Product Literature

Medical Insurance Management

System
Introduction______________________________________________________
Medical Insurance Management System (MiMS) is an integrated backend
application, uniquely designed to manage, monitor and process the full range of
managed care transactions and services.
MiMS contains functions for processing health claim transactions and managed care
encounters. The features include centralized client management, membership
management, contract/policy management, product benefit plan definitions,
case/encounter management, claim management, health screening management,
payment/billing, and reporting. MiMS benefits include streamlined data entry and
adjudication of claims, utilization management, managing multiple provider networks
for payors/insurers, setting up and managing complex payor/insurer policy, and
importing and exporting of member data.
As the managed care industry is growing, industry changes are always expected. If
these changing needs are not met, business opportunities will be lost. Thus MiMS is
designed to provide flexibility to respond to the changing needs. MiMS allows the
third party administrators to manage their business effectively, significantly reduce
risk and cost, increase productivity and profitability.
Business Challenges_____________________________________________________________
Some of the major challenges faced by TPA(s) pertaining to back office administration
of managed care transactions and services include the following: o
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Inability to offer an overall administration system that can create, configure and
manage all the myriad different managed care contracts, benefits and claims
definition in the market today
Unable to support the transfer of existing plan details from one contract to
another
Inability to provide options for billing to different parties and settlement of one
receipt to many invoices or one invoice to many receipts
Difficulty in importing member & dependant details from external sources directly
into the system. Manual data entry is time consuming and prone to human errors
(invalid data, double entry)
Difficulty in managing complex health care claims as it involves multiple parties
(medical providers, members/dependants, employers and insurers)
Difficulty in generating periodical and ad hoc reports
Not connected directly with external parties (clinics, hospitals, employer, insurers
and members/dependants). Communication via fax and phone calls may be time
consuming and difficult to track, thus impairing response time and customer
service standards

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Main Components__________________________________________________
MiMS provides TPA(s) with a scalable and reliable system that addresses the critical
business operation requirements in the functional areas of Product Administration,
Client Administration, Policy & Member Administration, Case & Claims Processing,
Payment & Billing and Reporting.
Hence there are thirteen (13) components that make up the Medical Insurance
Management System, namely:

Product Management
Client/Contact Management
Contract Management
Member Management
Member Administration
Case Management
Claim Management
Health Screening Management
Payment & Billing
System Administration
Operational and Management Reports
Data Export and Import Facility
Simple Document Management System

Salient Features & Functions ____________________________________________________

Product Management
o Create, configure and maintain all the different benefit categories and benefits
o Enable administrator to create, configure and maintain life and non-life
product scheme (group/individual/family)
o Reuse existing benefits and riders in a new product scheme.
o Create provider networks to group together panel providers for a payor/insurer
o Customization of Card Number Formats for card numbers that are generated
for members of a contract. Card number formats can be defined for companies
and payor/insurer
Client Management
o Developed around a Common Client concept (companies, subsidiaries,
medical providers, insurers, broker/agency, customers/individual insured share
the same client details)
o Simplified maintenance of client information. Captures contact information of
clients in one centralized location
o Store multiple addresses and contact details for clients (General, case/claims,
financial correspondence)
o Complete telephone, fax, email directory
o Able to set up multiple type of fact information of medical provider/individual
doctor
Contract/Policy Management
o Contract and Policy Administration
Able to setup multiple policies of an insurer under a single contract.
Each clients policy can have different policy start date/end date/policy
period

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Plans

Multiple pricing cycles per policy normally 1 year, but can be short or
long
Parameter driven set-up of eligibility and simplified underwriting rules,
claims settlement rules, premium rates and formulas etc. for each
benefit
Create any type of benefit with different coverage rules, sum assured,
number of days, percentage reimbursable, deductible amount.
Flexibility in choose and match benefits into standard packages or
tailored plans, where administrator is able to combine benefits into
standard packages or tailored plans for complete flexibility
Automated calculations of sum assured for each benefit category (flat
rate, multiple of salary, multiple years of salary).
Add / terminate client policies during the contracts price cycle
Termination/Renewal can be done at both the policy level and the
contract level
Administration
Flexible plan benefit configuration. Benefit that have been setup in the
system can be mixed and matched together to form the plans of the
contract
Create any plans with different benefits and benefit coverage rules
(E.g. plan limits, coverage days, percentage reimbursable etc.)
Existing plans can be copied and modified for other contracts

