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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

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

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

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