JLN Process Framework

As one of the first excercises, the JLN created a process framework according to the Collaborative Requirements Development Methodology (CRDM) applied by PATH. A process framwork describes a set of processes that define the boundaries of a domain and the relationships between them and other systems and domains.

The following process areas were identified for the health insurance domain:

• The Factory contains the following process groups:

  • Beneficiary Management (1)

  • Provider Management (2)

  • Premium Collection (3)

  • Claims Management (4)

  • Accounting (5)

• The process area Performance Management contains the following process groups:

  • Analyzing Performance:

    • Care Management (6)

    • Utilization Management (7)

    • Provider Quality Management (8)

  • Fiduciary Fund Management

    • Actuarial Management (9)

    • Medical Loss (10)

    • Audit/Fraud (11)

• The process area Scheme Policy contains the following process groups:

  • Benefit Package Formulary

  • Provider Rates

  • Eligibility Requirements

  • Provider Policy Setting

• The National Policy formulation provides the legal framework regarding the target population set by the country.