| Major Process Groups | Business Processes |
---|
Core
Processes
| Beneficiary Management
| Enroll beneficiary |
---|
Assign beneficiary to a Primary Care Provider (PCP) or primary care unit | Eligibility inquiry by provider | Eligibility inquiry by beneficiary | Preauthorization | Provider Management
| Register/ empanel provider | Provider agreement | Premium Management | Premium collection | Claims Management
| Claims processing | Claims status inquiry | Claims dispute and appeals | Claims adjustment and voids | Accounting
| Payment to providers | Accounts receivable | Accounts payable |
Supportive
Processes
| Care Management
| Manage costs of catastrophic cases |
---|
Identify chronic disease management cases | Enroll into chronic disease management programs | Monitor chronic disease management cases | Utilization Management | Utilization management | Pharmacy benefits management (PBM) | Provider Quality Management | Provider quality management | Financial / Audit Management
| Actuarial management | Provider rate | Set premium | Reserve fund management | Medical Loss | Manage medical loss ratio (MLR) | Audit and Fraud
| Identify fraudulent cases | Manage fraudulent cases |
Source: Joint Learning Network Report 2012 » |