Employee Health Insurance (EHI) PDF

Employee Health Insurance (EHI)
Functional Requirement Document
TCS Internal
Table of Contents
1. Introduction........................................................................................................................................................3
2. Requirements.....................................................................................................................................................3
3. Module 1: Registration.......................................................................................................................................3
3.1 Employee Registration:...........................................................................................................................3
3.2 Registration Approval Procedure for Employee:....................................................................................4
3.3 Dependent Registration:.........................................................................................................................5
3.4 Registration Approval Procedure for Dependent:..................................................................................5
3.5 Escalation Report:...................................................................................................................................6
3.6 Generate e-Card:....................................................................................................................................6
4. Module 2. Claims................................................................................................................................................7
4.1 Domiciliary Claims:.................................................................................................................................7
4.2 Approval Procedure for Domiciliary Claims:...........................................................................................8
4.3 Hospitalization Claims:...........................................................................................................................8
4.4 Approval Procedure for Domiciliary Claims:...........................................................................................9
4.5 Claims Search:.......................................................................................................................................10
5. Module 3. Hospital Details Management.........................................................................................................11
5.1 Add Hospitals:.......................................................................................................................................11
5.2 Hospital Search:....................................................................................................................................11
5.3 Value Added Services...........................................................................................................................12
6. Change Request: ..............................................................................................................................................12
7. Coding Instructions...........................................................................................................................................13
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1. Introduction
Employee Health Insurance (EHI) is a Third Party Administrator (TPA) of Health Insurance
Policies and It form a vital link connecting all other stakeholders of the Health Care Domain. It enables
cashless hospitalization at pre designated points of healthcare delivery like hospitals and nursing
homes, and in case of reimbursement claims, it assures speedy settlement of the same.
2. Requirements
Employee Health Insurance (EHI) is providing health insurance to the corporate
employees/organizations. Employee can register his details with EHI and be part of the Insurance
scheme. Employee can add, update and delete his details. Employee can also add, update and delete
his dependent details. Employee can see all the networking hospitals under the EHI and also avail the
services from any networking hospitals. Third Party Administrator is the super admin he can add or
delete or update networking hospitals to the EHI. And also he can approve the claims comes from the
employees. Third Party Administrator has access to all the system.
3. Module 1: Registration
3.1 Employee Registration:
Employee/Employer has to register details in the Employee Health Insurance system. The
details are given below.
Employee Name (Text box)
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Employee Id (Text box it should accept only digits/numeric)

DOB ( it should be date (DD-MM-YYYY))
Gender (radio button Male/Female)
Email (Text box it should accept only mail ids)
Alternate Email (Text box it should accept only mail ids)
Phone number (Text box it should accept only numeric/digits)
Alternate Mobile No (Text box it should accept only numeric/digits)
Policy start date ( it should be date (DD-MM-YYYY))
Policy Period (in years)(Text box it should accept only digits)
Total Sum Insured (Text box it should accept only digits with decimal values)
Premium Amount (per Year) (Text box this value should be auto populated )
Bank Account No.(Text box )
Name of the Bank(Text box )
IFSC Code (Text box )
Once Employee/Employer registered successfully. Health Insurance Id (HI-ID) has been
generated. Employee/Employer has to pay premium for the total sum insured that will be decided by
the Third Party Administrator (TPA) of health Insurance policy.
Note: - Premium amount should be auto calculated. I.e. 2% of the Total Sum Insured per year.
3.2 Registration Approval Procedure for Employee:

Employee Health Insurance Id Activation: Health Insurance id is activated by Third Party Administrator
(TPA). Rules for Id activation.
1) Once employee submits the registration form the request is going to TPA. And an auto mail
should generate for both Employee and TPA.TPA has to activate or approve the request.
2) The SLA time should be there for each request. Once SLA time crossed an auto escalate mail
has to trigger to the TPA saying that the requests are crossed SLA.
3) SLA time should not include national holidays / festival holidays and weekends. And also it
should not include non business hours. (Business hours 9 AM to 6:30 PM , we consider only
these hours per day i.e. 9AM to 6:30PM )
4) SLA time for each request is 48 hours from the request being submitted.
5) Once TPA approve or activate Employee Insurance id, an auto mail should generate to
employee saying that request has been approved.
Note1: - For example if request is submitted 14th Feb 2015 @ 7PM and TPA approves the request on
16th Feb. 2015 @ 10:30AM. Then the TPA has taken only one and half hour to approve the request.
Because 14th fed is Saturday and 7pm is non-business hour, Saturday and Sunday is weekend. From
Monday i.e. 16th Feb. @ 9AM onwards SLA time will start
Note2:- Auto generated mails are optional, those mailing messages should be shown in screen
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3.3 Dependent Registration:

Employees can add their dependents to the health Insurance policy. If they added their
dependents, they have to pay extra premium for each person. They can add any no. of dependents.
Below details are require to add dependents.
Employee Id (Text box it should accept only digits/numeric)
Beneficiary Name (Text box)
Relation (drop down)
Date of Birth (DD-MM-YYYY)
Gender (radio button Male/Female)
Policy start date (DD-MM-YYYY)
Policy Period (in years)(Text box it should accept only digits)
Total Sum Insured (Text box it should accept only digits with decimal values)
Premium Amount (per Year) need to calculate through formulae
Once Employee has provided all the dependencies details, Health Insurance Id (HI-ID)
would be generated for each of the registered dependent.
Note:- Employee can add or update or delete his dependents
3.4 Registration Approval Procedure for Dependent:

Employee Dependent Health Insurance Id Activation: Dependent Health Insurance id is activated by
Third Party Administrator (TPA). Rules for Id activation.
1) Once employee submits the dependent registration form the request is going to TPA. And an
auto mail should generate for both Employee and TPA.TPA has to activate or approve the
request.
2) The SLA time should be there for each request. Once SLA time crossed an auto escalate mail
has to trigger to the TPA saying that the requests are crossed SLA.
5) Once TPA approve or activate Employee Insurance id, an auto mail should generate to
employee saying that request has been approved.
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3.5 Escalation Report:

Escalation report should be generated with the below fields and whose total time taken for approval is more
than 48 hours.
Employee ID
Employee Name
Health Insurance ID
Request Submit date
Request Approved date
Total Time Taken for Approval (TTTA)
Is SLA crossed (Yes/No if TTTA is greater than 48 hrs is SLA crossed is Yes else No) this field is optional because
this is escalation report this value is always Yes.)
Reason for SLA crossed
3.6 Generate e-Card:

Employee has access to generate eCard it will be accepted across the all net working
hospitals under this health Insurance policy. The e-Card should contain the following details.
Policy No
Beneficiary Name
Health Insurance ID(HI-ID)
Employee Code
Relation
DateofBirth
Primary Insured
Note:1. In the e-card issued to the employee Employee Code is the employee id and both beneficiary
name and Primary Insured are same as the name of the employee.
2. In the e-card issued to the dependents Employee Code and Primary Insured are the employee
id and name of the employee whereas the beneficiary name is the name of the dependent.
3. The e-Card should also contain contact details of the health Insurance office and 24 hrs toll
free numbers so that it could be easy to get information at any point of time.
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4. Module 2. Claims
Employee can apply for claim in two ways
1) Domiciliary Claims
2) Hospitalization Claims
4.1 Domiciliary Claims:

Domiciliary treatment covers all illnesses (subject to policy conditions) that do not include
hospitalization. It only includes treatments taken either from a physician or at the OPD (Out Patient
Department) in a hospital.
Employee should be able to submit claim through a form containing the following details:
EmployeeId (should auto populated)
Beneficiary (select box should auto populate all beneficiaries under that employee)
Health Insurance Id(HI-ID)
Mobile number(autopopulated)
Address
Alternate EmailId
Treatment Start Date
Treatment End Date
Date Of Injury
Name of Doctor
Ailment / disease / injury / contracted / sub stain
Total Claim Amount
Upload option for all documents
Following are the mandatory documents required for processing the Domiciliary Claims:
a) Doctors prescription with details of the nature and duration of illness. No payment details
should be mentioned in this document.
b) Original pre-numbered bills from the doctors official receipt book, with pre-printed doctors
information and receipt number.
c) Original medical bills or receipt along with prescriptions for the medicines purchased from the
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pharmacy stores.
d) Copies of all investigations/ labs/ test reports (wherever applicable) from hospitals or from
other lab or diagnostic centers during and before or after the Hospitalization.
Once employee has filled all the details, he has to submit the claim request. On submission claim No
will be generated, that will go to Third Party Administrator (TPA) of health Insurance policy for the
approval. Once approval has been done, amount will be credited to employee bank account.
4.2 Approval Procedure for Domiciliary Claims:

Approval procedure for domiciliary claims as given below.
1) Once employee submits the domiciliary claims the request is going to TPA. And an auto mail
should generate for both Employee and TPA.TPA has to approve the request.
2) The SLA time should be there for each claim request. Once SLA time crossed an auto escalate
mail has to trigger to the TPA saying that the requests are crossed SLA.
5) Once TPA approve claim request an auto mail should generate to employee saying that
request has been approved.
4.3 Hospitalization Claims:

Hospitalization benefits are applicable only if the insured person is admitted to a hospital
continuously for a minimum of 24 hours (with exception to Day Care Procedures mentioned in the
policy).
Following are the mandatory documents for processing the Hospitalization Claims:
a) Original and detailed admission or discharge summary/card issued by the hospital.
b) Detailed hospital bills along with break-up bill of all Hospitalization expenses.
c) Original and numbered bill/receipt/cash memo issued by the hospital.
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d) Copies of all investigations, lab or test reports (wherever applicable) from hospitals or from
any other lab or diagnostic centers during and before or after the Hospitalization.
e) Original medical bills or receipts with prescriptions for the medicines purchased from the
pharmacy store
Claim form should contain the following details:
Employee ID
Employee Name
Email ID
Mobile No
Company Name
Name of Patient (select box)
Gender
Relationship
Age
Health Insurance Id(HI-ID)
State
City
Hospital Name
Address
Date of Admission
Date of Discharge
Name of Doctor
Details of illness/Injury
Reason for Injury Alcohol(redio button yes/no)
Total Claim Amount
Upload option for all documents
Once employee has filled all the details, he has to submit the claim request, claim No will be
generated, that will go to Third Party Administrator(TPA) of health Insurance policy for the approval.
Once approval has been done, amount will be credited to employee bank account.
4.4 Approval Procedure for Domiciliary Claims:

Approval procedure for Hospitalization claims as given below.
1) Once employee submits the Hospitalization claims the request is going to TPA. And an auto
mail should generate for both Employee and TPA.TPA has to approve the request.
2) The SLA time should be there for each claim request. Once SLA time crossed an auto escalate
mail has to trigger to the TPA saying that the requests are crossed SLA.
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5) Once TPA approve claim request an auto mail should generate to employee saying that
request has been approved.
4.5 Claims Search:

Employee can able to see all his claims/claim history and status. Below are the fields
required to search claims.
Claim Type (All/Domiciliary Claims/Hospitalization Claims)
Policy Year (2015-2016/2014-2015/2013-2014 ..etc)
Relationship(All/Father/Mother/Spouse..etc)
These 3 are drop downs.
Or By giving Health Insurance Id(HI-ID), pull the all claim reports under this id.
fill above details and submit search button below report will be displayed with the fields.
Claim Type
MediAssist Claim No
Claim Raised on
Patient Name
Relation
Claim Amount
Approved Amount
Claim Status
Action
Claim Escalation
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5. Module 3. Hospital Details Management

5.1 Add Hospitals:
Third Party Administrator (TPA) of health Insurance can add or update or delete the
networking hospitals. To add net working hospitals following details are required.
Hospital Id
Hospital Name
Address
City Name
State Name
PinCode
STDCode
Phone Number
To update hospitals he can update all the information w.r.t Hospital Id
To delete hospitals he can delete hospital details w.r.t Hospital Id
5.2 Hospital Search:

User has choice to search hospitals by either state and city or pin code or by directly giving
hospital name.
Network Hospital List: It should display all the networking hospitals list with the following details.
Hospital Name
Address
City Name
State Name
PinCode
STDCode
Phone Number
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5.3 Value Added Services

In value added services EHI provide Health checkup befits to the all his customers. The customer who wants to
avail these benefits has to register. Below details are required for Health checkup registration.
Employee Id
Employee Name
Gender
Age
Mobile No
Email Address
Appointment for (self/Dependent Names)
Health Insurance Id (this should be auto populated based on selection of Appointment for)
State (drop down)
City (drop down auto populated all cities under the state)
Location (drop down auto populated all the networking hospital locations under city)
Hospital Name (drop down auto populated all net working hospital names based on location)
Preferred Date& Time
Note:-the preferred date & time should be exclude non business (business hours 9AMto 6:30PM) hours and
only Sundays and national holidays.
Once request has submitted successfully registration id will be generated which goes to TPA for approval. The
approval procedure is same as above mentioned in section 4.3 and 4.4 modules.
For health check up registration, once customer registers successfully, system will not allow him to register
again up to 3 months. This validation should be maintained.
Note:-The 3 months validation should be done through backend.Custmoer data should be maintained
6. Change Request:
1) User/Employee can download e-Cards in pdf format.
2) User/Employee can download all the networking hospital list in excel format.
3) User/Employee can download all his claims requests in excel and pdf format based on
selection.
4) Networking hospital information should be read through excel not from data base.
5) Apply logging and security for all modules.
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7. Coding Instructions
Apart from functional requirements, below points should be ensured while developing
the case study:
1. Login feature with different user roles is mandatory. One super user - Admin has to be created
with full access followed by other user roles.
2. Implemented case study should be assured to have required protection against SQL Injection.
3. All pages and layout should be compliant to Web Accessibility Concepts.
4.
Basic Error Logging mechanism is mandatory E.g Logger implementation in Java.
5. All configurable parameters like database credentials should be specified through Property
File/Common class with Constant values/XML.
6. Real time deployment should be simulated when case study is shared for Testing as well
presented for FI. E.g WAR file deployment in Java.
7. All features of the case study should work when site is hosted from different machine and
accessed from other client.
*** All The Best ***
TCS Internal

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Employee Health Insurance (EHI)

Functional Requirement Document

Employee Id (Text box it should accept only digits/numeric)

3.2 Registration Approval Procedure for Employee:

3.3 Dependent Registration:

3.4 Registration Approval Procedure for Dependent:

3.5 Escalation Report:

3.6 Generate e-Card:

4.1 Domiciliary Claims:

4.2 Approval Procedure for Domiciliary Claims:

4.3 Hospitalization Claims:

4.4 Approval Procedure for Domiciliary Claims:

these hours per day i.e. 9AM to 6:30PM )

4.5 Claims Search:

5. Module 3. Hospital Details Management

5.2 Hospital Search:

5.3 Value Added Services

Basic Error Logging mechanism is mandatory E.g Logger implementation in Java.

* All The Best *

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