| 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 |
Preauthorization |
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 |