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Major Process Groups | Business Processes | Proposed module | legacy | Modular | comments | |
---|---|---|---|---|---|---|
Beneficiary Management Management | Enroll beneficiary 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 | |||
Provider management (Price list) | would be only based on the price list, pre-authorisaiton required to have the eligibility for provider and Beneficiary | |||||
Policy | X | Apr 21 | ||||
Accounting | does it include prevaluation ? difficulty: M | |||||
Location and Health Facility (sub level) | X | Apr 20 | ||||
Location and Health Facility (price list link) | X | Apr 20 | ||||
Premium collection Premium collection | Contribution (Policy - contribution) | X | Apr 21 | |||
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 | ||||
Payment to providers providers | Accounting (batch run) | X | account report available | |||
Payments to beneficiaries (e.g. sickness benefits, funeral benefits) | Accounting | |||||
Accounts receivable receivable | Accounting | Plan for TZ | ||||
Accounting | Plan for TZ | |||||
Utilization Management Management | Utilization management management | Reports / cubes | ~ | Apr 21 (DHIS2) | Report available on service and Item | |
Provider Quality Management Management | Provider quality management Quality Management | |||||
Benefit plan (insurance product) | ~ | done via Relative pricing, pricelist and scheme drugs price | ||||
Provider management (Price list) | X | |||||
Contribution plan | X | Apr 21(FS) | ||||
Reserve fund management Fund Management | Benefit plan (distribution) | |||||
Reports / cubes | ~ | Apr 21 (DHIS2) | multiple report can be use to compute the MLR | |||
Identify fraudulent cases cases | Claims + AI | ~ | Oct 19 + Apr 21 (AI) | based on product list and eligibility | ||
Manage fraudulent cases cases | Claims (feedback) | ~ | Oct 19 | Ask feedback from the beneficiary |
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possible module structure as reporting table based on module wiki pages
Process Group | openIMIS Module | FE repo | FE Version | BE repo | BE Version | Doc |
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Beneficiary Management | Policy | |||||
Insuree | ||||||
Provider Management | ||||||
possible property table in a module page
Module Name | |
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FE repo | |
BE repo | |
Dependencies |
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