the software systems expert

For Medical FUNDS & MEDICAL AID SOCIETIES

 

OmniSol Scheme Genius

Fund, Benefits and Claims Management System

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Overall System Features and Quality Assurance

 

The following features have been developed and tested by the OmniSol team:

 

FUND SETUP

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The system generates bills for corporate members.

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The system maintains scheme settings in locked state and only changed by certain users. When these changes occur, claims will be handled according to how the system was configured at the time of treatment – not at the time received/captured.

Scheme/fund CANNOT change during its policy year, but IF corrections are made, system will recalculate for all newly-captured claims in affected period.

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The system maintains a ‘dependant type’ categorization which determines the waiting period.

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The beneficiary’s active date (a.k.a commencement date of cover, benefits date, join-date, and effective date) can be set in future or past, no matter what date it is captured.

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System allows unlimited levels of limits (parent-child limits) to be set and used in claims adjudication.

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Audit trail will show both the date captured and effective date for each member. This feature is provided in the form of a membership history.

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Member record can be updated even when member is not active or paid up.

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Pre-auth function to allocate to Specific:

1.       Tariff/treatment

2.       Discipline

3.       Provider

4.       Starting date

5.       Duration

6.       Amount limit

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The pre-auth awarded is linked to the member’s benefit balance so as to appropriately adjudicate correct available balances for incoming claims and not to overpay

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User can view, for each member:

1. Claims paid,

2. Claims captured not paid,

3. Claims pre-authorized

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Non-medical benefits, e.g. cashback when admitted, are included as benefits and awarded thru the system.

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Option to set a fixed shortfall per plan as an amount or as a percentage

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Option to set numbering of claims which is unique for each plan

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Option to configure the whole system as:

·         Funeral Assurance

·         HealthCare Fund Management

·         Vehicle Insurance

·         Regular Medical Aid Society

·         Legal Aid

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Feature to create a new plan which follows the structure of an existing plan, enabling the user to add a plan with all benefits fully defined and unique in a few minutes

 

MEMBERSHIP DEPT

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Membership card generation, printing.

Integrated Billing for cards printed

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Card printer queue management

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System generates member numbers and suffixes

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Enable moving a dependant from one family to another, or to be a stand-alone.

All the claims that the member had will follow that particular member, regardless of changes in family or plan

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Old membership numbers retained

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Users can search for members by:

·         Member number

·         Old member number

·         National ID

·         Name, surname

·         Employment number

·         File/account number

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Additional dependants can be added using a file upload.

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New members can be added using a file upload

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Date-driven membership status design:

·         The user does not have to calculate the actual member status (active, waiting period, et.c)

·         The user only captures the events which occur to the membership according to instructions from the client and the system uses this to determine status at time of treatment.

Membership_Event

Resultant_Status

Joined – Regular

Active

Suspended

Suspended

Terminated from Plan

Terminated

Black-Listed

Black-Listed

Joined – Late

Active

Reinstated

Active

Terminated from Fund

Terminated

 

·         The system uses the table above for mapping and thus determining what status the member is in at a specific date. This is also dependant on the status of the principal member.

·         A member is changed to another plan by capturing a ‘Joined’ event to the new plan.

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The system automatically calculates the waiting period depending on whether late-joiner or regular-joiner.

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Billing:

·         The system can generate bills for all member for a specific period

·         The bills can be generated going back into the past

·         The system checks to ensure a member does not get 2 bills for the same month

·         Produces corporate invoice

·         The bill picks up and includes miscellaneous charges such as printed cards

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Archiving and viewing of scanned documents against each member’s electronic file, with an emailing and printing option.

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Scanned documents will be tagged to indicate their content and type.

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Archiving and opening audio and video attachments to each member’s file

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Uploading member signature and photo

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Viewing member statement. This can be printed and/or emailed. The statement shows all the treatments and corresponding benefit allocations for all the dependants on a selected family

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Printing member confirmation letter

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Customizable data pages: this is a feature which enables an unlimited set of information about each member to be captured, with provision for different data types (text, numeric, drop-down). These can be customised without recourse to additional programming work.

