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) would be 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 (batch run) X account report available Accounts receivable Accounting Accounts payable Accounting
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 ~ 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 Benefit plan (insurance product) X Reserve fund management Benefit plan (distribution) Medical Loss Manage medical loss ratio (MLR) Reports / cubes ~ multiple report can be use to compute the MLR Audit and Fraud Identify fraudulent cases Claims (checks) ~ based on product list and eligibility Manage fraudulent cases Claims (feedback) ~ Ask feedback from the beneficiary
Manage space
Manage content
Integrations