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Visio-HCRM Process V3-1
- 1. BusinessRetention Partner Prospecting User Tools (Tobe Defined) Administration Part2-PolicyIssuance Product Innovation FinalizingBusiness Risk Management Start Here Keep Going LCN LRN and Claim s Adm inistrationPolicy Administration Milestone: Start Renewal Process or Termination Process For Discussion Purposes Proposed HCRM Business Process Model Milestone: New Policy, Renewed Policy or Amended Policy Complete Part1 -Policy Q uote and Language N egotiation Decision Point: New Client, Renewal or Amendment Negotiations Succeed or Fail Business Acquisition HCRM Lifecycle Model Reference Milestone: Potential Client Milestone: Potential Product Applications (To be Defined) Data and Documents (To be Defined) N egotiating Business Lifecycle Layer Business Process Layer User Tool Layer Application Layer Data/Doc Layer Milestone: RFP, Renewal Letter, Amendment Request LT Credentialing HCRM Process V3-1, Process Model Maintained by: Pat and Mark
- 2. Definition of aProcess Note - The following is an explanation of the basic process attributes used during this process definition exercise. The basic “Process” definition used during this exercise was: “A series of coordinated events that lead to a common goal.” Process descriptors provided in the diagrams: This process: (definition) - A brief description of the process usually stated as a “from - through” statement including the final goal This process starts when: (beginning milestone) - Beginning event The goal of this process is: (ending milestone) - Ending event or goal This process uses: (inputs) - Beginning inputs - Interim inputs This process creates: (outputs) - Interim outputs - Ending outputs This process must have: (requirements) - Starting information - Outputs from another process HCRM staff: (coordinated internal activities) - Perform the listed “internal” activities HCRM staff interact with: (coordinated external activities) - An external client - Perform the listed “external” activities For Discussion Purposes Proposed HCRM Business Process Model Process Definition HCRM Process V3-1, Process Definition Maintained by: Pat and Mark
- 3. BusinessRetention Partner Prospecting Administration Part2-PolicyIssuance FinalizingBusiness Risk Management LCN LRN and Claim sAdm inistrationPolicy Administration Milestone: Start Renewal Process or Termination Process For Discussion Purposes Milestone: New Policy, Renewed Policy or Amended Policy Complete Part1 -Policy Q uote and Language N egotiation Decision Point: New Client, Renewal or Amendment Negotiations Succeed or Fail Business Acquisition N egotiating Business Milestone: RFP, Renewal Letter, Amendment Request Product Innovation Proposed HCRM Business Process Model Product Innovation Process Milestone: Potential Client Milestone: Potential Product LT Credentialing Product Innovation Process This process: (definition) - Identifies and creates profitable products for HCRM This process starts when: (beginning milestone) - There is an idea for a new product - There is an idea for a product enhancement The goal of this process is: (ending milestone) - A known product This process uses: (inputs) - A product concept (beginning input) - Market research (interim input) - Compliance research (interim input) This process creates: (outputs) - An internally approved product (ending output) - A state approved product (ending output) - Marketing material (ending output) This process must have: (requirements) - Detailed market analysis from Risk Management - An internal review, “Can we do this?” - A thorough compliance review to meet regulatory requirements HCRM staff: (coordinated internal activities) - Define the product idea - Draft language and parameters - Conduct an internal review to determine if HCRM can execute this product - Complete a compliance review - Complete state filing of the product - Prepare marketing material HCRM staff interact with: (coordinated external activities) - New and current markets to help identify new HCRM products - New and current markets to get feedback for product enhancements - New and current markets to get information leading to new services - Brokers and clients who use our Blue Sheets - State Departments of Insurance to file and approve policiesHCRM Process V3-1, Product Innovation Maintained by: Pat and Mark
- 4. BusinessRetention Administration Part2-PolicyIssuance Product Innovation FinalizingBusiness Risk Management LCN LRN and Claim s Adm inistration PolicyAdministration Milestone: Start Renewal Process or Termination Process For Discussion Purposes Proposed HCRM Business Process Model Partner Prospecting Process Milestone: New Policy, Renewed Policy or Amended Policy Complete Part1 -Policy Q uote and Language N egotiation Decision Point: New Client, Renewal or Amendment Negotiations Succeed or Fail Business Acquisition Milestone: Potential Product N egotiating Business Milestone: RFP, Renewal Letter, Amendment Request Partner Prospecting Milestone: Potential Client LT Credentialing Partner Prospecting Process This process: (definition) - Identifies and qualifies potential partners for HCRM. This may include prospective purchasers, prospective distribution channels, or prospective provider networks. This process starts when: (beginning milestone) - The prospective partner is identified The goal of this process is: (ending