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Storage of banking details

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Storage of agent/commission contract details for each member – where applicable

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Receipting of individual member payment

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Generating billing statement per member

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Generating claiming statement per member

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An audit trail which shows every successive snapshot of a member record as changes are done over time. This cannot be edited or deleted.

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Viewing a benefits summary which shows current usage levels for ALL the benefits which the member is eligible for at a given date.

 

CLAIMS

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·         An EDI (Electronic Data Interchange) feature to load encrypted claims files sent by providers

·         Claims received thru this platform will be instantly processed (and awarded per inbuilt rules) unless otherwise indicated for human intervention.

·         EDI file decryption is done with a password chosen by the provider

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A simple claim-capturing interface with controls to minimize user capturing errors

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The system automatically allocates benefits in real-time as you capture

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Amount to award is calculated and allocated by the system, shortfalling if benefits are no longer available

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Claims can be automatically rejected for different duplication scenarios

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User is given limited options to change the benefit allocation from a sub-list of applicable benefits, but the system automatically selects the most appropriate one.

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ICD-10 codes are pre-loaded into the system and the user can pick one for each claim line and for the whole claim(diagnosis)

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Modifiers are built into the system to automatically determine the maximum payable amount.

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Member reimbursement claims capturing

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Member Pre-authorization

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Member treatment pre-funding

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Flagging of claims based on their status:

Grey – awaiting capturer verification

Purple – verified but on hold without a specific problem

Amber – on hold pending human adjudication. May have a problem detected by the system of a user.

Red – Rejected

Green – Ok and ready for payment

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Provider’s own ref number for their own claims are captured in the system

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Printing of claim form

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Use of hash total to detect capturing errors

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Generating, emailing and printing a pre-authorization letter

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Generating, and sending a pre-authorization SMS

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A checklist is used to monitor/assess the activities around each claim(workflow). The steps in the checklist are customisable:

·         Claim Correctly Captured

·         Claim Stamped

·         Clinical Data Verified

·         Adjudication & Award

·         Final Authorisation

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For every claim line, benefit usage insights and analysis are provided:

·         Related Services' History

·         History of Same Diagnosis

·         Benefit Exhaustion History

·         Parent Benefit Exhaustion History

·         Global Limit Usage History

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An individual claim line can be flagged, and a whole claim can also be flagged. The whole claim’s flag monitors handling of the individual lines. If claim is rejected, then the individual claim lines do no access or hold benefits.

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Clinical data can be captured, even though it is generally not included on standard paper claim forms, including:

·         Date/time of admission and discharge

·         Next of kin in the case of an accident

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Per-claim audit trail:

·         For every claim, the system records and shows the trail of users who changed it, including the date/time and location(computer) used

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Claims navigator feature lists all claims according to the following criteria:

·         Dates treated/received/captured/paid

·         Payment Batch

·         EDI File

·         Fund

·         Paid only

·         Unpaid only

·         Current Member's History

·         Current Provider's Claims

·         Current Member AND Provider

·         This Whole Family

·         Payment Flags:

o   Pay - All OK

o   Pay - On Hold

o   Awaiting User Decision

o   Rejected

·         Capturing accuracy:

o   Hash Total Mismatch

o   Capturing Checked

o   Capturing Not Checked

·         Current user’s own claims:

o   Captured by me

o   My UnChecked Claims

·         Claiming Party:

o   Reimbursement Claims

o   Pre-Authorizations

 

Other navigator features:

·         Bulk deletion

·         Bulk movement to a different provider

·         Bulk setting of payment decision

·         Searching for a specific claim by system assigned number or provider’s reference

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Data Capturing Session (Capturing by Batch) – this speeds up capturing of a batch as the common details of the entire batch are entered only once and automatically set for each new claim in that session

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Each computer can be optimised either in favour of claims or membership

 

 

 

BENEFITS REPOSITORY ADMINISTRATION

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This is where the fundamental benefits which the system is capable of managing are configured. All schemes and plans are based on this feature.

