Health Policy Administration System

Transcription

1 Health Plicy Administratin System Universal Smp General Insurance C Ltd, (USGI) is first f its kind, in Public - Private Partnership in Indian General Insurance Industry. The jint venture has been capitalized with sharehlders funds f ver 470 cr. including share premium. USGI is ging t have its wn Administratr (HPAS) t Service health plicies issued by USGI. It cnsists f fllwing mdules Inward Outward Mdule The steps primarily invlved in inward and utward prcess are as fllws: Receive the Inward Dcket Segregate the Dcument Type Handver the Dcket t Cncerned Department Receive the Dcket fr Dispatch Dispatch the Dcket Cnfirmatin f Deliveries Receive Undelivered Curiers Inward Prcess Branch Prcessing Center Receive Dcument Update Inward Entry Tag dcument fr ut ward entry - CPC dispatch Update distpatch recrd against each inward ID Send Dcument t CPC CPC acknwledge dckets against inward id Update inward entry as per depart ment / dcument type Handver dcuments t respective dept /user Attach wrk flw User Acknwledege dcumnet sin the system

2 OUTWARD MODULE PROCESS TAG Dcument fr dispatch thru ut ward mdule Enter card number /claimnumber /cheque number Select disptach mde Select disptach type - snigle r bulk Submit the reuest and system generated utward ID Against utward id Update POD number. Update dispatch details Uplad cnfirmatin reprt against pd Enrlment Mdule It has the fllwing sub-mdules Retail Member Data Extract Retail member pht uplad: Retail member health card printing: Retail member health card dispatch Retail member health card reissuance. Member access t Plicy data Grup Plicy data Grup member pht uplad: Grup member health card : Member access t Grup Plicy member data Errr lg display and its maintenance Fllwing Departments will be using the system Enrlment Department Cashless department Claims payment Department Prvider Department Grievance Department Call Centre USGI OFFICES

3 Access t user fr pht uplad and health card Printing Fllwing External user will be using the system 1. Individual Members 2. Brker 3. Agents 4. Hspital / Service Prvider 5. Bank Branches 6. IRDA Reprts a. Frmat A B C i. Mnthly ii. Six Mnthly iii. Yearly b. Prtability Data c. Health Input as per frmat attached 7. External, 1. Optin t sub grup t dwnlad reprt against multiple card number r emp cde fr claims status Netwrk Service Prvider Mdule T develp Netwrk Service Prvider mdule fr Health Plicy Administratin System. The steps primarily invlved in netwrk prvider management prcess are as fllws: Map the Ptential Service Prviders in the Regin Receive the Empanelment Request Hspital Request Prcessing Physical Verificatin f the Hspital Grading and Tariff Designing f the Hspital Negtiatin f Tariff Signing f SLA Prfile Creatin in the Applicatin Mnitring and Due Diligence

4 Register Prvider Infrmatin and generate Unique registratin number Update Prvider Faclilty Sheet Update NEFT details Uplad phtgraphs Request apprved fr cmmiteeapprval Recmened t Cmmitte fr apprval /rejectin Grade the hspital and recmmend fr negtatin Update Discunt Sheet Generate Netwrk Prvider Cde & User ID Passwrd Generate Hspital Empanlement /rejectin letter Certificate Cashless Mdule The steps primarily invlved in pre-authrizatin prcess are as fllws: Receipt f Cashless Request Intimatin Intimatin f Cashless Claim Enter Cashless Request Details Cashless Claim Adjudicatin Cmmunicatin f Decisin status t the Netwrk prvider Cashless Prcess: Receive Fax dcument & Segregrate Attach Card N /Claim N Intimate Claim Update Cashless Request Frm Cashless Prcess by dctr and recmmened t Cmmittee Cmmittee takes final decisin n case Issue Authrizatin Letter /Rejectin letter /raise Query Infrm Hspital thru Fax & Cashless case Clse Hspital sends Original Claim dcument fr Payment

