1. TPA (Third Party Administrator)
The job of the TPA'sisto maintaindatabasesof policyholdersandissue themidentitycards with unique
identification numbers and handle all the post policy issues including claim settlements. In terms of
infrastructure, the TPA's run a 24-hour toll-free number, which can be accessed from anywhere in the
country. And they will have full-time medical practitioners under their employment who will
immediately take a decision on whether the ailment is covered under the policy.
Business Logic
1. All the records of medical insurance policies of an insurer will be transferred to the TPA.
2. TPA may issue identity cards to all the policyholders, which they have to show to the hospital
authorities before availing any hospitalization services.
3. In case of a claim, policyholder has to inform TPA on 24 hr toll free line provided by the TPA.
4. On informing the TPA, policy holder will be directed to a hospital where the TPA has a tied up
arrangement.Howeverpolicyholderwill have the option to join any other hospital of his choice, but in
such case payment shall be on reimbursement basis.
5. TPA issuesanauthorizationlettertothe hospital, for the treatment wherein the TPA will pay for the
treatment.
6. TPA will be tracking the case of the insured at the hospital and at the point of discharge; all the bills
will be sent to TPA.
7. TPA makes the payment to the hospital.
8. TPA sends all the documents necessary for consideration of claims, along with bills to the insurer.
9. Insurer reimburses the TPA.
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8. CRM SCREEN
The purpose of CRMscreen is to search for the individual or policy with the details of the insured like:
EIN (Employee Identification Number)
Company Wise Search
Employee / Insured Name
Card ID
Policy number
CCN (Claim Control Number),
9. Grievances Details Search
The resetbutton clears all the valuesfilledinthe givenfieldssothatnew valuescanbe inputagain.
The CRMScreenbutton processesthe search criteria.Afterfillingthe details/searchcriteriapressthe
CRM Screenbuttontostart the search.
The Home link takesyouback to thisCRM page (Home Page) fromanysectionwhere youare.
Company
Informatipon
Available
Balance &
Limit
11. • All underwritten data of members is collected by TPA for Enrollment. Insurers have now
started giving electronic data and online enrollment is now possible.
• Corporate clients intimate additions and deletions on a periodic basis to Insurer with a copy
to TPA. Corporate have started uploading data directly into TPA system
• All fields of the Insured are captured by TPA,s and ID card are generated and couriered to
Insured directly along with guidebooks.
• Insured/Insurer can track the enrollment/ID cards issuance and Dispatch details from TPA ,
Websites
• E cards can be generated from TPA website against Policy No / Card ID/Batch No/Employee
Code
Focus Web application covers the following areas of function:-
Collection
Data Entry
Cards
Claims
Account
Dispatch
Reports
System
Audit
Claim Document
A/C Utility
Inward Document
Grievance Control
The collection has been categorized into the following module
12. ۩ ADD COLLECTION:
► Colection > Add Collection
Add new Entry of collection of Policy as show below:-
14. ► Colection > Collection Report
Abstract
The new policy are generated by the Insurance company and hence the necessary information is
delivered to the TPA such the records in concern to these policies could be maintained. These
policies can be of type new, renew or endorsement and can be for either the Individual or Group
as needful.
Scenario
The collection module sums up the information of whatever new policy is generated, Criteria for
it is to uphold the details of the same. The particulars of the Underwriters along with the policy
specification as well as the entry form encircling policy type and the Endorsement if made any is
recorded.
Result
The outcome of the collection module results to summing up of the necessary details of the latest
policies ,as introduced by the Insurance Companies. In accordance to such information the TPA
maintains the annals for themselves and also for the Insured.
15. In Data Entry : FollowingMenusare there :--
۩ GROUP :
► Data Entry > Group
Abstract
This module covers the list of all the Underwriters involved in the process of Insurance .
Underwriter specification include its region, division and the branch. Any new Group account
could be created and could be further categorized as plant accordingly. Searching is possible on
16. the basis group name as well as option like Show is used to display Group details, Edit is used
for any required changes, Delete is used to delete the particular records along with the related
plant records.
Scenario
This module is mainly meant for the addition, editing or display of the records related to the
groups including its subcategories, employee’s information. Module encompasses the lay out of
Group showing its name, address specification, fax or contact details along with the cheque
name. Searching is possible on the basis of group’s name, the probability of Show, Edit, Deletion
is also available for the easy maintenance of the records. If one want to add the subcategory to
the existing Group the information is added as the plant(may or may not have the same address
description as the group).Whenever the policy is insured to the group the data particularizing the
Group details as well as the policy details is entered considering all the terms and conditions on
the basis of which any policy can be insured. This basically covers the details regarding the
policy that is the current policy and the previous policy, address specifications or the conditional
requirements like whether the policy is issued on the basis of the preexisting disease or whether
granted in concern to hospitalization, maternity, dental etc . On the basis of requirements
analogous to the stated conditions policy is issued to the group, it even specifies the maximum
dependents for the particular grade or categories. The module even pin down the details of the
employees working for the Group along with the possibility of searching the employee by
entering name, CCN no, Policy no, Card ID.
Result
The data entered for the Group module encircles the particulars of a Group(that is the searching,
listing of the same) the policy being issued to the group, even it notifies the Plant ( subcategory
of the Group) being added to the existing one ,also if any employee is added to the group then
the required details should be maintained allowing search on basis of any of the following Name,
CCN no, CardId , Policy No. All the records in relation to the group could be maintained easily
using the given module.
Employee search is possible on the basis any of the following,
Insured Code
Employee’s name
Card Id
Policy Number
CCN
All the information regarding the Underwriter Details, Policy Details, Insured Person’s details
and the Card Details are available through it .The direct addition or listing of the plant records is
possible and the options of Show, Edit, Delete, Edit policy, List Policy are also available for the
easy maintenance of the records .
The path for the above module is as follows:-
17. Data Entry > Group
The user may perform the desired task following any of given path
Add Group
Data Entry > Groups >> Add Groups
Group isdividedintofollowingSubmenus:--AddGroup :-
18. After adding group software ask for Add Plant for this group. If you want to add new Plant in this Group
then click on Hyperlink else click on Home Hyperlink.
Search Group
Data Entry > Groups >> Search Group
You Can Searchany group/PlantthroughsearchModule.
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22. List All Groups
Data Entry > Groups >> List All Groups
23. Add Group Policy
Data Entry > Groups >> Add Group Policy
24. Add Group Employee
Data Entry > Groups >> Add Group Employee
25. Search Group Employees
Data Entry > Groups >> Search Group Employees
List Of All Plant
Data Entry > Groups >> List Of all Plant
