The Medical Insurance system is a forefront for providing innovative management of medical insurance transactions in a most efficient and comprehensive manner. It serves as an easyto- use tool for the recording and manipulation of production, medical networks, claims, renewals, and reinsurance operations for groups and individuals.

As a pioneer in the insurance software industry, ESKADENIA Software’s insurance knowledge and system compliance with governmental regulations add more value to the product comprehensiveness and flexibility.

 Main Functionalities

• Setup
  The Setup module sets the company’s standards for Production, Claims, and Reinsurance through a comprehensive, yet simple, parameterised system settings and rules.
  
  The System applies all Medical Insurance business standards such as ICD-10 and ICD-9 along with the price lists of medical providers and medicines as regulated by the authorised syndicates of each country.
  
  The system supports the following general features:
  Authorised system administrators can set and configure the behaviour of all operations including Underwriting, Production, Claims and Reinsurance, whereby every definition represents a set of business rules for the following:
  
  

  • Several types of carriers; medical insurance companies, TPA funds, TPA Insurance and TPA out.
  • Hierarchically detailed benefits structure.
  • Various types of capitations such as HMO, dental, and optical.
  • Dental setup based on FDI and ADA standards.
  • Standardised and non-standardised Service CPTs that comply with governmental regulations.
  • Multiple fees tiers covering complex structures of government and company fees.
  • Advanced and flexible agent commission structure definition.
  • Closed period for production, claims and reinsurance transactions.
• Plans
  Flexible and parameterised insurance products can be defined in the system as “Plans” to meet customer requirements in different territory scopes by defining various plans and classes with different benefit covers, ceilings, premiums, exclusions, referrals and waiting periods for medical insured members.
  
  In addition, parameterised validations can be applied on policy, case, or member level for effective control and audit on claims such as class maximum cover limit, annual limit, case limit, policy limit, life limit, minimum deductible amount, maximum deductible amount, and pre-approvals for in-network and outnetwork cases.
  
  Comprehensive and flexible premium definition sets the engine for automatic premium calculation based on the Plan details. Several business rules can be set that vary from one insurance company to another such as net risk premiums and gross premiums based on benefits, age bands, gender, marital status, and family relations.
• Production
  The Production module uses the information defined in the system Setup and Plans modules to automate production of policies and eliminate human error in policy issuance.
  
  The system supports the complete production cycle covering quotation preparation, quotation versioning, policy issuance or converting quotations to policies, card printing, endorsements, and renewal of quotations and/ or policies.
  
  The system also allows underwriters to import a group of members using a pre-defined Excel spreadsheet in any stage of the underwriting cycle.
  
  The premium amount is automatically calculated based on the extra net risk premium, discount, and loading percentages which can be divided into commissions, profits, and administrations.
  
  For customisation purposes, tailored payment cycles are supported in the system. Moreover, document attachments and historical notes provide claims auditors with support for decision making.
• Quotations
  Based on the medical insurance plans, the system can issue and print quotations for prospective and existing customers. Two types of quotations are supported in the system based on age bands or actual insured members.
  
  The system automatically calculates the quotation premium based on the defined plan/ class fees, loadings and discounts.
• Endorsements Types
  The system enables users to add a number of endorsement types for policies and members including:
  
  

  • Policy extension, cancellation, and reactivation
  • Changing agents
  • Changing policy plans
  • Freezing and un-freezing policies
  • Member addition
  • Member correction, cancellation, and reactivation
  • Charging members for the printing of new membership cards

 Medical Networks

The Medical Insurance system enables users to define multiple medical networks whereby each network contains providers from different types, specialties, and prices. In addition, follow up periods and multi-discount ranges such as volume discount can be applied for each provider.

Users can define or import price lists of all providers at once or of each provider separately based on the medical services and specialities.

• Claims
  The Claims module resides on a powerful auditing engine that is rich with rules and validations defined in the system Setup and Plan/ Class modules on policy and member levels. Therefore, the system eliminates fraud and human error while facilitating claims entry and audit.
  The claims processors can enter network and none-network claims with filtration for provider speciality and plan/ class covers taking into consideration policy and member exclusions. Claims auditors are supported with automatic claims auditing features based on predefined validation rules for automatic calculation of the approved claim and fees amounts.
  
  The following claims entry methods are supported:
  
  

  • Comprehensive claim entry
  • Fast claim entry
  • None-network claims or automatic importing of claims from a predefined Excel sheet
  • E-claims entry via the Internet

  
  Medical pre-approvals can be recorded in the following methods:
  
  

  • Comprehensive approval entry
  • Fast approval entry
  • Fax approval
  • Online and automatic e-approval via the Internet

  
  The system contains a claims auditing engine that applies extensive validation rules on medical claims and can either reject claims or warn the user according to preset rules.
  
  In addition, the Claims module support different settlement types such as complete settlement, partial settlement, down payment, and adjustment.
• Reinsurance
  The system allows users to manage and control multiple reinsurance treaties and generate bordereaux that distribute shares based on the treaty definition.
  
  Different types of reinsurance treaties are supported by the system, such as proportional and excess-of-loss treaties. Moreover, the system supports automatic reinsurance distribution for policies, renewals, endorsements, and claims transactions.
• Claims Knowledge Base
  The Medical Insurance system is an intelligent system that has the ability to build a self-learning virtual utility based on the previous occurrences of ICD and CPT combinations.
  The system enables users to add a number of endorsement types for policies and members including:
  
  

  • Policy extension, cancellation, and reactivation
  • Changing agents
  • Changing policy plans
  • Freezing and un-freezing policies
  • Member addition
  • Member correction, cancellation, and reactivation
  • Charging members for the printing of new membership cards
• Reports
  The system provides numerous reports for production, claims, reinsurance, and statistical data. Supported reports include:
  

  • Standard production reports covering schedules, endorsements, members, and card printing vouchers.
  • Standard claims reports covering approvals, batch covers, claims details, and rejected claims.
  • Reinsurance reports covering bordereaux and loss advice.
  • Statistical reports covering loss ratio, reconsolidation, utilisation, and earned and unearned premium.
• Queries
  The Queries module allows easy search for policy members, premiums, approvals, benefits, providers, transactions, claims and settlements.
  
  Furthermore, the module allows users to generate real-time 2D and 3D diagrams in a professional graphically-attractive layout.