FAQ

MASTER

1.Why do we have master’s module?

Masters module performs the task of standardizing data for system operations.

3.What data does currency master stores?

Currency master stores the worldwide used currencies with their names and symbol

5.What is the room types stored in the masters?

The worldwide standard hospital rooms like operation theatre, observation room, ICU, etc, are stored in this sub-module.

7.What does dental benefit batch contain?

A dental benefit batch stores all the dental diagnosis codes covering the diseases under the policy benefits.

9.Who is broker? Why is it necessary to have a broker master?

A broker is an agent who sources contracts of insurance on behalf of their customers. Broker master is required to enter all details of transactions and broker commissions that effect the calculations in debit/credit note generation and policy admin reports.

11.Why do we enter coverage codes?

We enter coverage codes under coverage header which can be appointed to the class as per the requirement.

13.Why do we have a currency converter?

Currency converter is a hyper-link to a web page where we can view the different types of currency conversions that can be used for our software.


2.What are the features of masters?

The main features of masters are currency master, communication type, room type, ICD benefit batch, dental benefit batch, class hospital batch, broker master, coverage header, coverage codes, user master, password change and currency converter.

4.What data does communication type stores?

Communication type stores the worldwide used communication types like mobile, telephone, e-mail, etc.

6.What is ICD benefit batch? What data does it store?

ICD stands for International Classification of Diseases. Our system follows Australian 10A version (and can be updated). A list of all the ICD diagnosis available in the system is displayed, from which the batch is created by selecting the ICD codes covering the diseases under the policy benefits.

8.What is class hospital batch? What is it used for?

A hospital batch is created which contains the list of hospitals appointed for a class as per the policy.

10.What is coverage master? What is it used for?

All details about various other coverage’s classified by their specific headers are stored.

12.What is user master and password change?

User master has the details about the user accessing the system. Any editing or password changes required for the user information including the user level acess control.

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INSURANCE

1.Why do we have an insurance module?

Insurance module performs the task of storing various key codes used by the insurance company for the processing of approvals and claims.

3.Why are ICD codes stored?

ICD codes are entered in the insurance module which is listed with their diagnosis that are useful for the standardization of diagnosis data. They are stored for the creation of ICD benefit batch.

5.What is the use of medicine codes?

All the various medicines with their codes and prices obtained from ministry of health are stored which can be helpful for the processing of approvals and claims.

7.Why do we enter territory, country, and city?

All the territories of the world are given codes and entered. A territory can have one country or many countries. And under each country their specific cities are stored in the system.

9.Why do we give relation codes?

All the members insured are given relation codes for their families and stored in the system. It is used for the identification for the system for manual member addition and upload through excel file.



2.What are the features of insurance module?

Insurance module has various key codes that are useful for the processing of approvals and claims.

4.What is the use of dental codes?

Dental codes menu allows to enter & save codes for dental diagnosis. They are stored for the creation of Dental benefit batch.

6.What is CPT? What are CPT codes used for?

CPT stands for Current Procedural Terminology that includes all the current medical procedural terminology standardized by W.H.O that is practiced for the treatment of illness.

8.What is industry? How can it be used in the system?

Different industries belonging to different fields of interest prevailing in the world can be stored. It will be helpful to know which field of business the client belongs to.
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BENEFIT PROVIDER

1.What is benefit provider?

Benefit provider is the hospital that provides the benefits to be availed by the member’s as per policy benefits.

3.What information does hospital master store?

Hospital master stores the contact, sub-hospital addresses & bank account details of the hospitals.

5.What does * mean? Is it compulsory to enter the details which have *?

* symbol signifies mandatory fields.. Yes it is compulsory to enter failing which the system will not save the details.

7.What is average claim?

It’s an agreement on outpatient or day case according to which an average amount is agreed for certain services on the received number of claims.

9.What is IP? What is IPD approval amount?

IPD stands for in patient department, it means a patient can receive diagnosis and/or treatment involving an over night stay or more than that. IPD approval amount is the minimum amount of the service for which an approval has to be sent to the insurance company for availing the services.

11.What does OPD follow-up days mean? What is it used for?

OPD follow-up days means out patient department follow-up days where a patient can avail services from one particular doctor for consecutive number of days allotted.

13.What are the different types of pricelists in hospital contract? How do we upload the price lists?

The different types of pricelists in the hospitals contract are: Consultation Pricelist, Room and Board Pricelist, Service Pricelist, Supplies Pricelist, Package Pricelist that are uploaded through excel sheet standardized formats.


2.What are the features of benefit provider?

Benefit provider stores the contact and contract details, helps in bank accounting making it easy to work through net banking.


4.What is hospital contract? Why do we make a hospital contract?

The agreement of services & discounts offered by hospital to insurance company comprises the hospital contract. The terms and conditions of the contract, services of the hospital, the type of provides plan and the valid date of the contract are listed confirming the validity and authenticity of the contract.