milestone) - A known qualified partner that is ready to do business with HCRM This process uses: (inputs) - An identified prospective partner, (beginning input) - Partner analysis from Risk Management, (interim input) This process creates: (outputs) - Qualification results (interim output) - An approved distribution partner (ending output) - A knowledgeable purchaser partner (ending output) - Purchaser partner demographics and census information (ending output) - A provider network ready to start LifeTrac negotiation and credentialing (ending output) This process must have: (requirements) - Prospective partners identified - Prospective partners qualified HCRM staff: (coordinated internal activities) - Collect and manage information about prospective partners - Collect and manage prospective partner contacts - Conduct analysis of the partner market - Conduct analysis of specific partners HCRM staff interact with: (coordinated external activities) - Several external groups to identify prospective partners - Prospective distribution partners to complete the approval process. This includes brokers, TPAs, MCOs, and HCOs. - Prospective purchaser partners to promote a product sale. This includes HMOs, MCOs, physician groups, healthcare providers, insurance companies, and self-funded employer groups. HCRM Process V3-1, Partner Prospecting Maintained by: Pat and Mark
- 5. FinalizingBusiness N egotiating Business BusinessRetention Partner Prospecting Administration Part2-PolicyIssuance Product Innovation RiskManagement LCN LRN and Claim s Adm inistration Policy Administration Milestone: Start Renewal Process or Termination Process For Discussion Purposes Proposed HCRM Business Process Model Quote, Negotiate and Issue Process, Page 1 Milestone: New Policy, Renewed Policy or Amended Policy Complete Part1 -Policy Q uote and Language N egotiation Decision Point: New Client, Renewal or Amendment Negotiations Succeed or Fail Business Acquisition Milestone: Potential Client Milestone: Potential Product Milestone: RFP, Renewal Letter, Amendment Request LT Credentialing Policy Quote, Negotiate, and Issue Process - Page 1 This process: (definition) - Part 1 of this process moves a purchaser partner from a potential sale through successful negotiations using proven underwriting protocols. - Part 2 of this process moves the purchaser partner from successful negotiations to an executed contract and system readiness. - (Note) The group started discussing these activities as two processes because of the differences in “internal” activity. Further discussion pointed out that the client views these activities as a single process with the goal of an executed contract. These coordinated tasks are presented here as one process with a decision point separating the two parts. There are good points to put them together and good points to keep them separate. This process starts when: (beginning milestone) - A potential purchaser seeks to purchase, renew or amend a HCRM product. This can start with an RFP, a renewal letter or an amendment request. This process has an interim decision point (interim milestone): - If negotiations with the client are successful, this process will continue. If negotiations are not successful, the process ends. The goal of this process is: (ending milestone) - An executed contract (policy) with the client Part 1 of this process uses: (inputs) - An RFP, renewal letter, amendment notice (beginning input) - Basic client demographics and census information (beginning input) - Additional detailed client data (interim input) - Experience analysis from Risk Management (interim input) Part 2 of this process uses: (continued inputs) - Negotiated terms and conditions (interim inputs) - Responses from the internal review of the draft policy (interim inputs) - Responses from the client to the issued policy (interim inputs) Continued on the next page: HCRM Process V3-1, Quote, Negotiate and Issue, Pg1 Maintained by: Pat and Mark
- 6. FinalizingBusiness N egotiating Business BusinessRetention Partner Prospecting Administration Part2-PolicyIssuance Product Innovation RiskManagement LCN LRN and Claim s Adm inistration Policy Administration Milestone: Start Renewal Process or Termination Process For Discussion Purposes Proposed HCRM Business Process Model Quote, Negotiate and Issue Process Milestone: New Policy, Renewed Policy or Amended Policy Complete Part2 -Policy Q uote and Language N egotiation Decision Point: New Client, Renewal or Amendment Negotiations Succeed or Fail Business Acquisition Milestone: Potential Client Milestone: Potential Product Milestone: RFP, Renewal Letter, Amendment Request LT Credentialing Policy Quote, Negotiate, and Issue Process - Page 2 Part 1 of this process creates: (outputs) - A manual rate (interim output) - An underwritten quote (interim output) - Negotiated policy language (interim output) Part 2 of this process creates: (continued outputs) - Drafted and internally reviewed policy language (interim output) - Issued policy language to client, renegotiated if necessary (interim output) - An executed signed policy with final terms and conditions (ending output) This process must have: (requirements) - An RFP, renewal letter, amendment notice - Proven underwriting protocols - Accurate client data - Accurate client analysis - Detailed negotiation results - Specific and accurate Terms and Conditions - A thorough