| Major Process Groups | Business Processes | Proposed module | legacy | Modular | comments |
---|
Core
Processes
| Beneficiary Management
| Enroll beneficiary | Benefit plan (Policy) | X |
|
|
---|
Assign beneficiary to a Primary Care Provider (PCP) or primary care unit | Client registry | X |
|
|
Eligibility inquiry by provider | Provider management (Price list) |
|
| only based on the price list, preauthorisaiton required to have the eligibility for provider and Beneficiary |
Eligibility inquiry by beneficiary | Benefit plan (Policy) | X |
|
|
Preauthorization | Accounting |
|
| does it include prevaluation ? |
Provider Management
| Register/ empanel provider | Location and Health Facility (sub level) | X |
|
|
Provider agreement | Location and Health Facility (price list link) | X |
|
|
Premium Management | Premium collection | Benefit plan (Policy - contribution) | X |
|
|
Claims Management
| Claims processing | Claim (hf claim) | X | X |
|
Claims status inquiry | Claim (claim overview report) | X | X |
|
Claims dispute and appeals | Claim |
|
|
|
Claims adjustment and voids | Claim (review) | X | X |
|
Accounting
| Payment to providers | Accounting |
|
|
|
Accounts receivable | Accounting |
|
|
|
Accounts payable | Accounting (batch run) | X |
|
|
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 |
|
|
|
|
Pharmacy benefits management (PBM) |
|
|
|
|
Provider Quality Management | Provider quality management |
|
|
|
|
Financial / Audit Management
| Actuarial management | Benefit plan (insurance product) | ~ |
|
|
Provider rate | Provider management (Price list) | X |
|
|
Set premium | Benefit plan (insurance product) | X |
|
|
Reserve fund management | Benefit plan (insurance product) |
|
|
|
|
Medical Loss | Manage medical loss ratio (MLR) |
|
|
|
|
Audit and Fraud
| Identify fraudulent cases | Claims (checks) | ~ |
|
|
Manage fraudulent cases | Claims (feedback) | ~ |
|
|