Ayushman Bharat (PMJAY) claim denied? Use RTI to fix it (2026 guide)

NHA's own dashboard (March 2026) shows 22 lakh pre-authorisation requests every month, of which roughly 9% are rejected. Most rejections are reversed when challenged with the right HBP code reference — but families don't know how to challenge. RTI is the fastest, cleanest way to get the SHA to put its reasoning in writing.

You may have already tried:

• Beneficiary helpline 14555 — call-centre. Ticket logged. Often the response is “talk to your hospital”.
• NHA grievance portal at https://grievance.pmjay.gov.in — better than helpline, but the resolution can be a one-line “claim processed as per guidelines” with no specifics.
• Hospital's PMJAY counter — the hospital itself has no power over SHA decisions. They can only forward.
• District Implementation Unit (DIU) — the district-level coordinator. Useful for card-issuance issues but slow.

NHA is a Society registered under MoHFW = Public Authority under §2(h) RTI Act. Each State Health Authority (SHA) is similarly a public authority (most are state government departments or registered societies). Each empanelled hospital, when implementing PMJAY, is a “third party” but information about your claim must be disclosed to you under Aditya Bandopadhyay.

In short: 14555 and the grievance portal are requests. An RTI is a legal claim that produces a reasoned reply you can use for a fresh claim, escalation, or court.

Before filing, lock down the basics.

• Open https://pmjay.gov.in → “Am I Eligible?” — verify your family is on the SECC 2011 base list (or state-extended list — many states have added households).
• Open the AB-PMJAY app or PM-JAY Beneficiary portal → log in → check family list + e-KYC status.
• If your card is made, download the e-card (PVC card optional).
• Note your PMJAY Family ID and Beneficiary ID.
• Save screenshots of any rejection / portal status.

PMJAY has a 4-tier structure:

• Empanelled Hospital — claim originator. PIO at the hospital handles their own internal records (Beneficiary Identification System logs, pre-auth submission timestamps).
• District Implementation Unit (DIU) — district-level. PIO at the DIU office (usually under CMO/District Health Society).
• State Health Authority (SHA) — state-level. PIO at SHA HQ (usually under State Health/Family Welfare Dept). The SHA is where pre-auth approval/rejection actually happens — so SHA is the most important PIO for claim issues.
• National Health Authority (NHA), Delhi — central. PIO at NHA HQ for portal, policy, and HBP issues.

For most claim denials, file primarily at the SHA, with a copy to NHA for HBP-policy questions.

• Hospital PIO — usually the Medical Superintendent or Pradhan Mantri Aarogya Mitra (PMAM) in charge.
• DIU PIO — usually the District Programme Manager (PMJAY) under the Chief Medical Officer (CMO).
• SHA PIO — usually a Joint Director / Deputy Director under the State Mission Director (PMJAY). FAA is the Mission Director / CEO of SHA.
• NHA PIO — listed at https://nha.gov.in → “RTI”. FAA is the Joint Secretary at NHA.

• Indian Postal Order (IPO) ₹10 — payable to “Accounts Officer, State Health Authority, [state]” or “Accounts Officer, National Health Authority, New Delhi”.
• DD ₹10.
• Some states (like Tamil Nadu and Maharashtra) accept court fee stamp of ₹10.
• BPL waiver — attach BPL ration card. Most PMJAY beneficiaries automatically qualify.

The template below is for the most common case — pre-auth rejected. If your card itself is stuck, swap the “Information sought” block accordingly (questions in italics).

