OpenHIE Finance and Insurance Service (FIS)

Finance and Insurance Service stores, categorizes, and facilitates the administration of centralised claims and finance related data to care provision to patients within the HIE. The service receives claims/financial data from Point of Service applications (including financing applications acting as a point of service interface outside of other PoS systems) and curates the management of them.

See also Non-Functional Requirements.

Core Processes

Major Process Group: Beneficiary Management

#	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; HFW-001
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; HFW-003
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; HFW-004

Major Process Group: Provider Management

#	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

Major Process Group: Premium Management

#	Business Processes	Recommended
FISF-08	Premium collection: Timely, accurate collection of money due from beneficiary and their sponsors (government, employer)	BP Required; WF required

Major Process Group: Claims Management

#	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; HFW-004
FISF-10	Claims status inquiry: Provide timely status of submitted claims.	BP required; HFW-005
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

Major Process Group: Accounting

#	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

Supportive Processes

Major Process Group: Care Management

#	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

Major Process Group: Utilization Management

#	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

Major Process Group: Provider Quality Management

#	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)

Major Process Group: Financial / Audit Management

#	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

Major Process Group: Medical Loss

#	Business Processes	Recommended
FISF-27	Manage medical loss ratio (MLR): Assure sustainability of the Fund by computing and/or analyzing MLRs to understand where medical costs are being sustained and what the trend is in that spending Correct and balance any inequities or variances across regional boundaries and across service provision types	BP recommended

Major Process Group: Audit and Fraud

#	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