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Inpatient/Outpatient Restriction:

·         Not Specific

·         In-Patient Only

·         Out-Patient Only

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Male/female restriction

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Minimum age restriction

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Restriction to specific service provider disciplines

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Restriction to specific hospital units:

·         Maternity

·         Neonatal & Nursery

·         ICU/CCU

·         Accident & Emergency

·         Operation/Theatre

·         Renal

·         Rehab

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Defining a benefit restricted to specific treatments, or which specifically excludes specific treatments

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Hospital grade restriction

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Tying a benefit to a specific fund only

 

TARIFF CODE MANAGEMENT

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The Tariff codes system is used to identify treatment or service delivered by providers to members. It is a vital component of the whole Scheme Genius ecosystem.

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The codes defined in the system are the only ones which the system will recognise and use for purposes of benefits adjudication and award.

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Alphanumeric codes are used, they need not conform with other systems by other regulatory bodies, but those who submit claims must be familiar with them.

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Each code has a price and can optionally have a co-payment fixed

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Each code has a flag(colour code – Green, Amber, Red) which is shown each time a user captures it.

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Codes can be placed in ‘clash classes’ so that if 2 tariff codes are in the same ‘clash class’ then they cannot be on the same claim together.

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A frequency class can be defined, so that frequency restriction rules can be applied to it (e.g max number of times per day, month, 6 months, 1 year, et.c)

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A maximum quantity can be set

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Inpatient/Outpatient Restriction:

·         Not Specific

·         In-Patient Only

·         Out-Patient Only

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Whether pre-authorisation is required or not

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Hospital grade restriction

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Filtering out tariff codes without benefit allocation

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Adding service provider disciplines which can deliver/claim for the particular tariff code’s corresponding service(s)

 

BANKS AND BRANCHES MANAGEMENT

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This feature enables you to maintain an up-to-date list of banks and their branches, along with the branch codes

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Each bank’s Electronic Data Interchange method is also indicated, the system has some methods already inbuilt, namely Paynet and Stanbic files.

 

SUBSCRIPTIONS AND BILLING CODES

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An item code system is used to identify the different subscription rates for members

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Any other item for which a member can be billed (e.g card replacement) is also defined here

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Each item code is assigned a class which will be used in generating a summarised corporate bill

 

SCHEME/FUND MANAGEMENT

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All the schemes/funds/companies are managed using this feature.

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Corporate receipts are made from this window

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Any monthly fixed charges per member are configured from this window

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Benefit limits for the whole fund can be set as global, annual or monthly

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Member numbering can be set here in terms of prefix and number range.

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If the particular scheme is restricted to specific providers, these providers are listed using this feature

 

BANK ACCOUNTS MANAGEMENT (“Our Bank Accounts”)

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The bank accounts used to pay providers are set up using this feature

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Account currency is also set using this feature

 

SHORTFALL REASONS

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Shortfalls and rejection reasons are edited using this feature

 

MEDICAL/CLINICAL NOTES

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This feature can be utilized in conjunction with providers who have higher-compatibility software for EDI (Electronic Data Interchange) and typically with corresponding consent agreements with the patients themselves. This is because it enables detailed clinical information to be submitted about the patient. This is over and above mere billing/financial data.

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An unlimited number of details can be so captured under different categories.

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Data field types supported are text, numeric and drop-down

 

MEMBER DATA CONFIGURATION

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This feature enables the system administrator to configure the custom data page of the member data file

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An unlimited number of details can be so captured under different categories.

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Data field types supported are text, numeric and drop-down

 

SMS TEMPLATES

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SMS message templates to be used for the various triggers are defined using this feature. This enables the system to compose personalised and specific messages to members either on-demand or by pre-defined triggers.

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Pre-defined variables can be used to form the templates.

 

MEMBER TAGS

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This feature enables management of the member tags. These tags distinguish the member and directs how the member is billed. The fundamental tags are:

·         Corporate

·         Individual

·         Student

 

ATTACHMENT TYPES

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This feature enables configuration of the attachments used by the system

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You can specify the icon and application to be launched for each file

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The file types managed are:

·         Picture

·         Video

·         Audio

·         PDF

 

BRANCHES

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This enables management of your branches

 

EDI

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EDI (Electronic Data Interchange) features in the system include:

·         Member File Bulk Upload

o   Only specific column headings are to be used

o   Each file would contain members on the same scheme AND plan, not a mixture.

o   An error report is displayed while loading is occurring

o   Entire file’s content can always be traced back to this file and can all be deleted in one command as a batch.

