The Operational System

"Supporting end-to-end health insurance processes"


The MedNext+ Operational System offers on-line, real-time processing for all core functions of heath insurance.

It enables you to manage complex information requirements, integrate and optimise your processes, and achieve operational excellence. It supports a vast range of health insurance products for both individual and group policies on the same system platform.

The Operational System consists of 12 fully integrated modules that provide functionality designed to support the entire policy lifecycle and all operational needs of the health insurance business.



Key Features:

  • On-line, real-time processing for all core functions of health insurance.
  • Supports all types of health insurance products without programming or IT support.
  • Multi-company.
  • Multi-lingual.
  • Multi-currency.
  • Pure web-based user interface with rich functionality through Oracle`s ADF-Faces.
  • Flexible and adaptable to business needs with extensive configuration options and user-defined custom fields.
  • 360° visibility of member claim history across policies and products.
  • Independent of specific standards for diagnoses and procedures. Can work with multiple standards and home-grown lists.
  • Comprehensive provider management and provider contracting.
  • Sophisticated care management functionality.
  • Fully automated claim adjudication process including user-defined edits.
  • Integrated customer service.

Module Key Features
Product
Configuration
Sophisticated definition of structure (plans, benefits) and coverage rules (limits, deductibles, co-pays, waiting periods, exclusions, etc)of diverse health insurance products without programming or any specialised IT support.
Automatic calculation of claims based on product rules and "realtime" update of member balances.
Rules that automatically link medical information of claims to member benefits.
Flexible premium definition based on multiple user-defined criteria (age, sex, etc).
Premium calculation based on multiple components and user-defined formulas.
Supports an enormous range of health insurance products including traditional indemnity, managed indemnity and managed care products as well as all types of coverage including inpatient, outpatient, pharmaceutical, dental, vision and allowances.
Indexing functionality that can automatically adjust premiums and coverage levels at configurable time intervals.

 

Module Key Features
Sales &
Commission
Management
Maintains all types of intermediaries (e.g. agents, brokers, direct sales force, etc.) organised under configurable sales channels.
Supports user-defined sales force hierarchies.
Configuration of complex commission arrangements including commission distribution across hierarchies.
Calculation and payment of commissions.

 

Module Key Features
Provider
Management
Maintains a comprehensive database of healthcare providers of all types (e.g. hospitals, physicians, diagnostic centres, pharmacies, etc.).
Supports grouping of healthcare providers under user-defined provider groups (networks, panels, etc.) with different administrative procedures, levels of coverage and reimbursement arrangements.
Extensive provider query capabilities supporting customer service.

 

Module Key Features
Provider
Contracting
Sophisticated functionality for managing different types of provider contracts including rates for provider services.
Variety of rate methodologies including fee schedules, flat rates, discounts, per diem, per stay, etc.
Automatic calculation of provider contracts at claim processing time.

 

Module Key Features

Application
Management & Underwriting

Effective and efficient processing of applications (proposals) for health insurance.

Captures all application data including the medical questionnaire, which is dynamic and user-defined.

Supports all stages of the underwriting process including access to the underwriting knowledgebase of Munich Health’s NorMRisk®.

Premium loadings and exclusions for individuals of increased risk.

Accepted applications can be converted to policies without additional data entry.

Comprehensive functionality for preparing and managing Quotations.

 

Module Key Features

Policy & Member Management

Functionality supporting the entire lifecycle of a policy from initial issuance to endorsement and renewal.

Management of both individual and group policies on the same system platform.

Configurable production of all policy material including policy/member documents, cards, guides, etc.

Sophisticated management of endorsements including premium calculation and maintenance of time-based images of policies and members.

Single instance of Policyholders and Members offering 360° visibility across multiple policies and products.

Coinsurance functionality enabling multiple insurance companies to share the risk of a policy.

 

Module Key Features

Premium Billing & Collection

Configurable issuance of premium bills.

Management of premium payments (collections).

Manual and automatic matching of payments to bills.

 

Module Key Features

Care Management

Captures information about medical cases (episodes of care) of the insured population together with all related incidents of care (e.g. inpatient, outpatient, etc.).

Offers sophisticated utilisation management functionality by supporting the process of review and authorisation of medical services.

Works with any (as well as multiple) diagnoses coding standard,
e.g. ICD9, ICD10, etc.

Automatic calculation of authorisations according to product and
provider contract rules.

Automatic creation of pre-invoices in order to reserve member
balances.

 

Module Key Features

Claims Processing

Automatic adjudication of all types of health insurance claims including reimbursement and direct-billing.

Uniform processing of different types of invoices (institutional, professional, allowance, etc) through the same claims engine yielding the same results.

Works with any (as well as multiple) procedure coding standard e.g. CPT, HICPS, local standards, home-grown lists, etc.

Automatic calculation of the amount payable to the provider based on contracted rates.

Automatic calculation of the insured member contribution based on the coverage rules of the insurance product.

Automatic calculation of allowance amounts based on product allowance schedules.

Flexible capturing of invoice line amounts through configurable, user-defined amount fields.

Powerful Review concept enabling manual review of suspended invoices.

Hundreds of data consistency and validation rules that the user can activate/deactivate as necessary.

User-defined rules (edits) that enable suspension of claims for review.

Sophisticated claim adjustment functionality including accurate automatic recalculation of affected claims.

Comprehensive Claims Reserves module that enables enforcement of different definitions of claims and reserving on multiple levels of the product structure.

 

Module Key Features

Claims Payment

Easy and secure payment of claims to various entities including provider, member, policyholder, principle, etc.

Automatic generation of cheques and bank transfers.

 

Module Key Features

Customer Service

Captures details of issues related to members, policyholders, providers, agents, etc., and manages all the necessary activities required to resolve those issues.

Manages inbound and outbound issues.

Fully integrated within MedNext+,providing customer service representatives with all necessary information to manage customer issues in a "one-stop" process.

Extensive use of predefined pieces of text to speed up data entry and enforce consistency.

 

Module Key Features
Reinsurance

Effective management of quota share reinsurance treaties.

Flexible definition of quota share percentages for multiple reinsurers and for different components of the product structure.

Comprehensive reinsurance reporting.

Generation or reinsurance statements of account.