internal review - A thorough compliance review - Specific system set-up criteria During Part 1, HCRM staff: (coordinated internal activities) - Begin a quote tracking process - Prepare and deliver a manual rate - Receive and analyze additional client data - Underwrite a quote (with alternatives if necessary) - Negotiate final policy language - Negotiate a final policy rate based on the quote During Part 2, HCRM staff: (coordinated internal activities) - Draft policy language based on negotiation results - Complete an internal review of the proposed policy - Complete a compliance review of the proposed policy - Issue the policy to the client and resolve any differences - Execute signed copies of the policy - Set-up downstream systems, or provide policy terms and conditions to other processes HCRM staff interact with: (coordinated external activities) - The client to request and attain additional client data - The client to finalize policy terms and conditions and execute the final contract HCRM Process V3-1, Quote Negotiate and Issue, Pg 2 Maintained by: Pat and Mark
- 7. BusinessRetention Partner Prospecting Administration Part2-PolicyIssuance Product Innovation FinalizingBusiness RiskManagement LCN LRN and Claim s Adm inistrationPolicy Administration Milestone: Start Renewal Process or Termination Process For Discussion Purposes Proposed HCRM Business Process Model Policy Administration Process Milestone: New Policy, Renewed Policy or Amended Policy Complete Part1 -Policy Q uote and Language N egotiation Decision Point: New Client, Renewal or Amendment Negotiations Succeed or Fail Business Acquisition Milestone: Potential Client Milestone: Potential Product N egotiating Business Milestone: RFP, Renewal Letter, Amendment Request LT Credentialing Policy Administration Process This process: (definition) - Starts upon the completion of an executed policy and administers all of the financial transactions associated with the policy. These include premium billing and collections, commissions and ceded re-insurance. This process also monitors the financial performance of a policy to determine if HCRM should seek a renewal of the business or terminate the business. This process starts when: (beginning milestone) - A policy has been executed, with all terms and conditions defined - System set-up is complete and the system is ready to administer the policy The goal of this process is: (ending milestone) - The successful administration of premium, commissions and ceded re-insurance This process uses: (inputs) - Finalized terms and conditions of the policy; specifically premium, commissions and ceded re-insurance terms (beginning inputs) - On-going financial performance analysis of the policy (interim inputs) This process creates: (outputs) - Periodic reporting and analysis of financial performance (interim outputs) - Contract year-end reporting and analysis of financial performance (ending outputs) - Recommendation for renewal or termination (ending output) This process must have: (requirements) - Exact policy terms and conditions covering premium, commissions and ceded re-insurance from the Policy Quote, Negotiate and Issue Process HCRM staff: (coordinated internal activities) - Set-up and administer all functions necessary to bill and collect premium, pay commissions and administer ceded re-insurance for all policies - Monitor financial performance of all policies HCRM staff interact with: (coordinated external activities) - Clients, brokers, TPAs and LifeTrac to pay commissions - Clients, brokers and TPAs for monthly and annual reporting, including the 5500 report - Re-insurers and intermediaries for monthly billing statements and payments - Corporate accounting providing numerous reports including quarterly financial exposure and annual statement exhibits (Schedule S) HCRM Process V3-1, Policy Administrtion Maintained by: Pat and Mark
- 8. Policy Administration LCN LRN and Claim s Adm inistration BusinessRetention PartnerProspecting Administration Part2-PolicyIssuance Product Innovation FinalizingBusiness Risk Management Milestone: Start Renewal Process or Termination Process For Discussion Purposes Proposed HCRM Business Process Model Risk Management Process Milestone: New Policy, Renewed Policy or Amended Policy Complete Part1 -Policy Q uote and Language N egotiation Decision Point: New Client, Renewal or Amendment Negotiations Succeed or Fail Business Acquisition Milestone: Potential Client Milestone: Potential Product N egotiating Business Milestone: RFP, Renewal Letter, Amendment Request LT Credentialing Risk Management Process This process: (definition) - Performs critical analysis for other processes. It performs partner and market analysis and delivers financial performance analysis of on-going HCRM business. This process also provides analysis to determine if HCRM should renew or terminate current business. This process starts when: (beginning milestone) - Market analysis is required for the Product Innovation process - Risk analysis is required for the Partner Prospecting process - Financial performance analysis is required to manage current business - Financial performance analysis is required to renew business The goal of this process is: (ending milestone) - To deliver risk analysis information to other processes This process uses: (inputs) - Industry data for market and partner risk analysis (beginning inputs) - Finalized