6.What does PPP & EPP mean in hospital contract?

PPP stands for Preferred Provider Plan. This means the member can avail the services from list of hospitals appointed. EPP stands for Exclusive Provider Plan; this means the insured member can avail the service from only one hospital which has been appointed.

8.What is OPD? What is OPD approval amount?

OPD stands for outpatient department, it means a patient can receive diagnosis and/or treatment but do not stay overnight. OPD approval amount is the minimum amount of the service for which an approval has to be sent to the insurance company for availing the services.

10.What is day-case? What is day-case approval amount?

Day case is a department where patients receive diagnosis and/or treatment by hospital admission during day but not staying over-night. Day case approval amount is the minimum amount of the service for which approval has to be sent to the insurance company for availing services.

12.Why do we enter medicine discounts?

Medicine discounts are the discounts on medicine used for the treatment. This discount on medicine is given to the insurance company and therefore it is mentioned in the hospital contract.

14.What is volume discount? Why do we use it?

Volume discount is the discount offered by the hospital to the insurance company on larger number of claims incurred. It has a record about services on which large numbers of claims have been incurred.


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POLICY ADMINISTRATION

1.What is policy administration?

Policy administration is a module which deals with the underwriting of the policy.

3.What is client master?

Client master has the details of the client or customer with its contact details and logo.

5.What are the details stored in client master?

Client master stores the sponsor id, sponsor name, contact details, logo, and branch details of the client.

7.How many numbers of branches can be added in client details?

Client master can store as many number of client branches required.

9.What is policy number? How is it generated?

Policy number is a unique ID automatically generated by the system for every new policy created.

11.What is CCHI share and administration percentage, endorsement fee?

CCHI stands for Council of Corporative Health Insurance. CCHI Share is the percentage share of CCHI for every Insurance policy. Administration percentage is the administration charges applied for every policy. Endorsement fee is the charges applied for every amendment made to the policy document.

13.What is policy status?

Policy status gives the status of the policy, as it is active or inactive.

15.Can we edit the data after posting the premium?

No, we cannot edit any information once the premium is posted.

17.What does CCHI policy class mean?

CCHI policy class has standardized class details which fall directly for every new policy class created minimizing manual entry of the details every time.

19.What is premiums and out territory?

Premiums and Out Territory – gives the details of premiums for the employee and its dependents. The services allowed for out-territory and their charges applied are mentioned.

21.What are deductibles?

Deductibles – gives the details about the deductibles applied on the member of that particular class.

23.Why do we enter rooms in class master?

We define the hospital rooms whose services (within the amount and days limit.) can be availed by the beneficiary’s under the benefits of the policy.

25.What are exclusions?

Exclusions are the diagnoses which are not covered as per the policy, therefore are excluded from the benefit batch Inclusions.

27.What are sub-limits? Why is it necessary to enter sub-limits?

A sublimit of the total limit comprises the Sub-limit. Sub limit is defined for Dental, Maternity and Optical department, determining that; a member can avail the treatment of the respective diagnoses up to the defined sub-limit only.

29.What is class master?

It is the class of the clients that belong to the policy. Different classes are made based upon their premiums, coverage and benefit limits defined.

31.What is member import? How useful is member import?

Member import is an option to upload the members in the system, through excel sheet. Maximum no. of members can be uploaded, in just one click with least possible time. This option is useful as it is time saving, systematic and reduces the hassles of individual entries.

33.Why do we have maximum and minimum age limit for employee?

A person who is an adult and whose age is between the minimum and maximum age limit, is authorized to be an employee and can enroll the policy.

35.What are event, coinsurance and aggregate?

Event is the deductible paid by the member before availing the services. Coinsurance is the percentage amount shared between the insured and the insurance company. Aggregate is a deductible that is first paid by the member up to a certain amount after which the insurance company pays.

37.What is provider inclusion?

Provider inclusion is the hospital which is appointed and is within the network providers for the class.

39.What is territory exclusion?

Territory exclusion shows the list of territories which are excluded for the class.

41.What is member migration?

When a member migrates (upgraded or downgraded) from one class to another, it is known as member migration.

43.What is member delete?

This is an option where a member can be deleted.

45.What is member card print?

Member card print is an option where member card can be printed.

47.Why do we have mobile number option? How useful is it?

Mobile number option is very helpful, as it gives the quick notifications to the member through sms.

49.What is meant by member addition/deletion request?

It is the request sent by the clients either for adding the member or deleting any existing member.

51.What are the details under member insured list?

Members insured list report gives the details of the members in a policy according to their classes with their premiums according to pro-rata.

53.What is member addition commission report?

Member addition commission report gives the details of the members added to a policy and the broker commission for each member.

55.What is member migration report?

Member migration report gives the details about the members who have been migrated from one class to another within the policy.

