JLN IT TRACK WORKSHOP DUBAI MARCH 2013

1. JLN IT TRACK WORKSHOPDUBAI MARCH 2013 CLAIMS MANAGEMENT WITHIN NHIA, GHANA Perry Nelson Acting Director, Claims

2. WHY CLAIMS MANAGEMENT Claims management is a vital component of any insurance organisation Like all other insurance organisations, the very survival of NHIS is dependent on prudent and effective claims management

7. CLAIMS PROCESSING WITHIN THE NHIS Claims are currently managed from over 155 centres (districts). This approach is not only ineffective but fraught with serious challenges that threaten the sustainability of the scheme. In response to these challenges, the Claims Division was set up in November 2009 to streamline, manage and coordinate claims processing activities nationwide. It was also to manage the pilot Claims Processing Centre and the set up of other CPCs in other parts of the country.

8. CLAIMS PROCESSING WITHIN THE NHIS cont’d All claims from the Volta Region, All Teaching and Regional Hospitals and some select facilities across the countryare being processed at the CPC Meanwhile claims processing within the District schemes continues in all other regions with the support of the CPC until the consolidation process is gradually completed

9. CLAIMS PROCESSING WITHIN THE NHIS cont’d Current Claims Processing PROVIDERS PROVIDERS GENERATION DELIVERY RECEIPT & PROCESSING PAYMENT RECOMMENDATION PAYMENT 155 Schemes CPC 1 PAYMENT RECOMMENDATION NHIA PAYMENT

10. THE FUTURE OF CLAIMS PROCESSING WITHIN NHIS Operationalize CPC Claims Software and ICT equipment Introduction of E-Claims submission Set up zonal CPCs (CPC ACCRA, CPC TAMALE, • CPC CAPE COAST , CPC KUMASI) Consolidation of claims management from 155 centres to zonal Claims Processing Centres (CPCs) Digitization of Claims from Schemes to CPCs.

11. THE FUTURE OF CLAIMS PROCESSING WITHIN NHIS cont’d CLAIMS SUBMISSION OPTIONS Paper based claims - digitization of claim forms and automatic electronic vetting of claims according to specified business rules Web-based E-claims entered directly into NHIA claims application via internet E-claims generated from Hospital Information Systems (HIS) or any other application and submitted via CD-Rom, e-mail, FTP or via internet access to NHIA Claims Software

12. CLAIM SUBMISSION OPTION 1 : Paper Based Claims Workflow PROVIDERS PROVIDERS GENERATION Paper claims generated from healthcare providers RECEIPT Registration of claims Fulfillment and preparation Delivery to CPC/Scanning of paper claims Storage of claims Scheme 1 Scheme 2 Scheme 3 SCANNED CLAIMS SCANNED CLAIMS SCANNED CLAIMS ADJUDICATION CPC ACCRA, CPC TAMALE, CPC CAPE COAST , CPC KUMASI Data Entry Quality Check Rules Engine Vetting (Adjudication) Audits PAYMENT RECOMMENDATION NHIA PAYMENT

13. WORKFLOW PAPER CLAIMS SUBMISSIONS Health care Provider ARCHIVE PAYMENT CLAIMS APPLICATION SOFTWARE Assessment, Adjudication + Detection of Fraud, Errors & Abuse NHIS claim documents Claims Data High Volume Scanner Data Capture & Data Entry

14. Claims Submission Option 2 E-Claims Direct Entry via internet on NHIA Claims Application http://eclaims.nhia.gov.gh/Login.aspx Healthcare provider can create and amend claims, view the status of all claims . Dashboard functionality allows instant overview of volume and status of claims.

15. Claims Submission Option 3 E-Claims submission by providers with Hospital Information Systems (HIS) Hospital Information System Claims Data File

16. E-CLAIMS SUBMISSION Option 2 Option 3 Health Care Provider Direct Claims Entry via NHIA Claims Application WEBFRONT E-claims generated from Hospital Information Systems (HIS) CLAIMS APPLICATION SOFTWARE Assesment, Adjudication + Detection of Fraud, Errors & Abuse CPCs PAYMENT & ARCHIVING

17. Implementation of Zonal CPCs Establishment of CPCs in other parts of the country to process all claims generated across the nation.

18. CLAIMS PROCESSED at CPC - 2012 CLAIMS DIVISION

19. THANK YOU