Processes Processes Financial / Audit ManagementMajor Process Groups Business Processes Proposed module legacy Modular comments
CoreBeneficiary 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
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 Pharmacy benefits management (PBM) Provider Quality Management Provider quality management Actuarial management Benefit plan (insurance product) ~ Provider rate Provider management (Price list) X Set premium Benefit plan (insurance product) X Reserve fund management Medical Loss Manage medical loss ratio (MLR) Audit and Fraud Identify fraudulent cases Claims (checks) ~ Manage fraudulent cases Claims (feedback) ~
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Manage content
Integrations