JLN Process Framework

As one 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 Fundamental System Factory contains the following process groups:
  • 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.