57.What is member addition client report?

Member addition client report gives the details about the member added whose request was sent from the client module.

59.What is member’s card print report?

Member’s card print report gives the printed form of report of members whose cards have been printed.

61.What is meant by credit note? What are the different reports that can be generated for credit note?

Credit note is a memo to pay a certain amount of money to the provider, and to the client in case of reimbursement. There are three types of credit notes, they are member addition, member deletion and member migration.

62.How can the previous debit/credit note be generated again?

To regenerate the debit/credit note that has already been generated, the user must click on clear first, and then the "previous debit/credit note" option is enabled. The user can then enter the credit/debit note number and regenerate again.

63.Members Upload Validations

1) Error in Member Head row.
2) Invalid DIVISIONCODE : DIVISIONCODE not Exists.
3) Invalid Nationality : Nationality not Exists.
4) Invalid TPA Card Number : TPA Card Number already exist.
5) Duplication of TPA Card Number.
6) Invalid EmiratesId : Employee EmiratesId already exist.
7) Invalid TPACardNo : TPACard No length should be less than 25.
8) Duplication of EmiratesId.
9) Invalid EmiratesId : EmiratesId length should be in-between 15 and 20.
10) Invalid Employee No : Employee No already exist.
11) Duplication of Employee No.
12) Invalid Location
13) Invalid Regulatory
14) Invalid Sex / Relation : Premiums are not defined for this Age band.
15) Invalid Relation : Premiums are not defined for this Relation.
16) Duplication of Head Name.
17) Invalid Head Name. Head Name already exist
18) Invalid Dependent Head Name . Employee is not existed with Head Name.
19) Invalid Dependent EmployeeNo . Employee is not existed with EmployeeNo
20) Dependent Enrollmentdate should be greater than or equal to member Enrollment date
21) Employee Enrollmentdate should be Between Policy FromDate And Policy ToDate
22) Max No.of Childrens Exceeded.
23) Max No.of Spouses Exceeded.
24) Max No.of Dependents Exceeded.
25) Childrens not allowed for this plan.


2.What is group master?

Group master stores the data regarding the client as an individual group.

4.What is the difference between group master and client master?

A group is nothing but a client under which different categories of clients can be entered. e.g : XYZ is a group of companies, under this there are different industries like xyz communications, xyz automobiles, etc,. Group is only one, under one group there can be many clients.

6.Why do we enter sponsor id? How does it help?

Every client has a sponsor and sponsor id. This is helpful for the personalization and identification of every member account.

8.What is policy master? What data does policy master store?

Policy is the contract between the insurance company and the client. It stores all the necessary terms and conditions of the Insurance policy.

10.What is inception and expiry date?

Inception date is date on which the policy starts and expiry date is the end date of the policy.

12.What does payment terms mean?

Payment terms are the terms of premium payment between the insurance company and the client. It can be monthly, bi-monthly, quarterly, half yearly or annually.

14.What is meant by premium post? When do we post a premium?

Premium post is the posting of premium that is done after the uploading the members in the policy class. No changes can be made after posting the premium, and accordingly credit and debit notes can be generated.

16.Why do we have a notes column? How helpful is it?

Under every category we have a notes option as it allows the user to write any suggestions or added information or remarks related in this column.

18.What is general and eligibility?

General & Eligibility – has the basic member eligibility criteria details.

20.What are benefits?

Benefits – gives the details of benefit limits for the member & dependants.

22.What is territory provider – doctor?

Territory provider – doctor gives the list of appointed hospitals for that particular class and their doctor exclusions (if any). And also shows the territories which are excluded for that class.

24.What are inclusions? Why do we enter inclusions?

Inclusions give the details of the ICD and Dental benefit batch appointed for each class. These batches have the diagnosis codes of the coverage’s applied for the member as per the policy.

26.Why do we enter exclusions?

Exclusions are entered as per the policy coverage. All the diagnosis which are not covered under the policy benefits are entered as exclusions.

28.What is medicine and supply exclusions?

The medicines and medical supplies ex: Medical equipments, which are not supplied by the appointed provider as per the contract.

30.What is other coverage? Why do we enter other coverage?

A coverage header created, under which the selected ICD codes included as per the client’s coverage requirement can be mentioned as the other coverage for a policy. A coverage defined up to a particular limit, with limited no.of visits and for a particular duration, also can be entered in the system under other coverage’s.

32.What does authorization for OPD, IPD and second opinion mean?

Authorization for OPD, IPD and Second Opinion is the minimum amount of the service (which would be availed by the member), for which a pre-authorization (approval) has to be sent to the Insurance company.

34.What is out of network reimbursement within territory?

Out of network reimbursement with territory defines the reimbursement request for the services availed by the member, in a provider; which is within the included territory, but does not fall under the Network preferred providers.

36.What does maximum per visit mean?

Maximum per visit means the maximum amount the member pays for availing the services per visit.

