Major Process Groups | Business Processes | |
---|---|---|
Processes | Beneficiary Management | Enroll beneficiary |
Assign beneficiary to a Primary Care Provider (PCP) or primary care unit | ||
Eligibility inquiry by provider | ||
Eligibility inquiry by beneficiary | ||
Preauthorization | ||
Provider Management | Register/ empanel provider | |
Provider agreement | ||
Premium Management | Premium collection | |
Claims Management | Claims processing | |
Claims status inquiry | ||
Claims dispute and appeals | ||
Claims adjustment and voids | ||
Accounting | Payment to providers | |
Accounts receivable | ||
Accounts payable | ||
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 | |
Pharmacy benefits management (PBM) | ||
Provider Quality Management | Provider quality management | |
Financial / Audit Management | Actuarial management | |
Provider rate | ||
Set premium | ||
Reserve fund management | ||
Medical Loss | Manage medical loss ratio (MLR) | |
Audit and Fraud | Identify fraudulent cases | |
Manage fraudulent cases |
Manage space
Manage content
Integrations