The standard INSIS claim adjustment module is enhanced with medical claim processing functionality. The claim processing follows the normal claims cycle: registration, indemnity calculation, payment approval, and settlement. The claims can be processed on request of an insured person or on request of contracted medical service provider. In both cases the system controls that only contracted services from contracted providers are indemnified.
Pre-determination. For expensive services or drugs, although contracted, the company may require preliminary approval of the treatment or the prescription. Those services by default are excluded from the coverage and can only be added after approval of the company experts. The approval is done using a special predetermination protocol where services with the accepted prices have to be confirmed by one or more than one company specialists
Claim registration
Reimbursement claims. Indemnity is payable to the insured.
Provider payment claims. Indemnity is payable to the providers upon providing the service as stipulated in the respective declarations.
Service/drugs control against diagnosis. The configuration of INSIS health includes a list of all types of diagnosis according to the IDC (International Diagnosis Code) and maintains relationships between diagnoses and treatments, and between diagnoses and drugs. During the claim processing INSIS produces warnings for the cases for which there is no correspondence between the diagnosis and the treatment or drugs. The operator can either
approve these cases or reject them.
Indemnity calculation control based on contracted service/drugs prices. The indemnity calculation is based on contracted prices with each particular provider and each particular service. During the claim registration all claim details are entered in the claim evaluation
screen in which each detail corresponds to a single drug or to a single treatment provided to the insured. For each of the details the requested indemnity is registered and is compared with the contracted price. If the requested amount is higher than the contracted price, the system limits the indemnity up to the contracted price. If deductibles/franchises or coinsurance is set in the policy terms, these are applied in order to calculate the final indemnity amount
Limit control(per service, per visit, per diagnosis, per year, etc)
