Workflow Stages
An integrated workflow for managing healthcare services, medical care, and claims efficiently and transparently, beginning with insurance coverage setup and ending with financial settlements and analytics.
Preparation, Design, and Issuance
Preparing, designing, and issuing all insurance-related documents, including insurance cards, medical benefits schedules, medical directories, user guides, and other related materials.
Beneficiary Identification and Verification
Beneficiaries visit an approved healthcare provider, where their identity and insurance coverage are verified using a smart medical insurance card or mobile application. Available benefits are then displayed, and the remaining medical coverage limits are monitored.
Medical Service Delivery — Healthcare Network
Healthcare services are provided through approved medical centers and providers, including consultations, laboratory tests, medical imaging, hospitalization, medications, and other necessary treatments.
Data Reception and Processing
Medical and financial claims and data are received electronically, registered in the electronic system, and securely archived, with ongoing support and follow-up provided through the customer service center.
Triple Audit and Review Stage
All claims undergo a thorough review across three key areas:
- Administrative Review: Verifying the validity of the insurance policy, coverage limits, and exclusion terms.
- Medical Review: Assessing the medical necessity and appropriateness of treatment and ensuring compliance with medical indications and protocols.
- Financial Review: Verifying prices, discounts, and agreed-upon rates with healthcare providers.
Claims Management Stage
Claims are evaluated and assigned one of the following decisions:
- Finally Approved: Payment is authorized, and the patient’s co-payment is calculated, if applicable.
- Modification / Additional Documentation Required: Additional documents or supporting information are requested to reassess the claim.
- Finally Rejected: The claim is rejected if the service is not covered or violates the applicable terms and medical protocols.
Financial Settlement and Analytical Reporting Stage
Approved payments are transferred and settled periodically with the healthcare provider network. Comprehensive periodic reports are also prepared for institutions and companies, providing insights into medical service utilization and healthcare expenditure.
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