·         Member Details Update File Upload

o   Only specific column headings are to be used

o   An existing system identifier (e.g member # and suffix, employment number) must be used

·         Claims Batch File Upload

o   A special file format has been developed and distributed to providers

o   A log is generated while a file is being loaded, which shows the activity and any errors

o   Only compliant 3rd party software can produce the file

o   A stand-alone encryption program is provided to providers who are using non-OmniSol software for managing their claims and billing records

o   A feedback file is generated, which is sent back to the provider for their own reconciliation within their own system.

 

ACCOUNTS – PAY CLAIMS (Bulk Payment Run)

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This feature starts the claims payment process. The first step is batching of the individual claims per recipient (member or provider). The first batching process produces a payment amount.

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Claims are first isolated by fund

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Provider claims are done on their own; reimbursement claims are done on their own

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System can filter out recipients who don’t have banking details configured yet.

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Each payment is assigned a reference number (‘Payment Ref #’)

 

ACCOUNTS – MANAGE PAYMENT BATCHES

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This feature provides the final payments processing steps. It is used after a Bulk Payment Run

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Payments are grouped and locked together to form a BATCH.

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A Batch is printed for final authorization, and the same batch is also authorized within the system

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When a user authorizes a batch, the system records the user ID and time

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The system has been designed to cater for multiple authorisation points, up to 5 users.

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The system allows the user to determine how many payments to batch because the user is aware of funds availability in the bank account.

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Payments are processed one fund at a time (not mixed)

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Payments can be filtered by:

·         Date of run

·         Provider's Payments only

·         Reimbursements only

·         Run but not Exported to Bank

·         Not yet Queued for Authorisation

·         Queued but Not yet Authorised

·         Authorised

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Batch can be exported to Paynet or Stanbic file formats

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Checksum is calculated and included in the file, for file integrity (preventing alteration outside the system) in the case of Paynet.

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Remittance advice is generated and printed or emailed directly from within the system

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Payments are color-coded:

·         Purple – Not even Queued for Authorisation

·         Amber – Pending Authorisation

·         Green – Authorised

 

BENEFITS ADJUDICATION ENGINE

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This is the feature which at the core of the basic purpose of the system: benefits and claims management. It is the element which runs a standard set of tests on every claim to ensure it is eligible for benefits according to policy.

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The rules to be run are categorised under:

·         Organisation Validity

·         Member Validity

·         Beneficiary Validity

·         Service Provider Validity

·         Claim/Visit Validity

·         Tariff/Treatment Validity

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The following tests are run each time:

·         Organisation Validity

1.       Is organization identified (registered with us)?

2.       Are subs paid in treatment period?

3.       Are funds still available?

·         Member Validity

1.       Are subs Paid and up-to-date?

2.       Does global limit still cover?

3.       Is principal member Active?

·         Beneficiary Validity

1.       Is waiting period over?

2.       Is beneficiary Active?

·         Service Provider Validity

1.       Is the discipline applicable to treatment?

2.       Was service Provider identified?

3.       Is service Provider on our network?

4.       Is service provider assigned to this organisation?

·         Claim/Visit Validity

1.       Is claim submitted within 3 months?

2.       Is provider's claim number/account ref unique?

3.       Is Service Provider Specified?

4.       Is the disease Specified?

·         Tariff/Treatment Validity

1.       Specialist treatment has referral?

2.       Is Tariff code recognised?

3.       Is the waiting period for this benefit over?

4.       Where required, is authorization code present?

5.       Is quantity valid?

6.       Within max expected quantity contiguous?

7.       Is treatment date in the past?

8.       Do benefits cover this treatment?

9.       Is this NOT a duplicate claim?

10.   Is treatment date before submission date?

11.   Where required, is authorization code for correct discipline?

12.   Where required, is treatment before authorization code expiry?

13.   Where required, is authorization code recognised?

14.   Is treatment date after joining date?

15.   Can this benefit's limit accommodate this treatment?

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A claim is paid when it passes the above tests

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This engine runs seamlessly without user activation; however, this feature configures which rules are active or not.

