| Major Process Groups | Business Processes | Proposed module | legacy | Modular | comments |
|---|
Core
Processes
| Beneficiary Management
| Enroll beneficiary |
|---|
Benefit plan () | X | Apr 21 |
| | Assign beneficiary to a Primary Care Provider (PCP) or primary care unit |
Client registry| Insuree | X | Apr 21 |
| | Eligibility inquiry by provider | Provider management (Price list) |
|
| would be only based on the price list, preauthorisaiton required to have the eligibility for provider and Beneficiary | | Eligibility inquiry by beneficiary |
Benefit plan () | X | Apr 21 |
| | Preauthorization | Accounting |
|
| does it include prevaluation ? | Provider Management
| Register/ empanel provider | Location and Health Facility (sub level) | X | Apr 20 |
| | Provider agreement | Location and Health Facility (price list link) | X | Apr 20 |
| | Premium Management | Premium collection |
Benefit plan | Contribution (Policy - contribution) | X | Apr 21 |
| Claims Management
| Claims processing | Claim (hf claim) | X |
XXX| Oct 19 |
| Accounting
| Payment to providers | Accounting (batch run) | X |
| account report available | | Accounts receivable | Accounting |
|
| Plan for TZ | | Accounts payable | Accounting |
|
| Plan for TZ |
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 | Reports / cubes | ~ | Apr 21 (DHIS2) | Report available on service and Item | | Pharmacy benefits management (PBM) |
|
|
|
| | Provider Quality Management | Provider quality management |
|
|
|
| Financial / Audit Management
| Actuarial management | Benefit plan (insurance product) | ~ |
| done via Relative pricing, pricelist and scheme drugs price | | Provider rate | Provider management (Price list) | X |
|
| | Set premium |
Benefit (insurance productX |
| | Reserve fund management | Benefit plan (distribution) |
|
|
| | Medical Loss | Manage medical loss ratio (MLR) | Reports / cubes | ~ | Apr 21 (DHIS2) | multiple report can be use to compute the MLR | Audit and Fraud
| Identify fraudulent cases | Claims |
(checks| + AI | ~ | Oct 19 + Apr 21 (AI) |
~ | | based on product list and eligibility | | Manage fraudulent cases | Claims (feedback) | ~ | Oct 19 | Ask feedback from the beneficiary |
Source: Joint Learning Network Report 2012 » |