38.Why do we exclude doctor?

A doctor can be excluded on various reasons such as high fee or any kind of abuse, etc.

40.What is member master?

Member master is the sub-module where member addition can be done manually. Member migration, member deletion, member stop/restart, etc, can be also be done in this module.

42.What is member stop or restart?

An option to change the status of the member as "STOP", for a particular duration, during which, member cannot avail the services. Member RESTART is the status change, the active status. Hence, the member is eligible now to avail the services

44.What is meant by member level benefits? How is it useful?

Member level benefits gives the individual details for every member about their premiums according to pro-rata, benefits, deductibles, etc,. The user can view the complete detail for premiums, benefits, etc,. for each member.

46.What does import members to CCHI mean?

It is a link to the secured site of CCHI where the user can upload the member files.

48.What is meant by client member request?

Client member request is the option where the user of the insurance company can view the member addition/deletion requests sent from the client module and take the decision.

50.What are the details under policy member details?

Policy member details give the report of the members listed under the policy.

52.What is member addition report?

Member addition report gives the details of the members who have been added to a policy via reporting day’s period.

54.What is member deletion report?

Member deletion report gives the report about the members who have been deleted from a policy.

56.What is member migration commission report?

Member migration commission report gives the details about the member migration and the broker commission for each member.

58.What is member deletion client report?

Member deletion request report gives the details about the members deleted whose request was sent from the client module.

60. What is meant by debit note? What are the different reports that can be generated for debit note?

Debit note is a memo to earn certain amount of money from the client. There are three types of debit notes that can be issued for the client, they are first premium, member addition and member migration.


26) Spouses not allowed for this plan.
27) Dependents not allowed for this plan.
28) Invalid Age:It should be between Minimum age and Maximum age.
29) Invalid Relation : Relation Not Exists.
30) DOB should not be greater than or Eqaul to Todays Date
31) Invalid ClassCode : ClassCode not Exists
32) Member Type Should not be empty
33) Invalid MemberType : MemberType should be EMPLOYEE/DEPENDENT
34) Member Name Should not be empty
35) Invalid character '-' found in Name Of Employee
36) DOB Should not be empty
37) Invalid: DOB: Not a valid date
38) Error_Description1 is null
39) SEX Should not be empty
40) Invalid Sex : Sex should be MALE/FEMALE/UNKNOWN
41) RELATION Should not be empty
42) TPA Card Number Should not be empty
43) NATIONALITY Should not be empty
44) Hiredate should not be greater then Todays Date
45) Invalid HIREDATE: Not a valid date
46) EMIRATESID Should not be empty
47) Please enter a valid email
48) Please enter a valid Mobile No.
49) ENROLLMENTDATE Should not be empty
50) Invalid Enrollmentdate: Enrollmentdate should be between Inception & Expiry Date's
51) Invalid Enrollmentdate: Enrollmentdate should be Greater than or Equal to DOB.
52) Invalid Enrollment Date: Enrollment Date should be greater than Hire Date
53) Invalid ENROLLMENTDATE: Not a valid date,DIVISIONCODE Should not be empty
54) DIVISIONCODE Should be same as selected Endorsement DIVISIONCODE
55) Invalid Coc_Date: Not a valid date
56) Invalid COC_RECEIVEDATE: Not a valid date

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APPROVALS

1.What is meant by approvals?

Approval / pre-authorization is a request sent by the benefit provider to the insurance company when a member approaches to avail the health services.

3.What is meant by approval request?

Approval request means a request sent from the hospital to the insurance company to approve the services to be given to the member.

5.Where do we get the diagnosis code? Can we enter it manually?

Diagnosis codes can fetched from the system, through ‘Search’ option available.Yes, the system also has the option to enter the diagnosis manually in the approval request form.

7.How do we take the approval decision?

When the approval request is sent from the hospital, the insurance company receives the request. A unique approval request number is generated by the system automatically. The user then, can click on that approval number, review the approval and take the decision.

9.What is system review?

System review gives all the underwriting details about the policy, the status of the policy, member and all the necessary information confirming that the approval sent is authentic.

11.What is meant by UCAF, OCAF, and DCAF?

UCAF- stands for United Claims Administrative Form. It is the approval form for basic and maternity diagnosis. OCAF – stands for Optical Claims Administrative Form. It is the approval form for optical diagnosis. DCAF – stands for Dental Claims Administrative Form. It is the approval form for dental diagnosis.

13.What is meant by rejection codes? What is it used for?

Rejection codes are the codes reasoning the rejection of approvals and claims. Different rejection codes are stored in the system with their description giving the brief reason for that particular rejection.

15.What is approval request status report? Can it be generated in print form?

A portfolio report of all the approval requests, status wise, can be generated. System gives the option to generate the report of all the requests from single member, report from a particular hospital, and also the report of approvals received in a duration.


