A beneficiary self-management portal which allows viewing and – to some extend - personal information changes on the platform: • Beneficiary should see the claims paid by which provider • Feedback on quality of services (not on medical interventions) could be included. • Self-renewing functions for periodic payments • Reminders (e.g. renewal activities, payment delays)
This was the idea mentioned during interviews with various stakeholders in February 2021.
Subsequently various contributions were received in exchanges during the IC call and especially inputs from documents shared by @Luciana Rajula, @Nirmal Dhakal & @Saurav Bhattarai for similar solutions from the Kenyan, Nepal and Cambodia.
Based on various contributions, the platform should support:
Registration of members (with or without dependents and depending on business rules including supporting documents), employers, sponsors and other categories that would like to register a person, family or group. A verification process by the insurer for entered data and authentication of individuals registered is needed but might vary depending insurers business rules.
Updating details (including in and out migration/movement within a family/group) of members, employers, sponsors and other categories that would like to register a person, family or group. This should include as per insurers business rule as well an approval process (where applicable).
Making contribution payments for members, employers, sponsors and other categories that would like to register a person, family or group. A verification process as per insurers business rules for checking due amount, remaining balance, authenticating, approving payments, accepting and activating policy coverage is needed but might vary depending insurers business rules.
Clients to submit their bills in case of reimbursement including attachments (prescriptions, reports, etc.)
Checking contribution payments for members, employers, sponsors and other categories that would like to register a person, family or group.
Making inquiries on personal or coverage related details. Who can initiate the request and verification mechanism of requests as per insurers business rules needs to be accommodated.
Generation of, and Print E-card where applicable as per insurers business rules. Support viewing family details with e-card.
Product/Policy configuration for an individual/family or group based on insurers offered benefit packages and rules.
Querying of policy expiration date
Querying past policies history
Querying of balance from the Sum insured and co-payment related information
Querying of physician Rate sheet and co-payment related information
Querying of Procedure Rate sheet by network service provider and co-payment related information
Querying of test Rate Sheet and co-payment related information offered by network service provider
Searching for available service provider in insurer network including based on current location as well filtering through filters like types of services, location, rating, etc.
Management of first point of care (allocated facility) if allowed as per business rules
Placement of online appointments to physician or network provider.
Placing online order for medicines.
Summary of last treatment (potentially more - say 5 or 10 past claims) and payment related details
Viewing diagnostic details provided in past claims/treatments.
e-consultation with Physician for follow ups and other consultations.
M-Web version but as well all features developed should be thought for online scenarios (through developed application) and offline scenarios (to extent possible enabling short communication through USSD and out going through SMS)
Attached reports of test conducted
Support generation and saving of reports
All modules to come with necessary integration tools (what types?)
Capturing and monitoring of the beneficiaries basic health checkup information
SMS enabled communication (if chosen by client) with clients for verification (eg. at the time individuals card is used) or to provide summary information after completion of treatment
USSD enabled querying for offline settings to allow retrieval of client information (eg. payment details or due amount), or to get appointment with Enrolment Agent to complete registration/renewal (self enrolment in offline setting providing basic info and rest completed with agent).
Capturing of client consent preferences on what information of theirs can be shared and for what purpose, and what can they be contacted for or not.
Verification of uniqueness of individual/family/group in system taking into account multi entry points to register individual now and stop duplicate registrations.
Out communication to clients towards preventive public health measures (eg. COVID related alerts), reminders for renewals and payments, health insurance scheme performance, other events - enabled for online as well offline settings (SMS based)
Capturing of feedback from clients on specific treatments/claims or on health facilities or on the broader health insurance scheme (scale/rating based as well qualitative)
Choosing of language of choice
Management of payments (past, current and upcoming) including penalties and discounts as per business rules
Login through alternative verification methods as per context and set business rules (through accounts issued by insurer or authenticated through external systems like national ID, or employer issued ID number, or scan of bar code from employee ID, or SMS verification code, etc.)
Client complaint reporting and tracking of complaint status till resolution and subsequent rating of service
Additional information from insurer eg. contact numbers or address of local offices.
History or log of all actions performed by user
Possibility for logging in with primary account as well dependent accounts
Did you encounter a problem or do you have a suggestion?