5 Reimbursement Mdule The steps primarily invlved in claims prcess are as fllws: Receipt f Claim Intimatin Intimatin f Claim Receive Claim Dcuments Scanning f Claims Dcuments Enter Itemized Hspitalizatin Bills Claim Adjudicatin Cmmunicatin f the Claims Decisin t the Insured Internal Audit Claim File Strage Secnd level requirement - Inward Prcess -Central Prcessing Center Receive Dcument at the receptin Seggregarte the Dcument dperatment wise Update intial Inward Entry Update inward entry as per depart ment / dcument type Attach wrk flw Handver dcument t respective user User Acknwledege dcumnet sin the system

6 Inward Prcess Branch Prcessing Center Receive Dcument Update Inward Entry Tag dcument fr ut ward entry - CPC dispatch Update distpatch recrd against each inward ID Send Dcument t CPC CPC acknwledge dckets against inward id Update inward entry as per depart ment / dcument type Handver dcuments t respective dept /user Attach wrk flw User Acknwledege dcumnet sin the system Scanning Prcess Receive& acknwledge Dcument tagfr Scanning Seggregarte Dcument as per type f Dcument Prepare file fr Scanning Scan file save as per dcument cde Uplad image file in tiff frmat thru utility

7 Reimbursement Claims Prcess Receipt f Claim Dcument frm Insured and Hspital Capture Infrmatin in Inward Mdule and Segregate and tag dcument tpe Intimate the Claim and update claim frm infrmatin Scanning f Dcuments Enter Hspital bills details Claim Prcess by Dctrs and recmmend fr apprval Claim apprved /reject /raised query by cmmittee Payment advice nte send t accunts Amunt paid t Insured /hispital thru NEFT NEFT details updated in the system and mark claim as paid claim Claim file sent t Stre fr Strage. Investigatin prcess System triggrerd claims r Tag claim fr investigatin and Verificatin Enter areas t be investigated Investigate the case Scan dcuments Verify & Update Infrmatin Refer case t Cmmittee alng with recmmendatin Update final decisin in the system

8 Claims Payment Mdule NEFT Apprval Preparatin f Debit nte f apprved claims Claims Payment thru NEFT /RTGS/CHEQUE Recnciliatin f Claim Payment accunt with cre system NEFT / RTGS payment thrugh Bank up datin facility fr Cheque Printing facility Data mvement frm HPAS t Sun System n systematic basis TDS & Service tax accunting & related reprts Functinality t be prvided fr lwer deductin f TDS Bank Recnciliatin facility n standalne basis Payment thrugh varius banks Payment thrugh varius lcatins Audit Trail fr F&A Maker Checker facility Claims Payment Prcess Raise the Debit Nte f apprved claims Extract Payment advice sheet as per bank frmat r cre system Uplad file in the bank thru secured lgin Apprver apprves the claim payment and release the payment. Dwnlad reverse file frm bank fr Cheque n/utr n Uplad Cheque/UTR file against Claim n. Send Settlement letter/aut mailer/ SMS t beneficiary. Bank Recnciliatin with the cre system Update status f NEFT rejected (befre r after uplad )/stale cheques in the system fr reissuance. Reissue Cheques r uplad fr NEFT. 1.

9 Claims apprved and paid IN HPAS Paid data upladed in gensis Paid data alng with genysis claim updated in sun sytem genysis generate claim number in the system Call Centre and Custmer Care Mdule Integratin with HPAS fr real time update Enrllment and card Status Claims Status Claims payment Status Intimatin Grievance Grievances Mdule Basic functin f the department: Receive the Custmer Grievances Ensure Reslutin within defined timeline Analyze the Grievances and suggest imprvement areas t respective departments Share Grievance Reprt with Stakehlders Third party applicatin integratin with Health Plicy Administratin system Fax Server Integratin with HPAS fr fax in and fax ut Plugin with dedicated PRI

10 Call center applicatin Integratin with CRM Plugin with SMS & Aut mailer SMS & Aut mailer Integratin with HPAS fr Pull and Push SMS services Integratin with Mail Server fr Mail alerts Dcument Management System Integratin with Inward mdule fr Scanning and uplading f claims dcument. Cmmunicatin Letter Integratin with India pst vendr fr all Sending all cmmunicatin letters.