2.What are the key features of approvals?

The key features of approvals are: Approval request, Approval decision, and Approval request status report

4.Can the approval request be sent through hard copy and in print form?

Yes, the approval request can be sent through hard copy or printed form (through fax).

6.What is meant by approval decision?

It is the decision taken by the insurance company on the approval sent by the hospital for providing the services to the member.

8.Why is it necessary to click all the check boxes in approval decision page?

System reviews the services entered in the request and displays the decision ‘Yes’ or ‘No’. The user also has to click on the check boxes to approve the services and submit the approval to take the decision.

10.What is approve, reject, partial approve, second opinion, cancel, and close approval?

When an approval request is sent, the users of insurance company can take the following decisions according to their respective conditions. Approve – when all the underwriting and coverage conditions are satisfied, the approval request is approved. Reject – rejection takes place when any necessary underwriting/coverage conditions are not satisfied. Partial approve – If the Insurance company wishes to approve only the half of the amount or half of days (Incase of InPatient approval) based on various condition, then this can be done under ‘Partial approve’ option. Hence, Only a partial amount from the total amount will be approved. Cancel – Due to certain conditions, an approval request can be cancelled which can be done under ‘Cancel’ option. Close approval – it is an option to close the issue of the approval request. Second opinion – Insurance company can take the second opinion decision for an approval, if the services in the approval is found unsatisfactory. Second opinion is

12.What is approval request status?

Approval request status is the page where the user can view the status of the approvals like pending, approved, rejected, partial approved, closed, second opinion and cancelled.

14.What is meant by member info?

Policy and class details of the insured member can be reviewed in this page. Member info gives the details of member’s territory inclusions, territory exclusions, benefit limits exhausted and available, member approved hospitals, doctors and rooms, member excluded doctors, ICD and Dental batch exclusions are displayed.

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CUSTOMER SERVICE

1.What is meant by customer service?

Customer service is a help desk that provides end-to-end support for all the necessary and required information of the Insured member.


2.What are member details?

Member details screen give the complete details about the member: Member photo, benefit limits, limit available and exhausted, validity of the policy and the complete member approval and claims history.

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CLAIMS

1.What is meant by claim?

Claim is a demand for payment in accordance with an insurance company.

3.What is meant by claims batch?

When the insurance company receives a bundle of claims from the provider, in order to audit and settle them, users of insurance company create batches and input each claim into the system.

5.What is meant by claims batch month/year?

Claims batch month/year refers to the month and year during when, the claims were incurred.

7.What is claims entry?

Claims entry is the module where all the claims are manually entered in the system.

9.Why is it necessary to enter the deductible?

Claims upload is an enhanced version of claims entry. In claims upload the user has to upload the claims file (in excel format) in the system. As many number of claims can be uploaded through this module, in just one click and in least possible time.

11.What is meant by claims review?

Claims review is an option where the user can individually review each claim.

13.Why is it necessary to click on check diagnosis?

It is necessary to click on check diagnosis, as the system reviews the diagnosis of the claim, if it is included in the coverage benefit batch for the policy class. Hence, reducing the possibility of abuse.

15.What is list of claims review? What are the key features of list of claims review?

‘List of claims review’ is a module, where the system automatically reviews all the claims of a batch by just one click. The main feature of list of claim review is that,the system is sophisticated enough to consider the complete underwriting aspects and adjudicate any no.of claims in few minutes.

17.Can we generate the claims payment report for a single batch ?

Yes, by only selecting the respective claim batch number, only, claims payment report can be generated.

19.What is explanation of benefit report? Can it be printed?

Explanation of benefit report (EOB) is the payment report of the reimbursement claims. Yes, the explanation benefit report can be printed and can be exported into PDF, MS WORD, and EXCEL formats as well.

21.What is meant by claims credit note? Can we print the claims credit not?

Claims credit note is a memo to pay a certain amount of money to hospital or client (in case of reimbursement).

22.Can we print the previous claims credit note?

Yes, we can regenerate the previous claims credit note and print it as well.

23.TPA Claims Upload Validations

1) DATE_INCURRED Should not be empty
2) DATE_INCURRED : Not a valid date
3) DISCHARGE_DATE Should not be empty
4) DISCHARGE_DATE Should not be empty
5) RECEIVED_DATE Should not be empty
6) RECEIVED_DATE : Not a valid date
7) Error_Description1 is not null
8) Error_Description1 is null
9) Invalid PONO: Multipule Claim type are not allowed.
10) Invalid CLAIM_TYPE : Multipule Providers not allowed in a single PO
11) Claim Already Exists: Record is Duplicated in the file
12) Claim Already Exists: Record is already existed in system
13) PONO Should Not be Empty.
14) OPDIPD Should Not be Empty.
15) DATE_INCURRED Should Not be Empty
16) RECEIVED_DATE Should Not be Empty
17) DATE_INCURRED Should be less than todays date.
18) RECEIVED_DATE Should be less than Todays date.
19) INVOICE_NO Should Not be Empty


2.What are the key features of claims module?