[Your full name]
[Your address]
[Phone] · [Email]
[Date]

To,
The Public Information Officer
State Health Authority (PMJAY), [State name]
[full postal address]

Subject: RTI application under §6(1), RTI Act 2005 — denial of pre-authorisation under PMJAY

Sir/Madam,

I am a beneficiary under Ayushman Bharat - PM Jan Arogya Yojana (PMJAY). The following information is requested under §6(1) of the Right to Information Act, 2005:

PMJAY Family ID: [ID]
Beneficiary ID: [ID]
Patient name: [name]
Empanelled hospital: [name + city]
Date of admission: [DD-MM-YYYY]
HBP procedure code applied: [e.g., C002 — Angioplasty]
Pre-auth request reference: [number from BIS]
Date of pre-auth rejection: [DD-MM-YYYY]
Reason on rejection slip: [reason as printed]

Information sought:

1. The full pre-authorisation file, including:
   (a) the BIS-generated request as submitted by the hospital,
   (b) all documents uploaded (ECG, lab reports, clinical notes),
   (c) the specialist medical reviewer's note recording the reason for rejection,
   (d) the name and designation of the medical reviewer.

2. The exact clause of the **Health Benefit Package (HBP) Master List** under which my procedure was held inadmissible, with the specific version date of the HBP guidelines applied.

3. Whether the latest version of HBP guidelines (HBP 2.2 or later) was applied to my case; if not, the reason.

4. The escalation matrix — name and designation of the SHA medical reviewer who can reconsider the rejection on representation.

5. The procedure for filing a **post-discharge / fresh pre-auth claim** when an emergency admission has been rejected at first instance.

6. The list of all pre-authorisations approved/rejected for HBP code [code applied] by this SHA in the last 6 months, in aggregate (no patient identifiers).

7. The action proposed by the office on receipt of this application.

//(For card / e-KYC issues — replace 1-7 above with:)//
//1. The status of my PMJAY card application/e-KYC dated [date].//
//2. The specific reason for rejection / pendency, with the SECC 2011 / state-list reference.//
//3. The list of documents required to complete the family list correction.//
//4. The name and designation of the dealing officer.//
//5. The expected date of disposal as per Citizen Charter.//

Fee: I enclose IPO No. [number] dated [date] for ₹10 in favour of "Accounts Officer, State Health Authority, [state]".

I declare that I am a citizen of India.

[Signature]
[Name]

Always Registered Post with Acknowledgement Due (AD) — ₹40-60.

• Take application + IPO + a copy of your PMJAY card + (if rejection) the rejection slip + (if claim) hospital bills.
• Ask for “Registered AD”.
• Keep the receipt.
• AD card returns in 7-10 days, signed by SHA office.

A copy can be hand-delivered at the SHA office and stamped on a duplicate.

The 30-day clock starts on the AD date.

In parallel:

• NHA grievance portal at https://grievance.pmjay.gov.in → “Beneficiary”.
• PMJAY helpline 14555 — log a ticket, note number.
• CPGRAMS at https://pgportal.gov.in → MoHFW → NHA.
• District Grievance Nodal Officer (DGNO) — every district has one under PMJAY guidelines.

If silence on Day 31, file a First Appeal under §19(1) — free, registered post.

The FAA at SHA is usually the Mission Director / CEO.

To,
The First Appellate Authority
(Mission Director / CEO)
State Health Authority (PMJAY), [State]
[address]

Subject: First Appeal under §19(1), RTI Act 2005

Sir/Madam,

I filed an RTI application dated [original date] (received by your office on [AD date]) seeking information about my PMJAY pre-authorisation rejection. The 30-day window under §7(1) ended on [day 30]. I have received [no reply / a vague reply not addressing my questions].

I file this First Appeal under §19(1), RTI Act 2005, and request that the FAA direct the PIO to provide the information sought, and pass any further orders deemed fit including penalty under §20 for the deemed refusal.

Enclosed: (a) copy of original RTI, (b) postal AD acknowledgement, (c) PIO's reply if any.

[Signature]

If FAA also fails within 45 days (§19(6)), file Second Appeal at the State Information Commission (SIC) — for state-level SHA — or the Central Information Commission (CIC) for NHA matters.