Member Management
o Member Movement
Member/Dependant movement entries can be entered through manual
data entry or imported from a file (Excel spreadsheet). Save time on
data entry as information can be imported into system directly - no
redundancy issue
Single batch entry across multiple contracts, policies, subsidiaries or
even different kind of member movement transaction
Regular administration which tracks all member movement transaction
of financial and non-financial changes
Type of Member movement transactions:
Add (Members and Dependants)
Financial Endorsements (Change benefits, plans, salary)
Transfer member to another subsidiary
Termination and reinstatement
Reversal of member movements across multiple price cycles.
Correction of member/dependant details.
Member/Dependant movement batch entries can be validated for data
errors prior to posting into the database
o Member Administration
View all details of members/dependants in one single screen
Able to view member/dependant endorsement history (date when
endorsement was performed, endorsement type, user that made the
endorsement)
Able to view members plan, benefits, utilization limits, and claim
history
Member details for a policy can be exported into an external file

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Case Management
o Supports various types of cases (admission, outpatient specialist, outpatient
GP, dental, maternity, accident, death/permanent disability)
o Support case entry and processing of both type of credit and reimburse cases
o Patients are selected from member records that have been posted into the
database, thus ensuring automatic and accurate creation of primary contact
details and case records
o Case load distribution monitoring. Notified cases can be assigned/reassigned
to specific users for processing. Users can view cases that are assigned to
them
o Standard claim data entry with auto validation
o Insured details validation and eligibility check at initial stage of data capture.
o Captures the proposed and actual diagnosis, treatment plans and procedures
(CPT, ICD).
o Captures the drug prescriptions
o Captures referral/admission/discharge details for admission cases
o Captures the past medical history of the case and patient/family.
o Captures details of the provisional/final billing from medical providers. Items in
the bill can be mapped to the patients covered benefits
o Captures various type of facts/notes related to the specific case.
o Generating guarantee letters for admission cases. Guarantee letters can be
submitted online to the providers or printed out in hard copy for faxing.
o Central module for customer enquiry services. All details of a case can be
viewed in a single screen. Other related modules (Member, Client, Claims) are
linked and can be easily accessed from one screen
o Able to view claim utilization at benefit level for a particular insured
o Able to view the history of cases for a particular patient
o Able to support batch processing of minor claims
o Through templates, standard letters can be printed and reminders sent after
predefined period
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Claims Expert System
o Create claims from the cases that have been captured in the system.
o Supports myriad types of claims such as death claim, medical claim,
outpatient claim, personal accident claim, dental claim, maternity claim, major
medical claim, critical illness claim, disability claim
o Availability of a comprehensive claim validation and assessment rules
including insured details validation such as member coverage date range and
benefits covered, claims validation such as for example for medical claims of
co-existing, benefit cover (per disability/per life/per day/per year/ per visit/as
charged/per family/fixed reimbursement amount), continuous/related claims,
max amount reached (visits, days, coverage), claim periods allowed (pre
claim, post claim and confinement), co-payment, type of medical center,
deductable option and hold/pending claim
o Auto validation and settlement base on multiple benefit claim eligibility and
validation rule setup
o Claims workflow process. Date and time for the completion of task can be
captured and analyzed for performance monitoring
o Claims validation (System & user defined resolutions) with continuous claims
support
o Tracking of claims provision and admission
o Claims worksheet computation. The worksheet can be printed out for payment
advise
o Able to view the history of claims created for a case and also related claims by
a patient

