changes.mady.by.user Uwe Wahser
Saved on May 02, 2019
Saved on Oct 21, 2022
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
Pre-authorization
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
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
Pharmacy benefits management
PBM
Provider Quality
Provider
Quality Management
Financial / Audit Management
Actuarial management
rate
Set
premium
Reserve
Fund Management
Medical Loss
Manage medical loss ratio (MLR)
Audit and Fraud
Identify fraudulent
cases
Manage fraudulent
Source: Joint Learning Network Report 2012 ( PATH 2012 )