terms and conditions of the policy; specifically premium, commissions and ceded re- insurance terms (beginning inputs) - On-going claims experience, financial experience and network evaluation detail (interim inputs) This process creates: (outputs) - On-going analysis of claims experience, financial performance and network evaluation (interim outputs) - On-going updates for financial and reserve projections (interim outputs) - Contract year-end analysis of claims experience, financial performance and network evaluation (ending outputs) This process must have: (requirements) - Exact policy terms and conditions covering premium, commissions and ceded re-insurance from the Policy Quote, Negotiate and Issue Process HCRM staff: (coordinated internal activities) - Perform on-going (or ad-hoc) analysis of actual claim experience, aggregate claim experience, network performance and medical management results. HCRM staff interact with: (coordinated external activities) - Brokers or TPAs to obtain reports and analysis of new clients and renewal clients HCRM Process V3-1, Risk Management Maintained by: Pat and Mark
- 9. BusinessRetention Partner Prospecting Administration Part2-PolicyIssuance Product Innovation FinalizingBusiness RiskManagement LCN LRN and Claim s Adm inistrationPolicy Administration Milestone: Start Renewal Process or Termination Process For Discussion Purposes Proposed HCRM Business Process Model LifeTrac Credentialing Process Milestone: New Policy, Renewed Policy or Amended Policy Complete Part1 -Policy Q uote and Language N egotiation Decision Point: New Client, Renewal or Amendment Negotiations Succeed or Fail Business Acquisition Milestone: Potential Client Milestone: Potential Product N egotiating Business Milestone: RFP, Renewal Letter, Amendment Request LT Credentialing LifeTrac Credentialing Process This process: (definition) - Moves a potential transplant network partner through a detailed credentialing process as defined by LifeTrac standards. (Note) This process is unique to the LifeTrac product. This process is not used by other HCRM products. This process starts when: (beginning milestone) - A LifeTrac transplant network contract has been signed with the provider network The goal of this process is: (ending milestone) - The completion of the credentialing process This process uses: (inputs) - LifeTrac credentialing standards, (beginning input) - Detailed credentialing process results, (interim input) This process creates: (outputs) - A fully credentialed transplant provider network, (ending output) This process must have: (requirements) - An executed contract with the provider network HCRM staff: (coordinated internal activities) - Initiate, monitor and evaluate the results of the credentialing process HCRM staff interact with: (coordinated external activities) - The provider network being evaluated to complete the credentialing process HCRM Process V3-1, LT Credentialing Maintained by: Pat and Mark
- 10. BusinessRetention Partner Prospecting Administration PolicyIssuance Product Innovation FinalizingBusiness RiskManagement LCN LRN and Claim s Adm inistrationPolicy Administration Milestone: Start Renewal Process or Termination Process For Discussion Purposes Proposed HCRM Business Process Model LCN LRN and Claims Administration Process Milestone: New Policy, Renewed Policy or Amended Policy Complete Policy Q uote and Language N egotiation Decision Point: New Client, Renewal or Amendment Negotiations Succeed or Fail Business Acquisition Milestone: Potential Client Milestone: Potential Product N egotiating Business Milestone: RFP, Renewal Letter, Amendment Request LCN LRN and Claims Administration Process This process: (definition) - Administers the re-pricing and payment of claims as defined in executed HCRM policies. This process starts when: (beginning milestone) - The policy holder submits a notice of a large claim/referral or an actual claim The goal of this process is: (ending milestone) - Correct re-pricing or payment of a claim based on the terms and conditions of the policy This process uses: (inputs) - The submission of a large claim notification or a large referral notification (LT), (beginning input) - Historic claim data, (interim input) This process creates: (outputs) - Reserve amounts, allowed amounts, payable amounts, (interim outputs) - (LT) a re-priced claim, (ending output) - An explanation of benefits and paid claim if appropriate, (ending outputs) - Detailed data showing claim experience, reserve detail, network detail used in the Risk Management process This process must have: (requirements) - Exact policy terms and conditions for allowable charges and claim payment terms from the Policy Quote, Negotiate and Issue Process HCRM staff: (coordinated internal activities) - Receive the claim LCN or LRN, register the claim and start the tracking process - Set a reserve amount with actuary review if necessary - Re-price (LT) or adjudicate the claim as defined by policy terms and conditions - Request payment and distribute EOBs HCRM staff interact with: (coordinated external activities) - Policyholders with claim payments - Clients, brokers and corporate accounting for EOBs - Other payers and providers for claim re-pricing (LT) - Policyholders for follow-up correspondence - Vendors for requests for reviews LT Credentialing HCRM Process V3-1, LCN LRN Claims Administration Maintained by: Pat and Mark