MAPS: ERP For Health Insurance Administration
MAPS: Mediclaim Administration & Payment System
MAPS is the acronym for Mediclaim Administration & Payment System". MAPS is a proprietary solution developed by WebEdge Technologies to facilitate the administration of health insurance - Underwriting, Enrolment and Claims - by TPAs and/or insurers.
The distinguishing feature of MAPS is the "Rule Engine" developed by WebEdge based on over 8 years of association with TTK Healthcare TPA, right from Day 0 of the introduction of TPAs in India. The WebEdge team had the privilege of working with TTK on a wide variety of health insurance products introduced by insurers, spanning indemnity, fixed benefit and hybrid products for Individual, Corporate and Affinity Group policies.
The Rule Engine is unique to the health insurance industry and automates the decision making on claims with the option to override the decision (based on access rights) if necesary.
Here is a quick look at some of the featues of the MAPS solution:
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MODULE |
Description of Features |
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PRODUCT DEFINITION |
a) Configure products with a wide variety of rules covering virtually every aspect of health insurance products
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b) Multi tiered rule definition to ensure process control |
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c) Inclusive / Exclusive rules to accommodate wide variety of rules |
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d) Service/Process -related rules, document rules, coupled with role based user administration |
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e) Configure services to be provided by TPA branches |
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f) Financial limits for Pre-authorizations, Claims and Payments |
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g) Allow/Restrict Providers by geographical segments, hospital types, categories and status, or a specified PIN Code or Hospital |
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h) Rules cater to requirements of all product families: Indemnity with or without Floater; Fixed Benefits of various types such as Hospital Cash, Surgical, Critical Illness, etc. or Hybrid of Indemnity and Fixed Benefit |
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i) Each product may contain any number of plans and each plan may have any number of benefits; Each plan / benefit can have its own rules and limits |
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ENROLLMENT |
a) User-friendly MAP--UPLOAD--VALIDATE--INSERT process to import data from wide variety of file formats from insurers as well as corporates
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b) Flexible field/column order with user interface for mapping. So corporates can send data in their own formats - Name can be in Col 3 by one corporate and Col 5 by another |
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c) File formats accepted are .csv, .xls, .dbf and flat files. Data may be received with the key fields in any order and may be mapped through a user interface to ensure upload accuracy. |
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EMPANELMENT |
Empanelment – Master data of Insurers and TPAs, Providers, Corporates (including their branches as per hierarchy)Brokers, Investigators |
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USER MANAGEMENT |
a) Role-based user management and access control |
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b) A user may have multiple roles and rights will be given accordingly |
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CLAIMS DATA ENTRY |
a) Inward process designed to accurately track every claim received |
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b) User friendly interface designed for high volume data entry |
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c) Provision to capture a wide variety of data, including minute aspects such as mode and details of claim receipt, documents received/missing, ICD 10, PCS and CPT codes etc |
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d) Bills may be entered easily with a Excel-like interface; enables capture of fine details such as the specific benefit and expense category to which it belongs. |
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e) In short, everything designed to ensure that claims processing is automated to the maximum possible extent and is accurate too |
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f) Maker-Checker-Approver to ensure accuracy of data entry |
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g) Level of detail captured provides excellent analytical insights |
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RULE ENGINE |
a) Hierarchical application of rules at TPA, Insurer and Product Levels
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b) Processes claims effortlessly and efficiently for products with rules well defined, policies associated accurately and claim information captured completely |
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c) Details of rules applied and results are displayed completely for the user to be well informed about the decision to be made on the claim |
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d) Examples of products that can be easily processed using this rule engine would include Citibank Good Health, Family Floater products with sub limits and conditions launched by National, Oriental, etc |
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SETTLEMENT |
a) 'Settlement' screen to view the results of Rule Engine Process |
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b) Permits user to make final decision on "Accept/Reject" of the recommendation by the Rule Engine |
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c) "Override" process may be invoked to modify the decision on claim settlement. – subject to user rights |
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PAYMENT RELEASE |
a) Payments will be released based on the decision taken at the Settlement process |
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b) Income Tax deduction at source (TDS) on payments to Providers with configurable rates |
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c) Cheque will be printed based on product rules that would have been predefined |
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d) Payment includes various modes such as 'Print Cheque", "Pay Advice to Bank", "Direct Payment by Insurer" etc |
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INVESTIGATION |
a) Flag doubtful claims for investigation Pre or Post payment. |
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b) Conduct investigation and submit reports for decision on further course of action |
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CALL CENTER |
Web based information access to Internal Users,CallCenters, Insurers, Corporates, Providers, Insured, Brokers |
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ID CARDS |
Integration with existing ID Card application OR A separate application for in-house/vendor usage. Cards may be printed on paper or eCards, Individual or Family |
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REPORTS |
Reports for Operations Management, Insurers, Corporates & Providers |
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ROADMAP |
Our Roadmap for this application includes the following: |
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