Processes 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 account report available Processes Financial / Audit Management Source: Joint Learning Network Report 2012 Other ProcessMajor Process Groups Business Processes Proposed module legacy Modular comments
CoreBeneficiary Management Enroll beneficiary Policy X Apr 21 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 Payments to beneficiaries (e.g. sickness benefits, funeral benefits) Accounting Accounts receivable Accounting Plan for TZ Accounts payable Accounting Plan for TZ
SupportiveCare 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 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 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
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