> ## Content Index > Fetch the complete content index at: https://carexaos.com/blog/llms.txt > Use this file to discover other available public pages before exploring further. # PMJAY claims: common reasons for denial, and how to prepare - URL: https://carexaos.com/blog/pmjay-claims-common-reasons-for-denial-and-how-to-prepare/ - Published: 2026-11-02T18:32:24.000Z - Updated: 2026-11-02T18:51:27.000Z - Description: The usual reasons PM-JAY claims are denied or cut, and a checklist to prepare cleaner claims, from admission to submission. - Author: Carexa OS - Tags: Billing Under Ayushman Bharat PM-JAY, eligible families get cashless cover of up to ₹5 lakh a year for secondary and tertiary hospital care at empanelled hospitals. For the hospital, getting paid depends on a clean claim. Most denials and deductions come from a short list of avoidable problems. Rules and document lists differ between State Health Agencies and change over time, so always check your state's current guidelines. The patterns below apply almost everywhere. ## The common reasons claims are denied or cut ### 1\. Pre-authorisation problems Most packages need pre-authorisation before treatment. Claims run into trouble when pre-auth was not raised, was raised for a different package, expired, or did not cover a change in treatment, such as a planned procedure that turned into a different one. Raise an enhancement or a fresh request when the treatment changes, before the bill is closed. ### 2\. Missing or unclear documents The single biggest cause. Typical gaps: no discharge summary, investigation reports missing or unsigned, operative notes absent for a surgical package, or required photographs missing or unclear. Scans that cannot be read count as missing. ### 3\. Details that do not match Names spelled differently across documents, admission or discharge dates that disagree between the summary and the bill, or a diagnosis in the notes that does not support the package claimed. Reviewers look for one consistent story. ### 4\. Package choice Claiming a package that does not match the documented procedure, booking procedures separately that the package already includes, or using a non-specific package when a specific one exists. ### 5\. Medical necessity not shown The notes must explain why the patient needed admission and treatment: findings, test results and the doctor's reasoning. A thin record invites queries. ### 6\. Late or duplicate submission Claims submitted after the deadline your scheme sets, or the same stay claimed twice, are rejected outright. ### 7\. Beneficiary identity The patient must be verified as an eligible beneficiary at admission. Mismatches between the verified identity and the hospital's records cause problems later. ## A preparation checklist - **At admission:** verify the beneficiary, record identity details exactly as verified, and raise pre-authorisation for the correct package. - **During the stay:** keep daily notes, record every investigation with its report, and raise an enhancement as soon as the plan changes. - **At discharge:** complete the discharge summary, with diagnosis, procedure, dates and the treating doctor, the same day. - **Before submitting:** run a final check against your state's document list: names, dates, package, reports, photographs where required, and signatures. - **After submitting:** answer queries quickly and completely, and track every claim until it is paid. - **Every month:** review your denials and deductions by reason. The same two or three causes usually account for most of them, and fixing those pays off fastest. ## Where software helps Most of these problems come from information that lives in different places: the registration desk, the ward, the lab and the billing office. A system that keeps it in one record, and flags what is missing before submission, removes much of the rework. Carexa OS brings ABHA registration, PMJAY claims and GST invoices into one system. See [Built for India](https://carexaos.com/india?ref=carexaos.com).