process
Empanelment is done online through the NHA's Hospital Empanelment Module, often reached via the PM-JAY provider portal.
- Register your hospital on the empanelment portal and create login credentials.
- Fill the detailed application: infrastructure, beds, staff, specialities, equipment and registrations.
- Upload supporting documents, including registration certificates, staff qualifications and ownership or lease proof.
- Select the specialities and packages you wish to offer.
- A District Empanelment Committee reviews the application and conducts a physical inspection.
- On approval, your hospital is empanelled and issued login access to the transaction system.
The State Health Agency drives the process in each state, so timelines and exact contacts differ between Uttar Pradesh and Bihar.
Claims and the TMS
Once empanelled, the day-to-day work happens in the Transaction Management System (TMS). The typical flow is: 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.
The most common reasons claims get delayed or rejected are weak documentation: missing discharge summaries, mismatched patient identity, incomplete clinical notes, or treatment that does not match the claimed package. This is exactly where strong record-keeping decides whether empanelment is profitable.
Documentation You Must Keep
For every PM-JAY case you should be able to produce a clean, consistent record: beneficiary verification, pre-authorisation, clinical notes, investigations, the discharge summary, and the itemised treatment. Each of these connects to one patient identity. If your records are scattered across paper files and disconnected systems, assembling a clean claim is slow and error-prone.
How Clinizy Supports PM-JAY Workflows
Clinizy is built to keep exactly the trail that PM-JAY claims depend on. Every patient has one unified record with a UHID, full visit and IPD history, digital prescriptions and EMR, and GST-compliant billing, so when you raise or defend a claim, the clinical and financial story is consistent and easy to export. The IPD bed management module tracks admissions and discharges that underpin inpatient packages.
Because Clinizy is ABDM and ABHA ready, you can create ABHA IDs in-app and link records to the national health ecosystem, which aligns your clinic with where government health schemes are heading. The owner dashboard shows live collections and dues, helping you track the cash flow timing that scheme claims create. Empanelment brings the patients; Clinizy helps you keep the records that get those claims paid. See pricing or start a free trial.
Frequently Asked Questions
What is the cover under PM-JAY?
PM-JAY provides eligible families up to 5 lakh rupees per family per year for secondary and tertiary hospitalisation, cashless at any empanelled hospital, funded by central and state governments.
How many beds does a hospital need to be empanelled?
Requirements vary by care level and state, but many empanelment norms expect a minimum number of inpatient beds, often around ten, with relaxed norms for aspirational districts and underserved regions.
What is the TMS?
The Transaction Management System is the NHA platform where empanelled hospitals verify beneficiaries, raise pre-authorisations and submit claims for adjudication and payment.
Why do PM-JAY claims get rejected?
Most rejections come from weak documentation, such as missing discharge summaries, mismatched patient identity, or treatment that does not match the claimed HBP package. Clean, structured records are the best defence.