Page Comparison

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Excerpt

	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 Pre-authorization
	Provider Management	Register/ empanel provider
	Provider Management	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
	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
	Audit and Fraud	Manage fraudulent cases

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