Process Group

Beneficiary Management

Objective

• Provider has secured timely assurance from insurer that proposed service will be admissible for payment through claim settlement

• Ensure beneficiary beneficiary receives efficient and effective utilization of services

• Protect payer from unnecessary costs

Input

• Beneficiary identifier

• Provider identifier

• Benefits class

• Benefit plan

• Clinical information

• Supporting documents

• Treatment plan

• Fee schedule

• Diagnosis

Output

• Approval with cost, service or unit boundaries or rejection

• Approval/ provisional approval (services can proceed but services may not be covered) disapproval

• Approval percentage (percentage of requests that are approved)

• Analysis of which services are being rejected (what provider, what services)

Measurable Outcomes

• Timely response to pre- authorization

• Approval of (time/cost and or unit based) list of services

• Financial metrics

• Fraud resolution

• Supports quality of care

• Patient satisfaction

• Accounts of insurer notified

Task Flow Diagram

Sources

• Joint Learning Network, 2012

• File: NHIIS_Phase_1_Public_Report_JLN_IT_Workshop_FINAL_Jan182012_A4.pdf