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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CLAIMS MANAGEMENT WITHIN NHIA, GHANA
Acting Director, Claims
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
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.
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
Current Claims Processing
RECEIPT & PROCESSING
Operationalize CPC Claims Software and ICT equipment
Introduction of E-Claims submission
Set up zonal CPCs (CPC ACCRA, CPC TAMALE,
Consolidation of claims management from 155 centres to zonal Claims Processing Centres (CPCs)
Digitization of Claims from Schemes to CPCs.
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
Paper claims generated from healthcare providers
Registration of claims
Fulfillment and preparation
Delivery to CPC/Scanning of paper claims
Storage of claims
SCANNED CLAIMS SCANNED CLAIMS SCANNED CLAIMS
CPC ACCRA, CPC TAMALE,
CPC CAPE COAST , CPC KUMASI
PAPER CLAIMS SUBMISSIONS
Health care Provider
CLAIMS APPLICATION SOFTWARE
Assessment, Adjudication + Detection of Fraud, Errors & Abuse
NHIS claim documents
High Volume Scanner Data Capture & Data Entry
Healthcare provider can create and amend claims, view the status of all claims . Dashboard functionality allows instant overview of volume and status of claims.
E-Claims submission by providers with Hospital Information Systems (HIS)
Hospital Information System
Claims Data File
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
PAYMENT & ARCHIVING