VishNMed–TPA
(VishNSys Medical Claim Administration System for TPA Organizations)
VishNMed – TPA is a state of the art software solution built up on Java technologies (J2EE) with features to meet all operational, claim administration and management requirements of any Third Party Claim Administrators (TPAs).
It is a scaleable, modular and integrated Medical Claim Administration system with product based policy condition configurations specifically designed for TPAs with a component model that is capable of administering any volume of medical claims to meet the requirements of a TPA and to address their clients’ claim processing needs through quick and easy operational procedures.
The easy to manage Insurance policy data creation modules such as upload of policy period, conditions etc. allows the TPA to configure the parameters that are required for claims administration.
It is a comprehensive and complete Medical Insurance System which helps the TPA organizations to manage their health insurance operations with the help of a state of the art Claim Administration module and a product based configurable Underwriting Module. The system was designed by bringing in together the experience and expertise of IT professionals, Doctors, Medical consultants, Health Insurance professionals and Accounting and Finance Professionals. Supportive and controlling functionality such as Process flow management, Management of documents related to underwriting and claims, Notification/alert of crucial events, user and role management, system administration etc. are built-in as integral parts of the system which helps in easy operation and administration. It also has a state of the art Reinsurance module that supports Proportional, Net based and XOL reinsurance arrangements. A number of reports/statements are provided as part of the system in order to enable smooth operation and help decision making. All features and functionality are defined carefully with parameterization to meet almost all requirements of all health insurance operations which enables fast implementation.
Key features:
- J2EE based enterprise application developed using JAVA technology with a state of the art application design
- Platform independent
- Database independent: Support for a variety of database engines such as Oracle, MS-SQL, IBM Informix etc.
- Multi-Company, Multi-Branch, Mutli-Currency
- A unique model with an organization unit concept
- Automated and rule based claim adjudication
- Guidelines for users during manual adjudication
- Auto assignment of claim batches to adjudicators
- Auto assignment of claim acknowledgement for reimbursements
- Compliant to health authorities (HAAD, DHA etc.)
- Open ended design to meet the requirements of health authorities in any country
- ICD-9 and ICD-10 compatibility with option to define bridge between both the versions
- Parameterization of business logic
- Definable templates for documents generated from the system
- Built-in member-insurance card design and printing
- Comprehensive policy amendment feature
- Product/Scheme based policy administration
- Individual and group medical Insurance products/scheme
- Client specific, network specific, general etc. products/scheme to manage the requirement of policies from any Insurance companies
- Comprehensive provider network management
- Inheritance feature between products and policies
- Easy methods for uploading policy conditions received from Insurance companies
- Integration components for directly incorporating policy details from Insurance companies
- Prior-authorization management with integrated work-flow
- Fax management module with editing features for physical claims and its process flow such as prior-authorization, clarification etc.
- Audit engine
- Audit trials with facility to generate business rules
- Fraudulent detection engine
- Built-in BI and standalone BI
- Early Warning System and alerts
- Built-in document management system
- Built-in work flow management
- email based work flow management
- Rule based approvals with approval levels in line with organization structure
- Online invoice tracker
- Real-time Interfacing with health authorities systems
- Seamless Integration with adjudication engines
- Seamless Integration with PBM
- Seamless Integration with DRG services
- Seamless Integration with email server, fax server and collaboration suite
- Multiple levels of deductibles
- Multiple levels of sub-limits
- Multiple levels of covers
- Differentiation of limits and sub-limits for various permutations and combinations of cover, deductible, geographical coverage, ICD, CPT, member category, scope of treatment etc.
- Comprehensive reporting
It is a knowledge based business application designed by involving a number of experienced and expert professionals in the relevant areas such as Administrators of TPA organizations, Health Insurance professionals, IT professionals, Health practitioners, Finance professionals, Management experts, System engineers, Project Management experts, Implementation consultants