The key features of claims module are claims entry, claims review, claims upload and list of claims review.

4.What are the types of claims?

There are two types of claims Hospitals claims: claims incurring from the network hospitals. Reimbursement claims: claims incurred from out of network or out territory hospitals.

6.What is meant by batch post? Why do we post a batch?

When all the claims are entered and reviewed by the system, the claims batch is posted/freezed after which, no changes can be done to the claims. Posting of the claim batch is done to generate the claims credit note.

8.Can we save the claim without selecting the diagnosis or services?

No, the claims cannot be saved without selecting the diagnosis or service. system automatically gives a pop-up stating that the data is incomplete.

10.What are claims upload?

Claims upload is an enhanced version of claims entry. In claims upload the user has to upload the claims file (in excel format) in the system. As many number of claims can be uploaded through this module, in just one click and in least possible time.

12.How do we review a claim?

The unique claim number (automatically generated by the system after entering and saving the claim) should be selected. User should click on the system review system then reviews the claim based upon the various underwriting aspects, click on ‘check diagnoses’, and click on all the user approved check boxes of services and accordingly take the decision.

14.Why do we post a claim?

Posting of claim is done following claim review, after which user cannot make any changes to the claim. Posting of claims batch is done following posting of individual claims batch which is required for generating the claims credit note.

16.What is claims payment report? What are the different types of claims payment report?

Claims payment report is the payment report of all the claims in a batch. There are two types of claims payment report - Hospital claims payment report and Explanation of benefit report i.e. the reimbursement claims payment report. This report can be generated for the complete portfolio.

18.Can we print the claims payment report?

Yes, the claims payment report can be printed and can be exported into PDF, MS WORD, EXCEL formats as well.

20.What is meant by member claims verify report?

Member claims verify report gives the details about the payment report of all the claims incurred from a single member.





20) MEMBERNO Should Not be Empty or Zero
21) CLAIM_TYPE Should Not be Empty or Zero
22) SERVICE_TYPE Should Not be Empty
23) HOSPITALNO should not be Empty
24) HOSPITALNO should be unique for a Provider Claim
25) APPROVED_AMT should be less than or equal to
26) Invalid Approved Amount Please check. Amount should be Greater than or equal to 0
27) Invalid Approved Amount Please check the Amounts are not equal
28) Invalid CLAIM_TYPE Should be TPANO
29) Claim Already Exists
30) Invalid MEMBERNO MEMBERNO : MemberNo does not exists.
31) PONO Already exist
32) RECEIVED_DATE Should be Greater than DATE_INCURRED
33) DATE_INCURRED Date Should be greater than Member enrollment date
34) Warning : DATE_INCURRED Should be between Member coverage period.
35) Invalid DATE_INCURRED : DATE_INCURRED should be dd/MM/yyyy format.
36) Invalid Invalid : RECEIVED_DATE should be dd/MM/yyyy format.
37) Invalid DISCHARGE_DATE Should be greater than



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RATE MODULE

1.What is meant by rate module? What is it used for?

Rate module is the policy rating department in the system. This menu helps the insurance company to estimate and calculate the rate at which the quotation can be made and also assume the total utilization cost, annual premium, loss and profit ratio regarding the various aspects of insurance policy.


2.What is tariff module?

Tariff module is the department where the quotation rate of the premiums, for various benefits – Dental, maternity, basic and optical, can be generated.

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ACCOUNTS

1.What are accounts? Why is it necessary to maintain accounts?

Accounts module tracks all the transactions - first premium, member addition member deletion, etc done in the system and stores all the data. Vouchers for each transaction can be generated.

3.What is voucher? How is it useful?

A voucher is an accounting document that is usually produced after receiving a vendor invoice, only after the invoice is successfully matched to a purchase order. It represents an internal intent to make a payment to the vendor in the amount of the voucher.

5.What is meant by statement of accounts?

Statement of accounts is the basic statement report of all the accounting details of a policy, displaying all the debit and credit notes with their amounts (transactions) generated for a policy along with the aging of Out standings.


2.What is header master?

Header master is the module, where the various headers of the transaction ex: Member addition, member deletion etc , is entered and stored.

4.How many types of voucher are there?

The vouchers are of two types, i.e., receipt and payment.

6.Can we generate a print form of statement of accounts?

Yes, a printed form of this report can be generated

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REINSURANCE

1.What is meant by reinsurance?

Reinsurance Company is the insurance company that assumes all or part of insurance or reinsurance policy written by a primary insurance company.

3.What is reinsurance master?

Reinsurance master stores the contact details of all the reinsures

5.What is PLPOM report? Why do we require PLPOM report?

