Jln it track workshop dubai march 2013
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JLN IT TRACK WORKSHOP DUBAI MARCH 2013. CLAIMS MANAGEMENT WITHIN NHIA, GHANA. Perry Nelson Acting Director, Claims. WHY CLAIMS MANAGEMENT . Claims management is a vital component of any insurance organisation

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JLN IT TRACK WORKSHOP DUBAI MARCH 2013

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Jln it track workshop dubai march 2013

JLN IT TRACK WORKSHOPDUBAI MARCH 2013

CLAIMS MANAGEMENT WITHIN NHIA, GHANA

Perry Nelson

Acting Director, Claims


Why claims management

WHY CLAIMS MANAGEMENT

Claims management is a vital component of any insurance organisation

Like all other insurance organisations, the very survival of NHIS is dependent on prudent and effective claims management


Jln it track workshop dubai march 2013

CLAIMS PROCESSING WITHIN THE NHIS

Claims are currently managed from over 155 centres (districts). This approach is not only ineffective but fraught with serious challenges that threaten the sustainability of the scheme.

In response to these challenges, the Claims Division was set up in November 2009 to streamline, manage and coordinate claims processing activities nationwide.

It was also to manage the pilot Claims Processing Centre and the set up of other CPCs in other parts of the country.


Claims processing within the nhis cont d

CLAIMS PROCESSING WITHIN THE NHIS cont’d

All claims from the Volta Region, All Teaching and Regional Hospitals and some select facilities across the countryare being processed at the CPC

Meanwhile claims processing within the District schemes continues in all other regions with the support of the CPC until the consolidation process is gradually completed


Jln it track workshop dubai march 2013

CLAIMS PROCESSING WITHIN THE NHIS cont’d

Current Claims Processing

PROVIDERS

PROVIDERS

GENERATION

DELIVERY

RECEIPT & PROCESSING

PAYMENT RECOMMENDATION

PAYMENT

155

Schemes

CPC 1

PAYMENT RECOMMENDATION

NHIA

PAYMENT


The future of claims processing within nhis

THE FUTURE OF CLAIMS PROCESSING WITHIN NHIS

Operationalize CPC Claims Software and ICT equipment

Introduction of E-Claims submission

Set up zonal CPCs (CPC ACCRA, CPC TAMALE,

  • CPC CAPE COAST , CPC KUMASI)

    Consolidation of claims management from 155 centres to zonal Claims Processing Centres (CPCs)

    Digitization of Claims from Schemes to CPCs.


The future of claims processing within nhis cont d

THE FUTURE OF CLAIMS PROCESSING WITHIN NHIS cont’d

CLAIMS SUBMISSION OPTIONS

Paper based claims - digitization of claim forms and automatic electronic vetting of claims according to specified business rules

Web-based E-claims entered directly into NHIA claims application via internet

E-claims generated from Hospital Information Systems (HIS) or any other application and submitted via CD-Rom, e-mail, FTP or via internet access to NHIA Claims Software


Jln it track workshop dubai march 2013

CLAIM SUBMISSION OPTION 1 : Paper Based Claims Workflow

PROVIDERS

PROVIDERS

GENERATION

Paper claims generated from healthcare providers

RECEIPT

Registration of claims

Fulfillment and preparation

Delivery to CPC/Scanning of paper claims

Storage of claims

Scheme 1

Scheme 2

Scheme 3

SCANNED CLAIMS SCANNED CLAIMS SCANNED CLAIMS

ADJUDICATION

CPC ACCRA, CPC TAMALE,

CPC CAPE COAST , CPC KUMASI

Data Entry

Quality Check

Rules Engine

Vetting (Adjudication)

Audits

PAYMENT RECOMMENDATION

NHIA

PAYMENT


Jln it track workshop dubai march 2013

WORKFLOW

PAPER CLAIMS SUBMISSIONS

Health care Provider

ARCHIVE

PAYMENT

CLAIMS APPLICATION SOFTWARE

Assessment, Adjudication + Detection of Fraud, Errors & Abuse

NHIS claim documents

Claims Data

High Volume Scanner Data Capture & Data Entry


E claims d irect e ntry via internet on nhia claims application

Claims Submission Option 2

E-Claims Direct Entry via internet on NHIA Claims Application

http://eclaims.nhia.gov.gh/Login.aspx

Healthcare provider can create and amend claims, view the status of all claims . Dashboard functionality allows instant overview of volume and status of claims.


Jln it track workshop dubai march 2013

Claims Submission Option 3

E-Claims submission by providers with Hospital Information Systems (HIS)

Hospital Information System

Claims Data File


Jln it track workshop dubai march 2013

E-CLAIMS SUBMISSION

Option 2

Option 3

Health Care Provider

Direct Claims Entry via NHIA Claims Application WEBFRONT

E-claims generated from

Hospital Information Systems (HIS)

CLAIMS APPLICATION SOFTWARE Assesment, Adjudication + Detection of Fraud, Errors & Abuse

CPCs

PAYMENT & ARCHIVING


Jln it track workshop dubai march 2013

Implementation of Zonal CPCs

Establishment of CPCs in other parts of the country to process all claims generated across the nation.


Jln it track workshop dubai march 2013

CLAIMS PROCESSED at CPC - 2012

CLAIMS DIVISION


Thank you

THANK YOU


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