 

SECURITY

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User can their own password

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An administrator can add new users

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An administrator can users to groups – the group determines the permissions

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An administrator can reset another user’s password

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An administrator can define permissions for each User Group. The following are the actions/features which have restricted access:

·         Manage Branches

·         Manage Benefits Definitions

·         Assign Provider network to client

·         Extract Plan Configuration Report

·         Define Subscription Fees and Codes

·         Manage Tariff Codes

·         Map Tariff Codes to Benefits

·         Manage Shortfalls and Rejection Reasons

·         Define Our Banking Details

·         Manage Banks and Branches

·         Manage Service Providers

·         Configure Medical Notes

·         Configure Member Data

·         Manage SMS Templates

·         Manage Member tags

·         Manage Printout Templates

·         Create Icons and Attachments

·         Print Member Card

·         Print Membership Reports

·         Manage Membership Events

·         Generate Member Bills

·         Print Member statements

·         Print Corporate Invoice and Corporate Statements

·         Load EDI claims

·         Generate EDI feedback files

·         Upload Bulk Membership

·         Generate a Reversal Claim

·         Capture Claims

·         Do Pre-Authorization

·         Send Member SMSes

·         Manage Member Details

·         Print Member Confirmation Letters

·         View Benefits Summary per Member

·         View and Print Member statement

·         View Detailed Audit Trail per Claim

·         Override Flagging of claims

·         Override the Awarded Amount

·         Authorize Claims Payments

·         Generate Payment Runs

·         Payment files export

·         Email Remittances to Provider

·         View Payments by Batch

·         Payments Authorization Summary Report

·         View Fund Utilization Analysis reports

·         View Claims Data Capture Report

·         View General Audit Trail Report

·         Manage Benefits Adjudication Engine

·         Manage Scheme/Fund Creation and Renewal

·         Email Bills to Members

 

MY DIARY/APPOINTMENTS

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This feature enables setting of appointments with service providers.

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Each day is split into slots, each of duration:

·         5 minutes

·         10 minutes

·         15 minutes

·         30 minutes

·         1 hour

·         2 hours

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Personalised SMSes(reminders) can be sent to all schedules for the day

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The day’s schedule can be printed

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An entire day can be blocked to prevent any bookings being made on that date

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A whole month is visually represented with pie charts to indicate overall availability

 

SYSTEM OPTIONS

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This feature is used to configure various aspects of the system:

·         Receipt printer settings

·         Data entry – required fields

·         SMS trigger for every claim captured

·         Network connectivity settings

·         Commission contract settings

·         Folder locations of key files used

·         Remittance advice emailing

·         Mail server credentials

 

GENERAL AUDIT TRAIL REPORT

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There are actions which are automatically logged when they occur

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This report shows these actions, along with the user and time

 

MEMBERSHIP REPORTS

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The columns of membership reports are user-defined

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The following filtering parameters are used for each report:

·         Fund

·         Current Status (Active, Suspended, Terminated, Black-listed)

·         Date of Birth

·         Join-date

·         Principal Members only

·         Date captured

·         Last membership event

·         Card printing status

·         Record verification status

·         Account balance (plus, minus or zero)

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Report can be printed

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Report can be exported to CSV or XML

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Send personalized SMSes to all listed in report

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Drill down into more detail about each listed member

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Membership data capture report – shows the number of new members captured by each user

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MEMBER MOVEMENT REPORT

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This shows significance changes to the membership

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Columns are Join-Date, Activity, Effective-Date, Benefits Date

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You can filter by specific event types, or by fund

 

MEMBERSHIP REPORTS DESIGNER

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This is a tool for designing reports. A user basically gets to choose what columns will be on their report

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Users can share the reports they design

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The report’s on-screen title and printed title are entered by the user

 

BILLING REPORTS

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Bills List – lists all the generated bills. Enables filtering by date and billing cycle

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Income Analyses by Fund – a breakdown of revenue, showing # number of bills, total value, total outstanding

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Corporate Invoices

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Corporate Member Statements

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Detailed Corporate Bill

 

CLAIMS REPORTS

  1.  

