Health Insurance System

Health insurance system facilitates both policy management and claim application processing. The main emphasis was put on fast and convenient custom service collection creation and on using a wide range of criteria in compensation calculation. The system has its own client self-service portal, where clients are able to apply their claim applications easily, upload all necessary documents and follow the whole claim settlement process.

Functionality overview

Administration

  • User management;
  • Administrative roles and rights management.


Data classifiers

  • Employee and business entity structure editing and addition;
  • Hierarchical medical service list;
  • Service programs;
  • Service provider list, partnership agreement;
  • Service provider price lists (data import from Excel);
  • Program templates;
  • Program template details;
  • Patient contribution (co-pay) compensation.

Health insurance policy processing

  • Policy creation, collection definition;
  • Insured person addition or import from Excel;
  • Payment plan generation, policy issue, commission calculation, invoice generation;
  • Policy printouts along with insured person list:
    • Insured persons addition;
    • Insured persons removal;
    • Special policy terms and condition changes;
    • Open policy limit increase.

Claim application

  • Claim application creation;
  • Receipt input, delivered service input;
  • Compensation calculation;
  • Automatic claim generation in Claim Management System (ZRS).


Claim Management System out-of-box functionality

  • Reserve accounting;
  • Indemnity decision management;
  • Processed payments.

Reports

  • Health card remainder report;
  • Health insurance policy report;
  • Policy renewal report;
  • Indemnity paid report;
  • Indemnity paid report grouped by programs.

Technology stack

The project is based on the modern Microsoft-oriented technology:

  • ASP.NET MVC 5 (C#);
  • AngularJS;
  • ServiceStack 3;
  • Entity Framework 6;
  • MS SQL Server Reporting Services;
  • MS SQL Server 2008+.

Notable features

Individual collections in policies

This feature was specifically designed to provide the fast and convenient custom collection creation, since most of the policies are prepared for very specific terms and conditions defined during a tender. This way the collection is responsible for defining included services and the order of mutual settlement that these services imply.

Compensation calculation

Calculation is performed in the accordance with a wide range of criteria, such as limits for services and service groups; single limit liability for service providers that either are or are not in the agreement with the insurance company or separately for the online transactions; usage count limit for the whole or the partial periods of time (with independent values for online transactions); constraints for processing transactions only in cash; constraints for services to be agreed upon in advance; mutually exclusive services.

SmartMedical internal web service integration

The system doesn’t synchronize all of its data with SmartMedical system. On the contrary, the specific web service methods are called that perform compensation calculation and transaction registration or cancellation.

Service and price list synchronization and import from SmartMedical

This should allow efficient and speedy reaction to service and price list changes in the medical institution. In addition, it will be possible to print out an additional agreement after the changes are accepted.

Claim applications in the Internet

An end client can be authorized via internet banking application. This will allow the client to browse all his previous applied claims. The claim application, in turn, will be registered automatically in Health Insurance System.