PLPOM stands for Paid Loss per Occurrence Month report. It gives the details about the paid claims per occurrence month for a particular policy, as well for the complete portfolio.

7.What is POSLPUWM report? Why is it necessary?

POSLPUWM stands for Paid and Outstanding Loss per Underwriting Month report. It gives the details of both paid (settled) and Outstanding / incurred (not settled) claims per occurrence month for a particular policy, as well for the complete portfolio. This report also generates the earned premiums, paid loss ratio and incurred loss ratio.

9.What is meant by rate history report?

Rate changes by benefit history report displays the variation of the benefits and discounts offered by the hospital. It helps in assessing the change effect in the provision of benefits and its history.

11.What is meant by BPC report?

BPC stands for Burning per Class. It displays the total burning cost per class along with the loss ratio

13.What is meant by reinsurer premium report? Why is it necessary?

Reinsurer premium report displays the member’s insured list details along with the premium share amount of the reinsurer. It shows the premium charged by the insurance company, net risk premium deduction, and net risk premium. The reinsurer share is applied on NRP and reinsurer premium amount is generated.

15.What is meant by claims payment report under reinsurance?

Claims payment report gives the details about the claims incurred from different policies and also depicting the reinsurer share from the approved amount.

17.What do reinsurer debit notes mean?

It displays the list of the entire debit notes generated for different policies. When the user generates a credit note (member deletion, member addition, member migration), simultaneously a debit note is generated for the reinsurer.


2.How is it useful to have a reinsurer?

The total risk and the profit is shared among the insurance company and the Reinsurer.

4.What is treaty master? How is it helpful?

Treaty master has the details about the treaty / agreement made between the insurance company and the reinsurer with its contractual quota share.

6.What is ILPOM report? What is the difference between PLPOM and ILPOM report?

ILPOM stands for Incurred Loss per Occurrence Month report. It gives the details about the claims incurred per occurrence month for a particular policy, as well for the complete portfolio. The basic difference between PLPOM and ILPOM is PLPOM is the paid claims (settled) report and ILPOM is the incurred claims (not settled).

8.What is meant by earned premium report?

Earned premium report displays the premiums charged for benefits per underwriting and per occurrence month. Premium – deletion premium comprises of the Earned premium.

10.What is meant by BPCB report?

BPCB stands for Burning per Class and Benefit report. It displays the total burning cost per class and per benefit along with the total loss ratio.

12.What is the difference between BPCB and BPC reports?

The basic difference between the two is that, in BPCB report, the burning cost for all the classes belonging to a policy can be viewed individually by selecting the benefit type; whereas in BPC report, burning cost is generated in general for all the benefits.

14.What is meant by net rate premium report? Can we generate a printed form?

Net rate premium report displays the details about the premium charged by the insurance company, net risk premium deduction on the premium and then net risk premium amount.

16.What is meant by reinsurer credit notes?

It displays the lists of all the reinsurer credit notes generated for different policies. When the user generates a debit note (first premium, member addition and member migration), simultaneously a credit note is generated for the reinsurer.

18.What is meant by reinsurer claims debit notes list?

It displays the lists of reinsurer claims debit notes of claim batches generated for various policies. When the user generates a claims credit note (client or member),simultaneously a claims debit note is generated for the reinsurer.

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REPORTS

1.What are reports? How is it useful?

Reports can be generated to be viewed and printed. These are generated as per the requirements and for the maintenance of the record required by the client as well as the insurance company. Every report is having a criteria screen in order for the user to select options and then run the report filtered by the selected options.

3.What is policy template?

This is the standard policy template. All the general eligibility details, benefits, inclusions and exclusions, for the member under a policy are displayed.

5.What is policy analysis report?

This report displays the total analysis in terms of profit and loss occurred due to claims incurred in a particular period. It displays the premium received monthly, premium for the period under review, paid claims amount and outstanding claims amount.

7.What is meant by utilization report? How is it helpful?

The total utilization of the benefits by the beneficiaries of a policy in a particular duration is displayed. This report is very important for the figures of the company. It contains report from both insured and claims system.

9.What is age band report? What does it show?

This report basically defines the statistics of the claims. Claims of the policy are segregated according to its insured ages. It shows the age group and number of insured under each age group displaying the total number of claims under every age group and the claim amount.

11.What is list of hospitals?

All the providers entered in the system in Masters, are listed under this category.


2.What is computation of premium? Can we generate the report for computation of premium?

The details regarding all the classes under a policy, with no. of insured, segregated as Male employee, Wife, Son, Daughter and Female employee in a table with the premium charged on them. Total number of insured in each class and total premium in each class is also displayed. Yes we can generate a print report for the computation of premium.

4.What is table of benefits? How is it helpful?

Table of benefits is a tabular form displaying the benefits provided to the members under different classes belonging to the policy. Its helpful for the user to view the complete benefits - In-patient and out patient, maternity, dental, benefits covered for reimbursement claims and other additional benefits are displayed.