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o

Multicurrency claims processing

Health Screening Management

o Able to record complete test result of health screening report for individual
person include screening general detail, screening cost, screening test result,
findings, conclusion with recommendation/follow-up
o Able to record actual screening fact/finding in the form of certain primary
health
risk
system
such
as
Circulatory
system,
Dermatology,
Digestive/Gastrointestinal, Otorhinolaryngology, Respiratory System. The
result data such as risk status, report date, follow up status; result outcome,
consultant/physician, and output recommendation can be tracked.
o Availability of a comprehensive screening test panel templates for complete
data recording purpose include :
o Clinical examination (physical examination)
o Imaging examination (X-ray, Ultrasound, Endoscopy)
o Laboratory Tests Panel
Hematology
Renal Panel
Bone Joint
Liver Panel
Lipid Panel
Thyroid Panel
Hepatitis Panel
Tumor Markers
STD Screen
Urinalysis
o Test result status (Normal/Abnormal) of each screening test can immediately
be derived by system according to the standard reference range table setup
o Certain relevant type of At Risk warning for diseases/illness could be
detected and discovered by system base on predefined rules of combined mix
of risk/test result reading/measurement for a particular health screening case.
o Screening tracking activity could be recorded and follow up.
o Annual reminder on health screening is sent via email

Payment & Billing

o Flexible billing options to clients, insurer, medical providers, members and
broker
o Create invoices, receipts, and payment vouchers
o Settle invoices by receipts. Partial settlement of invoices by multiple receipts
o Partial settlement of vouchers
o Auto generation of payment records whenever a settlement is made for a
voucher
o Release holds claims on settlement.
o View outstanding invoices credit control
o Full reversal capability

Data Export and Import Facility

o To facilitate data transfer capabilities between MIMS core modules and other
external file formats or system.
o Flexible parameter-driven facility whereby it allows the setup of import and
export files with:
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Option to import of data especially member and dependant data

movements from large number of sources in different formats from a
client file directly, for example MS Excel, Text
Distribution channel such as payor/insurer or even large clients can
submit files in different formats
Among the data transfers capabilities are import of member census,
outpatient claims, payment transfer data, and export of claims,
members and related transaction data.
Save time on data entry as information can be imported into system
directly - no redundancy or double-entry issue.

Management and Operational Reports

o Internal reports can be generated on a regular or ad-hoc basis
o Ability to export data to spreadsheet for further analysis
o Consistent reporting because of common source

System Administration
o Creation of users and user groups
o Define user access authority. Able to define user access authority up to
module level
o Define the companys contact information (Name, address, e-mail, contact
number) and the companys logo. The information can be printed on reports
Simple Document Management System
o Automated generation of reminders
o Virtual file storage, which allows related templates, documents & reports to be
saved in specific folders. Ability to export data to spreadsheet for further
analysis

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Key Benefits ____________________________________________________________________

Some of the most noticeable benefits you can derive from implementing MIMS are: o
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Support for proven regional managed care practices

Scaleable, flexible, adaptive architecture that grows with your business
One stop customer service through easy access of all information
Parameter driven workbenches enables users to create, configure and manage
all the different benefits, plans and claims definition in the market today. Thus
providing the ability to manage complex managed care products
Supports various types of contract structures
Saving data-entry effort by allowing single batch entry across multiple policies,
subsidiaries and different kind of movement transactions
Save time on data entry as information can be imported into system directly
via the data export and import facility, hence no redundancy, double-entry or
human error issue
Provides access to real time information across your organization
Ensure consistent validation process thus assist in more prudent claims
processing resulting in incurring less claims and ultimately improves
profitability
Comprehensive case management module allows more effective management
of member/dependant encounters
Speeds up claim and payment processing, thus decreasing turnaround and
service time.
Generate real time reporting with standard and ad hoc reports
Direct connection to external networks via the Internet will allow the TPA(s) to
improve customer service and provide value added services to medical
providers, employers, insurers and members/dependants
Flexible security module with the ability to define user access up to the
module level
Can achieve greater profitability. MiMS can help you manage the business
effectively and efficiently with greater consistency
MiMS has been designed on a parameter-driven platform which makes it very
flexible and helps to minimize customization cost significantly in the long run

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