As on 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:
Provider Management (2)
Premium Collection (3)
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.