Major Process Groups | Business Processes | Proposed module | legacy | Modular | comments | |
|---|---|---|---|---|---|---|
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 |
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 | Claim (hf claim) | X | Oct 19 | |||
Claim (claim overview report) | X | Oct 19 | ||||
Claim | Restore | difficulty: M if more than just restore | ||||
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 | ||||
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 | 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 |
Source: Joint Learning Network Report 2012
Other process groups, not defined in JLN
Major Process Groups | Business Processes | Proposed module | legacy | Modular | comments | |
|---|---|---|---|---|---|---|
Other | Accident management | Accident case management | case auditing | should take over "feedback" D:M | ||
Accident assessment | case auditing | |||||
Payment of one- time cash benefit (e.g funeral benefits) | Cash financing | D:L | ||||
entitlement on recurring cash benefits (e.g. survivor benefits) | rights payment | D:XL | ||||
Social benefit/Family benefit | Retirement management | rights management | D:XL | |||
entitlement for recurring benefit (health insurance) | rights payment | D:XL | ||||
entitlement of one-time event based support | Cash financing | D:L | ||||
children financial support | rights management | D:XL |
...
possible module structure
Process Group | openIMIS Module | FE repo | FE Version | BE repo | BE Version | Doc |
|---|---|---|---|---|---|---|
Beneficiary Management | Policy | |||||
Insuree | ||||||
Provider Management | ||||||
possible property table
Module Name | |
|---|---|
FE repo | |
BE repo | |
Dependencies |
|