Table 4 Key variations in pre-authorization and claim management processes in the two states
| Â | Uttar Pradesh (Trust) | Jharkhand (Insurance) |
|---|---|---|
Pre-authorization | Some packages are pre-approved, the remaining are to be approved by the implementation support agency. Unspecified packages are approved upon inspection by the medical management team in the state health agency | Some packages are pre-approved, the remaining, including unspecified packages, are to be approved upon inspection by the medical doctor of the third-party administrator |
Claims Audits | Initial auditing of claims generated by the providers is done by the implementation support agency, and is later verified by the medical management team of the state health agency | Claims were approved by the third-party administrator, while the insurance company and state health agency only conducted audits of a random sample of claims |
Claims Rejection | All final decisions on claims were provided by the state health agency, including rejections | Claims rejected by the third-party administrator were reviewed by the state health agency and the decisions would be reversed where deemed appropriate |
Turn-Around Time (TAT) for Claimsa | 30Â days | 15Â days |
TAT for pre-authorizations b | 6Â h | 6Â h |