| Major Process Groups | Business Processes | Proposed module | legacy | Modular | comments |
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Core
Processes
| Beneficiary Management
| Enroll beneficiary | Policy | X | Apr 21 | informal sector : enroll Directly insuree (head of familly) and the dependent formal sector: contract per company for every period that include all the company worker
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Assign beneficiary to a Primary Care Provider (PCP) or primary care unit | Insuree | X | Apr 21 |
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Eligibility inquiry by provider | Provider management (Price list) |
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| would be only based on the price list, pre-authorisaiton required to have the eligibility for provider and Beneficiary |
Eligibility inquiry by beneficiary | Policy | X | Apr 21 |
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Pre-authorization | Accounting |
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| does it include prevaluation ? difficulty: M |
Provider Management
| Register/ empanel provider | Location and Health Facility (sub level) | X | Apr 20 |
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Provider agreement | Location and Health Facility (price list link) | X | Apr 20 |
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Premium Management | Premium collection | Contribution (Policy - contribution) | X | Apr 21 |
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Claims Management
| Claims processing | Claim (hf claim) | X | Oct 19 |
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Claims status inquiry | Claim (claim overview report) | X | Oct 19 |
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Claims dispute and appeals | Claim | Restore |
| difficulty: M if more than just restore |
Claims adjustment and voids | Claim (review) | X | Oct 19 |
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Accounting
| Payment to providers | Accounting (batch run) | X |
| account report available
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Payments to beneficiaries (e.g. sickness benefits, funeral benefits) | Accounting |
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Accounts receivable | Accounting |
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| Plan for TZ |
Accounts payable | Accounting |
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| Plan for TZ |
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 | Reports / cubes | ~ | Apr 21 (DHIS2) | Report available on service and Item |
Pharmacy benefits management (PBM) |
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Provider Quality Management | Provider quality management |
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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 |
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Set premium | Contribution plan | X | Apr 21(FS) |
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Reserve fund management | Benefit plan (distribution) |
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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 + AI | ~ | Oct 19 + Apr 21 (AI) | based on product list and eligibility |
Manage fraudulent cases | Claims (feedback) | ~ | Oct 19 | Ask feedback from the beneficiary |