6.What is meant by risk profile? How is it helpful?

This report is important for the figures of the insurance company. The claims of a policy are segregated according to amount levels, and the total numbers of claims with their amounts are displayed. It helps in keeping a track of the number of claims made and their amounts.

8.What is meant by pre-existing and chronic report?

The services and benefits availed by the insured of a policy for the pre-existing and chronic cases are displayed.

10.What is meant by client provider’s list?

The list of benefit providers appointed for clients of different policies is displayed. It also shows the service these providers render.


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COMPLIANCE REPORTS

1.What is meant by compliance report?

The reports designed based on the compliance of the regulatory body Council of Cooperative of Health Insurance is called as the CCHI reports.

3.How many numbers of members can we export at once?

We can upload as many numbers of members in just on click.

5.What is SAMA annual report?

It displays the annual claims payment report as per the SAMA specifications and requirements.


2.What is meant by CCHI members upload report? What is it used for?

CCHI stands for Cooperative Council of Health Insurance. The uploading of members when a policy is created and members are added under the policy, a notification is sent to the CCHI displaying the number of members with their necessary details. This report can be uploaded directly to CCHI with just one click.

4.What is meant by CCHI beneficiary report?

This report displays the beneficiaries report as per CCHI requirement and specifications. This report has the complete details of the member and can be exported into EXCEL and XML format.


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DOWNLOADS

1.What are downloads?

The user can download templates of the consultation, service, supply, package and members file by clicking on the excel sheet under downloads.


2.How helpful is this module?

This report displays the beneficiaries report as per CCHI requirement and specifications. This report has the complete details of the member and can be exported into EXCEL and XML format.

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CORPORATE MODULE

1.What is corporate module? How useful is it?

It is one of the modules of our software specially designed for the client. It is very helpful for the client as it is an online management system. The client can send the request for member addition or deletion online within least possible time. And also can check the status of the requests as well member verification.


2.What are the various features of corporate module?

The various features of corporate module are: Member Verification Member Addition Member Deletion Hospital Listing.

2.How easy is the search of the member details?

System allows the user to search the member details by the member name as well by the member number, which is easy.

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MEMBER VERIFICATION

1.What is member verification? How useful is it?

Member verification is the menu that is used to briefly verify the member details and policy details. It is very helpful as the client can easily view the member under the policy and keep the track about the member additions and member deletions. The client can even view the benefit limits according to the departments.


2.What is the function of the screen ‘View requested list’?

View requested list is a page that displays all the member addition requests sent from the corporate module along with the updated status of the requests.


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MEMBER ADDITION

1.What is member addition? How do we add a member from corporate module?

Under corporate module, member addition is a menu through which the client has the access to add a member from the corporate login. The member type has to be selected: Employee or the Dependent, selection of class, the rest of the member details has to be added and request has to be sent.


2.Why do we have view requested list in member deletion?

View requested list is a page that displays all the member deletion requests sent from the corporate module along with the updated status of the requests.

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MEMBER DELETION

1.What is member deletion? How do we delete a member from corporate module?

Member deletion is a module, through which the client has the access to delete a member from the policy. To delete a member, the user must only enter the member number; by which system displays all the member details automatically. User can click on the ‘delete’ button and the deletion request is sent to the insurance company.


2.How helpful is hospital module?

Member verification along with the online sending of approvals and claims are the main key features of the Hospital Module.

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APPROVALS

1.How can we send the approval from hospital module?

Approval can be sent from the Approval request screen. Member number / Member name has to be entered by the user, by which system fetches all the details of the member. User should enter, rest of the approval details and submit from the Hospital Module.


2.How do we verify member eligibility?

Member eligibility can be verified either by entering the member number or member name, and selecting the department like basic, optical, dental or maternity. On clicking "search", the system displays the information about the member status and the benefits covered.

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CLAIMS

1.How do we send claims from hospital module?

Claim batch has to be created, and then the claims entry has to be done and submit them online. Claims can also be uploaded by the system through soft copy (excel file), which would be received by the Insurance Company.

3. What is claims status?

Claims status page displays the status of the claims sent from the hospital module and whose decision has been taken from the Insurance Company.


2.What is approval status?

Approval status page displays the status of the approval requests sent from the hospital module and whose decision has been taken from the Insurance Company.

2.How helpful is claims upload from hospital module?

Claims upload is very helpful for hospital module, through which the user can easily upload as many numbers of claims in just a click reducing the time taken for the complete entry process.


Our Mission

To be a global leader in Claims Management and processing, using best available technology, to provide our valued customers quality, competitive and advanced solutions to their satisfaction while serving the community. Our employees and business partners will share our success, and our shareholders will receive a sustained, superior return on their investment.

Our Vision

To set new standards and to be recognized as a leader.

Our Values

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