Health Systems Transformation Platform (HSTP) leads the charge in providing technical support to the state government to implement the Biju Swasthya Kalyan Yojana (BSKY), the flagship government-funded health insurance scheme in Odisha. HSTP  closely collaborates with the State Health Assurance Society (SHAS), the scheme's implementing agency, to enhance personnel capacities, improve operational and clinical processes, ensure better engagement with stakeholders, and contribute to better financial risk protection and improved health outcomes for the beneficiaries.

A workshop on Strengthening Operations: Claim Adjudication, Medical Audit and ICD-11 Training for BSKY was conducted to improve the efficiency, effectiveness, and transparency of claim adjudication and medical audit processes within the BSKY scheme. Additionally, the workshop introduced the International Classification of Diseases (ICD-11) for standardized diagnosis documentation, which is expected to improve the transparency of these processes.

This report shares a summary of the discussions on introduction to BSKY, an overview of the scheme, its objectives, and the impact on healthcare delivery in Odisha, detailed health benefits packages under BSKY,  including eligibility criteria and benefits,  Principles of Claim Adjudication: Critical examination of the criteria and processes involved in evaluating and processing claims within BSKY.  IT Workflow of Claim Adjudication: Insight into the IT framework supporting claim adjudication processes, Principles of Medical Audit: Explored medical audit techniques, focusing on desk and field audits, to ensure accountability and quality in healthcare delivery, Fraud Prevention Strategies: Strategies to detect and prevent fraud, ensuring the transparency and integrity of BSKY operations, and Introduction to ICD-11 Coding: Training on the latest ICD coding system to standardize diagnosis documentation and improve healthcare data analytics.