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Major Process GroupsBusiness ProcessesCoreProcessesBeneficiary Management Enroll beneficiaryAssign beneficiary to a Primary Care Provider (PCP) or primary care unit Eligibility inquiry by provider Eligibility inquiry by beneficiary Pre-authorization Provider ManagementRegister/ empanel provider Provider agreement Premium ManagementPremium collectionClaims ManagementClaims processingClaims status inquiryClaims dispute and appealsClaims adjustment and voidsAccountingPayment to providersAccounts receivable Accounts payable SupportiveProcessesCare ManagementManage costs of catastrophic cases Identify chronic disease management cases Enroll into chronic disease management programs Monitor chronic disease management cases Utilization Management Utilization managementPharmacy benefits management PBMProvider Quality Management Provider quality management Financial / Audit ManagementActuarial management Provider rate Set premium Reserve fund management Medical LossManage medical loss ratio (MLR) Audit and FraudIdentify fraudulent cases Manage fraudulent cases Source: Joint Learning Network Report 2012»
Core
Processes
Supportive
Financial / Audit Management
Source: Joint Learning Network Report 2012
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