| Major Process Groups | Business Processes |
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Core Processes | Beneficiary Management | Enroll beneficiary |
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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 Processes | Care Management | Manage costs of catastrophic cases |
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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 |