Claims List – this lists claims, using filters by:

·         Payment batch

·         Payee

·         Fund

·         Date treated, received, captured, paid

·         Shortfall status

·         Banking details availability

·         Diagnosis

·         Payment Status

·         Award decision

·         Amount paid

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Overpaid claims – this show claims paid above the set tariff amount when the policy is “pay in full”

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Claims with Tariffs – this is similar to the report in (1) except that it is itemised, showing the details of each claim

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User-defined report – this is a report defined by the user in terms of what columns are shown and printed

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Claims data capture report – this tracks the rate of data capture by users

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Claims capture statistics

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ANALYSIS REPORTS

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Provider’s claims age analysis (condensed report)

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Symptom prevalence table and graph

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Claiming trends by tariff Code

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Funds Consumption by Benefit

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Claiming Trends by Age/Gender – age group, total value, outstanding, total paid, average per-claim

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Claims Analysis by Provider

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Reimbursement Claims Overview

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Benefits Utilisation Overview

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Members' Benefit Utilization

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Benefits and Rejection Reasons Overview

 

SERVICE PROVIDER MANAGEMENT

  1.  

This feature is for setting up the service providers.

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Multiple practitioner registration (e.g AHFoZ) numbers per provider. A provider can have multiple entries as long as each one has a unique practice registration number.

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Providers who are contracted (preferred provider network) are so indicated using this feature

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Banking details are managed thru this feature

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Default decision regarding payment of claims can be set here:

1.       Pay – All Ok

2.       Pay – on hold

3.       Don’t Pay – Warning

4.       Don’t Pay – Fatal

  1.  

Their EDI files decryption password is set here

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Their tax clearance status is set here

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The service units at their facility are indicated using this feature

 

 

Web Management Dashboard features

The dashboard was designed for the decision makers as it gives summarized information on how the health care department is doing, by just a click of a button.

·         Main Panel - Once you have logged in, it lands you to the dashboard’s main panel where it shows you how many active members by fund, terminated members by fund and daily user stats by department.

·         Navigator – To your right side there is the navigator which allows you to navigate through various reports, these reports are grouped by department

 

Membership Reports

1.       Active Members – This report gives you the number of active members per fund grouped by scheme.

2.        Terminated Members - This report gives you the number of terminated members by fund.

3.       Terminated Movement by month – This report gives you a breakdown of all terminated members by month.

4.       Movement Members joined by month – This report gives you an overview of how many new members who joined per each fund breaking down by each month of the year

5.       Age Profile Principle – This report shows you the age profile of all the principle members per fund.

6.       Age Profile Spouse – This report shows you the age profile of all the spouses per fund.

7.       Age Profile Grouped – This report shows you the age profile of all the members per fund.

 

Claims Reports

1.       Claims Value & Claims count monthly break down - This report gives you and overview of how many claims where captured and also the value of the claims grouped by month per fund.

2.       Claims by plan – This report gives you the total value of the claims that came the current year per fund breaking down by plan

3.       Claims by plan Male – This report gives you the total value of the claims that came the current year per fund breaking down by plan for males only.

4.       Claims by plan Female – This report gives you the total value of the claims that came the current year per fund breaking down by plan for females only.

5.       Claims by location – This report gives you the number of claims that came in the current year by location

6.       Claims by Diagnosis (Value) – This report shows top 10 diagnosis per fund – Value

7.       Claims by Diagnosis (Count) – This report shows top 10 diagnosis per fund – Count

 

Payments Reports

1.       How much are paying out - This report gives you an overview of how much money that was paid to providers per fund categorizing by Last week, this week, and also a monthly break down.

2.       Who are we paying the most – This report gives an overview of top providers and members who have been mostly paid.

 

Benefits Reports

1.       Fund Performance - This report gives you an overview of how much funds where utilized against the billed amount per fund

2.       Benefit Utilization – This report gives you the top benefits utilized and the value per fund

3.       In hospital – This report gives you a monthly breakdown of amount utilized for this benefit per fund

4.       Out Patient – This report gives you a monthly breakdown of amount utilized for this benefit per fund

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