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Table 2 Distribution of roles among agencies involved in empanelment and claim management in the two models

From: The trust and insurance models of healthcare purchasing in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in India: early findings from case studies of two states

Function

Trust (Uttar Pradesh)

Insurance (Jharkhand)

Provider contracting

Final approvals provided by the state health agency through district and state empanelment committees

Final approvals provided by the state health agency through district and state empanelment committees. These committees include a representative of the insurance company, among their members

Claim processing

By implementation support agency, with verification and final decision on claims by the state health agency

By third-party administrators contracted by the insurance company, with random verification of a sample claims by the insurance company. The state health agency only audits rejected claims and a sample of approved claims

Reimbursement of claims to providers

By the state health agency

By the insurance company. State health agency pays the premium to the insurance company