• “No acute event documented.” — Cite the HBP 2.2 (2024 revision) which moved many cardiac/stroke/sepsis packages to “investigation-based eligibility” — ECG + biomarkers + clinical notes are sufficient. Demand a copy of the version of HBP applied.
• “Diagnosis doesn't match HBP package code.” — HBP allows “closest match” mapping. Demand the BIS internal mapping note. NHA Operational Guidelines 2021 §7.4 requires the medical reviewer to suggest the correct package, not just reject.
• “Hospital empanelment expired/suspended.” — RTI to NHA for the empanelment register (it is publicly disclosable under §4(1)(b)). If the hospital was empanelled on the date of admission, the claim must be honoured — NHA Standing Operating Procedure 2022 §11.
• “Family list mismatch / e-KYC failed.” — Demand the SECC 2011 entry the system is matching against. Most failures are name spelling / father's name / age mismatch — fixable with Aadhaar + ration card.
• “Repeat hospitalisation gap rule.” — HBP has a 30-day gap rule for the same package. Cite §8(2) public interest if the second admission is for a complication; complications are not “repeat hospitalisations”.
• “Information is third-party (other patients' data).” — Aggregate data without identifiers is not third-party (§8(1)(j) does not apply).

Every PMJAY procedure has an HBP code (e.g., C002 = Coronary Angioplasty, OB001 = Caesarean Section, OR023 = Hip Replacement). The full HBP Master List is at https://nha.gov.in. Three things to know:

1. Package codes have versions. HBP 1.0 (2018), HBP 2.0 (2022), HBP 2.2 (2024) — the current version. Many denials cite outdated rules.
2. Each package has a fixed price and a list of inclusions (drugs, implants, post-op care). The hospital cannot charge you extra; if they do, file an RTI naming the hospital.
3. Stratification — Tier 1 metros, Tier 2 cities, and rural have different rates. Same procedure, different price.

If the SHA rejected your code, ask which alternative HBP code would have been admissible and submit a fresh pre-auth under that.

Q. The hospital wanted cash deposit despite my PMJAY card. Is that legal?
No. Empanelled hospitals are barred from collecting any deposit for PMJAY-listed procedures (NHA SOP §8.2). File RTI naming the hospital + date — the SHA can suspend empanelment and refund you.

Q. My family has 6 members but only 4 are in the list. Can I add the others?
Yes — through the Beneficiary Family Identification (BFI) process. RTI to DIU asking the procedure works, but the easier route is the Common Service Centre (CSC) with Aadhaar + ration card.

Q. Can I use PMJAY in another state?
Yes — PMJAY is portable across all states. The hospital must be empanelled in any state.

Q. My doctor said “PMJAY package is too low for this” and refused.
This is illegal. The hospital agreed to the package rate when they got empanelled. RTI to NHA + SHA naming the hospital — penalties include de-empanelment and refund.

Q. The card is made but the BIS shows “inactive”.
Common after Aadhaar e-KYC mismatch. RTI to SHA asking the exact field that mismatched usually solves it in one round.

Q. Will filing RTI affect my future PMJAY treatment?
No. Retaliation is barred under conduct rules. Lakhs of beneficiaries file RTIs each year.

PMJAY is the world's largest health insurance scheme — and it works, when you push back at the right place. A ₹10 RTI to the SHA forces the medical reviewer to put their reasoning in writing, which often reveals an outdated guideline, a wrong package code, or a fixable e-KYC mismatch. Kishore Devi got back ₹1.05 lakh in five weeks. The same path is open to you.

Don't accept “rejected” as the final word. Ask the SHA, in writing, why — under which version of HBP, by which medical reviewer, on what evidence. The answer almost always opens a route to reverse the decision.

• ESIC treatment denied — sibling guide
• Widow pension not credited — RTI guide
• EPF deducted but not deposited — RTI guide
• RTI in 12 simple steps
• All helplines — 14555, 14512, 14470
• RTI forms + state-wise fees

Last reviewed: 26 April 2026 by RTI Wiki editorial team. If you spot an error or an out-of-date phone/address, please post on the Q&A forum or write to admin@bighelpers.in.