Page Comparison

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

Assign beneficiary to a Primary Care Provider (PCP) or primary care unit 

Insuree

X

Apr 21

Eligibility inquiry by provider 

Provider management (Price list)

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

Pre-authorization  

Accounting

does it include prevaluation ? difficulty: M

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

Contribution (Policy - contribution)

X

Apr 21

Claims Management

Claims processing

Claim (hf claim)

X

Oct 19

Claims status inquiry

Claim (claim overview report)

X

Oct 19

Claims dispute and appeals

Claim

Restore

difficulty: M if more than just restore

Claims adjustment and voids

Claim (review)

X

Oct 19

Accounting

Payment to

providers

Accounting (batch run)

X

account report available

Payments to beneficiaries (e.g. sickness benefits, funeral benefits)

Accounting

Accounts

receivable 

Accounting

Plan for TZ

Accounts payable 

Accounting

Plan for TZ

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

Contribution plan

X

Apr 21(FS)

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 + AI

~

Oct 19 + Apr 21 (AI)

based on product list and eligibility

Manage fraudulent

cases

Claims (feedback)

~

Oct 19

Ask feedback from the beneficiary