| # | Business Processes | Recommended |
|---|---|---|
| FISF-01 | Enroll beneficiary: Verify identity and eligibility in a timely manner of persons seeking access to benefit plan services | BP required; |
| FISF-02 | Assign beneficiary to a Primary Care Provider (PCP) or primary care unit: Assign beneficiary to participating PCPs or primary health units based on rules (i.e., geography, load of beneficiary). Allow beneficiary to select PCP or primary health units from available list. | BP recommended |
| FISF-03 | Eligibility inquiry by provider : Provide accurate and timely indication of whether presenting individual is eligible for health care coverage at this point in time at this location and if specific services to be rendered are covered by the individual’s benefits plan | BP required; |
| FISF-04 | Eligibility inquiry by beneficiary : Provide Indication of whether beneficiary is eligible for health insurance coverage and details on specific services covered by plan benefits | BP recommended |
| FISF-05 | Pre-authorization : Provider has secured timely assurance from insurer that proposed service will be admissible for payment through claim settlement | BP required; |
| # | Business Processes | Recommended |
|---|---|---|
| FISF-06 | Register/ empanel provider : Verify provider credentials and qualified services and establish network assignments | BP required; WF recommended |
| FISF-07 | Provider agreement : Establish legal binding documents between health provider and health insurance | Recommended |
| # | Business Processes | Recommended |
|---|---|---|
| FISF-08 | Premium collection: Timely, accurate collection of money due from beneficiary and their sponsors (government, employer) | BP Required; WF required |
| # | Business Processes | Recommended |
|---|---|---|
| FISF-09 | Claims processing: Timely and accurate processing of claims to determine the validity of the claim and the amount to be paid. | BP required; |
| FISF-10 | Claims status inquiry: Provide timely status of submitted claims. | BP required; |
| FISF-11 | Claims dispute and appeals: Facilitate timely resolution through secondary review of adjudicated claims which parties (e.g., beneficiary and insurance provider OR provider and insurance provider) do not agree . | BP recommended |
| FISF-12 | Claims adjustment and voids: Timely processing of approved modified payment amounts for claims that have been through the claims dispute process. | BP recommended |
| # | Business Processes | Recommended |
|---|---|---|
| FISF-13 | Payment to providers: Pay approved/recoup claims or reimbursements per visit/service, capitation payment) in a timely manner to designated, plan approved providers | BP recommended, HFW-004 |
| FISF-14 | Accounts receivable: Record financial transactions in general ledger for monies due to the insurance provider (i.e., capitation payments, donations, premium) | BP Required; WF recommended |
| FISF-15 | Accounts payable : Record financial outflows accurately to GL and report out to national government and/or donor who provided the dollars (reimbursement to beneficiary, government, provider) | BP Required; WF recommended |
| # | Business Processes | Recommended |
|---|---|---|
| FISF-16 | Manage costs of catastrophic cases : Reduce costs of managing catastrophic cases | BP optional |
| FISF-17 | Identify chronic disease management cases : Identify target beneficiaries for chronic disease management programs | BP optional |
| FISF-18 | Enroll into chronic disease management programs : Enroll target beneficiary into specific chronic disease management programs to promote early screening, diagnosis and treatment to ensure appropriate cost-effective medical services are identified, planned, and obtained | BP optional |
| FISF-19 | Monitor chronic disease management cases : Monitor and assess beneficiary’s care management progress to ensure appropriate and cost effective services are obtained and assess treatment plan to determine if modifications are needed | BP optional |
| # | Business Processes | Recommended |
|---|---|---|
| FISF-20 | Utilization management: Determine over-use, under-use and misuse of benefits and take action to resolve and optimize pharmacy use | BP recommended |
| FISF-21 | Pharmacy benefits management PBM: Validate appropriate use of prescribed medicines. Guard against over-use, under-use and misuse of pharmaceutical therapies and take action to resolve. | BP recommended |
| # | Business Processes | Recommended |
|---|---|---|
| FISF-22 | Provider Quality Management: Ensure that the provider has delivered the necessary contracted quality of service | BP recommended (align with FR) |
| # | Business Processes | Recommended |
|---|---|---|
| FISF-23 | Actuarial management : Provide accurate projections for health spending projections for specified time period | BP recommended, WF recommended |
| FISF-24 | Provider rate : Optimize payments to reflect realistic economic conditions while minimizing medical loss ratio | BP recommended |
| FISF-25 | Set premium: Optimize premiums to reflect realistic economic conditions while minimizing medical loss ratio. | BP recommended |
| FISF-26 | Reserve Fund Management: Assure sustainability of the health insurance scheme, and to buffer the scheme from unpredicted liabilities by maximizing investment income | BP recommended |
| # | Business Processes | Recommended |
|---|---|---|
| FISF-27 | Manage medical loss ratio (MLR):
| BP recommended |
| # | Business Processes | Recommended |
|---|---|---|
| FISF-28 | Identify fraudulent cases: Identify cases of unusual patterns of insurance use that demonstrate suspicious utilization of program benefits by providers and beneficiaries | BP recommended WF recommended |
| FISF-29 | Manage fraudulent cases: Manage identified cases of suspicious program benefit utilization to closure | BP recommended |