Major Process Groups
Business Processes
Core 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
Pre-authorization
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
Supportive 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
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
Source: Joint Learning Network Report 2012 ( PATH 2012 )