| Major Process Groups | Business Processes | Proposed module | legacy | Modular | comments |
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Core
Processes
| Beneficiary Management
| Enroll beneficiary | Benefit plan (Policy) | X |
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| Assign beneficiary to a Primary Care Provider (PCP) or primary care unit | Client registry | X |
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| Eligibility inquiry by provider | Location and Health Facility | Provider management (Price list) |
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| only based on the price list, preauthorisaiton required to have the eligibility for provider and Beneficiary |
| Eligibility inquiry by beneficiary | Benefit plan (Policy) | X |
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| Preauthorization | Valuation | Accounting |
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| does it include prevaluation ? |
Provider Management
| Register/ empanel provider | Location and Health Facility (sub level) | X |
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| Provider agreement | Price listLocation and Health Facility (price list link) | X |
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| Premium Management | Premium collection | Benefit plan (Policy (- contribution) | X |
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Claims Management
| Claims processing | Claim (hf claim) | X | X |
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| Claims status inquiry | Claim (claim overview report) | X | X |
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| Claims dispute and appeals | Claim |
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| Claims adjustment and voids | Claim (review) | X | X |
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Accounting
| Payment to providers | ValuationAccounting |
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| Accounts receivable | ValuationAccounting |
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| Accounts payable | Valuation Accounting (batch run) | X |
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Supportive
Processes
| Care Management
| Manage costs of catastrophic cases |
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| Identify chronic disease management cases |
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| Enroll into chronic disease management programs |
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| Monitor chronic disease management cases |
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| Utilization Management | Utilization management |
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| Pharmacy benefits management (PBM) |
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| Provider Quality Management | Provider quality management |
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Financial / Audit Management
| Actuarial management | Reports/SchemeBenefit plan (insurance product) | ~ |
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| Provider rate | Provider management (Price list) | X |
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| Set premium | SchemeBenefit plan (insurance product) | X |
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| Reserve fund management | SchemeBenefit plan (insurance product) |
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| Medical Loss | Manage medical loss ratio (MLR) |
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Audit and Fraud
| Identify fraudulent cases | Claims (checks) | ~ |
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| Manage fraudulent cases | Claims (feedback) | ~ |
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