Health care payer
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Healthcare Payer functional view
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Health care payer
- 1. Enroll & Bill Customers Manage Member Benefits Manage Claims& Encounters Provide Customer & Provider Services Develop & Manage Health Care Delivery Networks Establish Market Presence Manage Distribution Channels Identify & Manage opportunities Conduct Salesand Renewals 1.5 Perform Underwriting & Rating 1.6 Manage Customer Relationships Receive & Prepare Enrollment packages Define Member Benefits Components Prepare & Receive Claims & Encounters Manage Inbound Inquiries Develop Network Strategies Setup & maintain Group Benefits Maintain Member Specific Benefits ProcessClaims & Encounters Resolve Inquiries Create & Maintain Networks Enroll & Maintain Member Information Link Benefits To Support Coverage Provide Reimbursement s Manage Service Delivery Contract With Networks Bill Customer Communicate Member Benefits Conduct Post Adjudication & Review Monitor & Assess Networks 2.5 Collect & Apply Premiums 6.5 Manage Network Relationships Payer Process Model Acquire & Renew Customer