JLN Process - OpenIMIS Mapping

	Major Process Groups	Business Processes	Proposed module	legacy	Modular	comments

	Major Process Groups	Business Processes	Proposed module	legacy	Modular	comments
Core Processes	Beneficiary Management	Enroll beneficiary	Policy	X	Apr 21	informal sector : enroll Directly insuree (head of familly) and the dependent formal sector: contract per company for every period that include all the company worker
		Assign beneficiary to a Primary Care Provider (PCP) or primary care unit	Insuree	X	Apr 21
		Eligibility inquiry by provider	Provider management (Price list)			would be only based on the price list, pre-authorisaiton required to have the eligibility for provider and Beneficiary
		Eligibility inquiry by beneficiary	Policy	X	Apr 21
		Pre-authorization	Accounting			does it include prevaluation ? difficulty: M
	Provider Management	Register/ empanel provider	Location and Health Facility (sub level)	X	Apr 20
	Provider Management	Provider agreement	Location and Health Facility (price list link)	X	Apr 20
	Premium Management	Premium collection	Contribution (Policy - contribution)	X	Apr 21
	Claims Management	Claims processing	Claim (hf claim)	X	Oct 19
		Claims status inquiry	Claim (claim overview report)	X	Oct 19
		Claims dispute and appeals	Claim	Restore		difficulty: M if more than just restore
		Claims adjustment and voids	Claim (review)	X	Oct 19
	Accounting	Payment to providers	Accounting (batch run)	X		account report available
		Payments to beneficiaries (e.g. sickness benefits, funeral benefits)	Accounting
		Accounts receivable	Accounting			Plan for TZ
		Accounts payable	Accounting			Plan for TZ
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	Reports / cubes	~	Apr 21 (DHIS2)	Report available on service and Item
	Utilization Management	Pharmacy benefits management PBM
	Provider Quality Management	Provider Quality Management
	Financial / Audit Management	Actuarial management	Benefit plan (insurance product)	~		done via Relative pricing, pricelist and scheme drugs price
		Provider rate	Provider management (Price list)	X
		Set premium	Contribution plan	X	Apr 21(FS)
		Reserve Fund Management	Benefit plan (distribution)
	Medical Loss	Manage medical loss ratio (MLR)	Reports / cubes	~	Apr 21 (DHIS2)	multiple report can be use to compute the MLR
	Audit and Fraud	Identify fraudulent cases	Claims + AI	~	Oct 19 + Apr 21 (AI)	based on product list and eligibility
	Audit and Fraud	Manage fraudulent cases	Claims (feedback)	~	Oct 19	Ask feedback from the beneficiary

Source:

Other process groups, not defined in JLN

	Major Process Groups	Business Processes	Proposed module	legacy	Modular	comments

	Major Process Groups	Business Processes	Proposed module	comments
Other	Accident management	Accident case management	case auditing	should take over "feedback" D:M
		Accident assessment	case auditing
		Payment of one- time cash benefit (e.g funeral benefits)	Cash financing	D:L
		entitlement on recurring cash benefits (e.g. survivor benefits)	rights payment	D:XL
	Social benefit/Family benefit	Retirement management	rights management	D:XL
		entitlement for recurring benefit (health insurance)	rights payment	D:XL
		entitlement of one-time event based support	Cash financing	D:L
		children financial support	rights management	D:XL

possible module structure as reporting table based on module wiki pages

Process Group	openIMIS Module	FE repo	FE Version	BE repo	BE Version	Doc

Process Group	openIMIS Module	FE repo	FE Version	BE repo	BE Version	Doc
Beneficiary Management	Policy

	Insuree


Provider Management
Provider Management

possible property table in a module page

Module Name

FE repo
BE repo
Dependencies	Module 1 Module 2

openIMIS

JLN Process - OpenIMIS Mapping

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