Processes Processes Financial / Audit ManagementMajor Process Groups Business Processes Proposed module legacy Modular
CoreBeneficiary Management Enroll beneficiary Policy X Assign beneficiary to a Primary Care Provider (PCP) or primary care unit Client registry X Eligibility inquiry by provider Location and Health Facility Eligibility inquiry by beneficiary Policy X Preauthorization Valuation Provider Management Register/ empanel provider Location and Health Facility X Provider agreement Price list X Premium Management Premium collection 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 Valuation Accounts receivable Valuation Accounts payable Valuation (batch run) X
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 Pharmacy benefits management (PBM) Provider Quality Management Provider quality management Actuarial management Reports/Scheme Provider rate Price list Set premium Scheme X Reserve fund management Scheme Medical Loss Manage medical loss ratio (MLR) Audit and Fraud Identify fraudulent cases Claims (checks) Manage fraudulent cases Claims (feedback)
Manage space
Manage content
Integrations