Health claims and TPA schemes

Version 2 runs a health scheme the way a TPA does: members with cards, eligibility at the point of service, pre-authorisation with medical review, direct billing from providers, adjudication line by line, explanations of benefits, and the client insurer's fund.

Members and cards

Members live on the policy's Members tab. Each has a member number, a date of birth, a relationship (principal, spouse, child, parent) and a plan. Add member enrols someone mid-term: the plan's yearly premium is billed pro rata for the days left, through an endorsement. Remove from the policy credits the unused premium the same way. Change plan bills or credits the difference. A principal cannot leave while a dependant is still active.

Card downloads a member's card as a PDF; All cards prints every active member on one sheet; Email cards sends them to the customer. Every card carries a QR code and a link to the digital card, a public page that shows the member's status today: eligible or not, plan, benefits and balances. The link is a long random token; only someone with the card can open it.

Eligibility check

Claims > Eligibility check is the question a provider's front desk asks: type a member number, a card number, an ID or a name, choose the date, the provider and the benefit, and read the answer: policy in force, member enrolled, premium paid, provider in the plan network, waiting period over, limit remaining, and what the member pays (copay, coinsurance). From there you can start a pre-authorisation or a claim.

Provider networks, contracts and price lists

Network > Provider networks groups providers in tiers; a plan names the network it accepts direct billing from. On a provider, the Contracts tab holds dated contracts with a discount and payment terms, Price list the contracted price per code (import it from Excel), and Credentials the licences and accreditations with their expiry dates. You are told 30 days before a contract or credential expires.

Network > Medical codes holds the diagnosis (ICD-10) and procedure codes. A shared starter list is provided; add your own or import a full list, including CPT codes you hold a licence for.

Pre-authorisation

Claims > Pre-authorisations: a hospital asks before treatment. Record the member, the provider, the benefit, the codes, the estimated cost and the admission date. The checks run at once: eligibility on that date, network, limits, the benefit's rules and the product's code rules. A request with a code that needs medical review, or a high cost, goes to medical review; a Medical Reviewer (a starter role) takes it and decides: approve, approve partially, or reject, with the validity dates. The decision can run through the Claims: decide a pre-authorisation approval chain. The requester and the customer are told; the approval is then used by the claim.

Direct billing and adjudication

A direct-billing claim is what a hospital bills you for a member's treatment. Register it from the pre-authorisation (Register the claim), from the member on the eligibility check, or from a provider batch. Add the invoice lines: code, description, quantity, billed amount, and the benefit each falls under.

Adjudicate decides each line against the plan:

Check	Result
Member eligible on the service date	Otherwise rejected: not eligible
Provider in the plan network	Otherwise rejected: out of network (the member may claim a reimbursement)
Waiting period of the benefit over	Otherwise rejected: waiting period
Pre-authorisation present when the benefit or a code rule needs one	Otherwise rejected: pre-authorisation missing
Same member, provider and date already received	Rejected: duplicate
Contracted price for the code, or the contract discount	Allowed amount reduced
Code rule caps, per-visit limit, benefit limit left	Allowed amount reduced
Copay (once per claim) and coinsurance	The member's share
Annual limit per member and per family	The plan pays up to what is left

The claim ends approved for what the plan pays, or rejected with a reason code. The explanation of benefits (PDF, emailed to the customer) shows each line: billed, allowed, member's share, plan pays, and why anything was reduced.

A reimbursement claim is the same, for a bill the member paid; attach the receipts under Files and pay the customer.

Provider batches

Claims > Provider batches: the claims a hospital sends together for the month. Register the batch, add each claim to it, then Adjudicate all, Approve for payment (through the Claims: approve a provider batch chain) and Pay the batch: one payment per approved claim, and the provider statement emailed to the provider with what was paid and why anything was reduced or rejected.

Schemes and funds (TPA)

A TPA runs each client insurer's book as a scheme (Network > Schemes and funds): its policies, the TPA fee (percent of premium, per member per month, percent of claims paid, or a fixed monthly fee) and the claims fund. Choose the scheme on the quote; claims on its policies are paid from the fund, and fees post by themselves (with the payment, or on the last day of the month).

When the fund falls below its threshold, finance is told and a replenishment request is raised and emailed to the insurer with the fund statement. Record the insurer's deposit when it arrives; it settles the request.