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 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

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

Manage fraudulent cases 

Claims (feedback)

~

Oct 19

Ask feedback from the beneficiary

Source: Joint Learning Network Report 2012

 Other process groups, not defined in JLN



Major Process Groups

Business Processes

Proposed module

legacy

Modular

comments



Major Process Groups

Business Processes

Proposed module

legacy

Modular

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

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

 

 

 

 

 

 

 

 

 

 

 

 

possible property table

Module Name

 

 

 

FE repo

 

BE repo

 

Dependencies

  • Module 1

  • Module 2