Major Process Groups Business Processes Proposed module legacy Modular comments Processes Beneficiary Management Enroll beneficiary Policy X Apr 21 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 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 Claim (hf claim) X Oct 19 Claim (claim overview report) X Oct 19 Claim Restore difficulty: M if more than just restore Claim (review) X Oct 19 Accounting Payment to providers Accounting (batch run) X account report available Payments to beneficiaries (e.g. sickness benefits, funeral benefits) Accounting Accounts receivable Accounting Plan for TZ Accounts payable Accounting Plan for TZ 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 Reports / cubes ~ Apr 21 (DHIS2) Report available on service and Item Pharmacy benefits management (PBM) Provider Quality Management Provider quality management Financial / Audit 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 Source: Joint Learning Network Report 2012 Other Process 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
Core
Supportive
Manage space
Manage content
Integrations