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ENROLLMENT - Ensure that all forms bear the current information including Hospital in the network.
Makes phone calls for corrections of errors
Log the form before dispatch for registration and ID card production.
DATA BASE ADMINISTRATION: Ensure that necessary changes are done in the database including additions, deletions and change of provider by enrollees.
LIST TO PROVIDERS: Ensure that list of enrollees are sorted from the database and sent to providers before the beginning of the month via e-mails.
CALL TO PROVIDERS: Ensure that calls are made to providers after mails are sent and advising them to download current list and use same for enrollee identification.
CLAIMS VETTING AND ENTRY: Ensure that fee for service claims are vetted according to agreed tariff. Verification of genuiness of claims by doing enrollee call back.
PAYMENT SCHEDULE: Prepare payment schedule by entering the total claims per hospital and forwarding to the Head Office for payment.
PAYMENT ADVICE: Ensure that hospitals are advised on payment made in relation to the claims made and giving reasons for shortfalls.
CLAIMS INFORMATION: Getting information on claims status and passing same to providers in cases of delay.
PROVIDER ACCREDITATION: Provider network adequacy assessment and provider due diligence. Development of tariff for fee for service benefits and negotiation of service tariff with providers. Ensure that contracts are signed and files opened for providers. Ensures proper documentation of provider correspondences including provider data, letters, and encounter returns.
PROVIDER EDUCATION: Arranging and delivering provider education to providers twice a year to ensure that provider staffs are conversant with the health care benefits of enrollees. Ensuring that the benchmark for service quality is communicated to all staff of the hospital.
CASE AND DISEASE MANAGEMENT: Ensure that all notified admission that are more than 48 hours are case managed. Follow up on chronic disease cases to ensure compliance and avoid complications. Logs all admitted cases with remarks on findings.
ANNUAL PROVIDER RECERTIFICATION: To carry out annual recertification of all network providers, identify gaps and communicate same to the provider management. Agree on time line to close the identified gaps.
CASE NOTE AUDIT: To carry out random case note audit of all providers at least once a year to ensure adherence to treatment protocols. To carry out case note audit on providers following report of maltreatment by enrollees.
COMPLAINT INVESTIGATION AND RESOLUTION: Ensure that all complaints are resolved within 48 hours of receipt by promptly calling or visiting the provider to ascertain facts and getting back to the enrollee and / or the client.
EXCLUSION MANAGEMENT: Assisting the client in the management of exclusions by negotiating cost, giving necessary approvals and ensuring that clients pay as soon as possible.
PREAUTHORIZATION AND APPROVAL: Giving necessary approvals and preauthorization after verifying eligibility. Negotiation of tariff with the providers when tariff is not in the agreement.
NOTIFICATION OF PREMIUM RENEWAL: Ensure that clients are notified of renewal 30 days to due date. Getting information on client staff update and enforcing changes in the database.
CLIENT RELATIONS MANAGEMENT: Ensuring that there exists a constant communication between clients and that issue affecting the scheme is constantly being addressed.