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+{{htmlmetatags>metatag-keywords=(ayushman bharat claim rti,pmjay claim denied rti,rti national health authority,sha state health agency rti,pmjay empanelment rti,ayushman claim stuck 2026)&metatag-description=(Ayushman Bharat PM-JAY claim denied or empanelment delayed? File RTI to the National Health Authority / State Health Agency to unlock claim-adjudication record and officer name.)}}
+====== Ayushman Bharat Claim Denied? RTI to NHA / State Health Agency ======
+{{ :social:auto:rti-for-ayushman-bharat-claim.png?direct&1200 |RTI for Ayushman Bharat claim — RTI Wiki}}
+{{page>snippets:dpdp-banner}}
+<WRAP info>
+**In one line.** PM-JAY (Pradhan Mantri Jan Arogya Yojana) under Ayushman Bharat covers ~55 crore beneficiaries. Claims are adjudicated by the State Health Agency (SHA) with NHA oversight. When claims are rejected or stuck, RTI extracts the claim-trail, officer, and exact ground.
+</WRAP>
+Part of **[[:rti-for-money-and-schemes|Pillar 4 — RTI for Money & Schemes]]**. Related: [[:rti-for-government-hospitals|RTI for government hospitals]].
+===== What is the problem =====
+Claims stall on:
+  * **Pre-authorisation (preauth) denial** — hospital's preauth rejected pre-treatment.
+  * **Post-treatment claim rejection** on medical / billing grounds.
+  * **Query raised** by SHA that hospital didn't address within 15 days.
+  * **Treatment-package mismatch** (wrong HBP code).
+  * **Eligibility flagged** during claim.
+  * **Empanelled-hospital payment pending** beyond 30 days.
+===== When to use RTI =====
+  * Preauth denied without specific reason.
+  * Post-claim reject SMS received; hospital silent.
+  * Hospital demanding cash despite PM-JAY card.
+  * Empanelled hospital claim pending > 45 days.
+  * Beneficiary-eligibility dispute.
+===== What you can ask =====
+  * Claim ID status in BIS / TMS portal.
+  * Preauth request date + adjudication date + decision.
+  * Reason recorded for rejection, with the specific clause of PM-JAY guidelines.
+  * Medical-officer / claim-adjudicator name.
+  * Hospital's preauth response / query-reply record.
+  * Treatment-package (HBP) code used + correct code per procedure.
+  * Payment status to hospital.
+  * Beneficiary-eligibility verification log.
+  * Grievance officer at SHA + NHA.
+===== Step-by-step RTI filing =====
+  * **State Health Agency (SHA)** → state RTI portal → Health & Family Welfare.
+  * **NHA (central)** → ''rtionline.gov.in'' → Ministry of Health & Family Welfare → National Health Authority.
+  * Rs. 10 fee; BPL free.
+===== Sample RTI application =====
+<code>
+To,
+The Public Information Officer,
+[State Health Agency / National Health Authority],
+[Address]
+Subject: Information under Section 6(1) of the RTI Act, 2005, regarding my PM-JAY claim.
+Sir/Madam,
+I, [Name], PM-JAY Beneficiary / HH ID [masked last 4 digits XXXX], resident of [Full Address], submit:
+Hospital name + Empanelment ID: ________
+Admission date: ________
+Discharge date: ________
+Claim / Preauth ID: ________
+Procedure undergone: ________
+HBP code (if known): ________
+Amount claimed: Rs. ________
+Please provide:
+. Current status of the claim in the BIS / TMS portal.
+. Preauth request date + adjudication date + decision (approved / queried / rejected).
+. Certified copy of the rejection memo with the specific clause of PM-JAY guidelines relied on.
+. Name and designation of the medical officer / claim-adjudicator who recorded the decision.
+. Hospital's preauth submission + any query-response record.
+. HBP treatment-package code applied to my procedure.
+. Payment status to the hospital for this claim.
+. Beneficiary-eligibility verification log for my case.
+. Procedure and timeline for appeal against rejection.
+. Grievance officer / First Appellate Authority contact at the SHA and NHA.
+I enclose IPO No. __________ for Rs. 10.
+I declare I am an Indian citizen.
+Yours faithfully,
+[Signature, Date, Place]
+</code>
+===== 10 RTI questions =====
+  - BIS/TMS portal status.
+  - Preauth timeline.
+  - Rejection-memo copy.
+  - Adjudicator name.
+  - Hospital preauth record.
+  - HBP code used.
+  - Payment to hospital status.
+  - Eligibility verification.
+  - Appeal procedure.
+  - Grievance / FAA.
+===== What happens next =====
+  * **Day 0–15** RTI routed; SHA claims cell pulls record.
+  * **Day 15–25** Many claims reassessed during this window; hospitals pressured to reply.
+  * **Day 30** Reply mandatory.
+===== Common mistakes =====
+  * Writing full HH ID — only last 4 digits.
+  * Not citing Preauth ID.
+  * Filing at hospital — hospital is not a public authority for RTI (unless government).
+  * Skipping HBP-code question — often the exact dispute.
+===== Pro tips =====
+  * **Parallel grievance** at ''pmjay.gov.in'' grievance portal.
+  * **For empanelled private hospital** refusing cashless — NHA grievance + SHA RTI.
+  * **Medical-record RTI** to hospital (if government) — see [[:rti-for-government-hospitals|hospital RTI guide]].
+===== FAQs =====
+**Q1. Is PM-JAY cashless?**\\ Yes, at empanelled hospitals for listed procedures.
+**Q2. Can I appeal rejection?**\\ Yes. Appeal to the SHA Grievance Cell, then to NHA.
+**Q3. Coverage limit?**\\ Rs. 5 lakh per family per year.
+**Q4. Does the card expire?**\\ No — valid for the family, subject to eligibility review.
+===== Conclusion =====
+Ayushman Bharat is large and rule-heavy. Claim disputes follow an adjudication trail — RTI extracts that trail and surfaces the specific decision point.
+===== Related reading =====
+  * [[:rti-for-money-and-schemes|Pillar 4 — Money & Schemes]]
+  * [[:rti-for-government-hospitals|RTI for government hospitals]]
+  * [[:rti-for-government-scheme-delay|Scheme delay RTI]]
+  * [[:pio-health-hospital-rti|PIO framework — health & hospital]]
+===== Sources =====
+  * PM-JAY Operational Guidelines
+  * NHA Circulars; SHA manuals
+----
+//Last reviewed: 21 April 2026.//
+{{tag>rti ayushman-bharat pmjay nha sha pillar-4 scheme}}

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