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The Tariff codes system is used to identify treatment or service delivered by providers to members. It is a vital component of the whole Scheme Genius ecosystem.
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The codes defined in the system are the only ones which the system will recognise and use for purposes of benefits adjudication and award.
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Alphanumeric codes are used, they need not conform with other systems by other regulatory bodies, but those who submit claims must be familiar with them.
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Each code has a flag (colour code – Green, Amber, Red) which is shown each time a user captures it.
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Each code has a price and can optionally have a co-payment fixed.
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Codes can be placed in ‘clash classes’ so that if 2 tariff codes are in the same ‘clash class’ then they cannot be on the same claim together.
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A frequency class can be defined, so that frequency restriction rules can be applied to it (e.g max number of times per day, month, 6 months, 1 year, et.c).
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A maximum quantity can be set.
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Inpatient/Outpatient Restriction
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- Not Specific
- In-Patient Only
- Out-Patient Only
- Whether pre-authorisation is required or not
- Hospital grade restriction
- Filtering out tariff codes without benefit allocation
- Adding service provider disciplines which can deliver/claim for the particular tariff code’s corresponding service(s)
Tariff Code Management
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The system can generate bills for all member for a specific period.
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The bills can be generated going back into the past.
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The system checks to ensure a member does not get 2 bills for the same month and produces corporate invoice.
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The bill picks up and includes miscellaneous charges such as printed cards.
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Mass-mailing of member bills, e-mail and SMS reminders.
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Client statements (automated) and cash receipts.
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Integration with accounting systems such as Pastel -(batch or real time) - our references for successful Pastel integrations can be supplied upon request.
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Archiving and viewing of scanned documents against each member’s electronic file, with an emailing and printing option.
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Scanned documents will be tagged to indicate their content and type.
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Archiving and opening audio and video attachments to each member’s file.
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Viewing member statement. This can be printed and/or emailed. The statement shows all the treatments and corresponding benefit allocations for all the dependants on a selected family.
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Printing member confirmation letter.
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Customizable data pages: this is a feature which enables an unlimited set of information about each member to be captured, with provision for different data types (text, numeric, drop-down).These can be customised without recourse to additional programming work.
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Storage of banking details.
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Storage of agent/commission contract details for each member – where applicable.
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Receipting of individual member payment.
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Generating billing statement per member.
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Generating claiming statement per member.
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An audit trail which shows every successive snapshot of a member record as changes are done over time. This cannot be edited or deleted.
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Viewing a benefits summary which shows current usage levels for ALL the benefits which the member is eligible for at a given date.
Billing
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Membership card generation, printing.
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Integrated Billing for cards printed.
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Card printer queue management.
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System generates member numbers and suffixes.
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Enable moving a dependant from one family to another, or to be a stand-alone.
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All the claims that the member had will follow that particular member, regardless of changes in family or plan.
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Old membership numbers retained.
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Electronic remittance advise uploading.
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Electronic claim status feedback uploading.
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Genarations of Quotations, invoices, receipts....
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Users can search for members by
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- Member number
- Old member number
- National ID
- Name, surname
- Employment number
- File/account number
- Additional dependants can be added using a file upload.
- New members can be added using a file upload
- Date-driven membership status design: The user does not have to calculate the actual member status (active, waiting period, etc.)
- The user only captures the events which occur to the membership according to instructions from the client and the system uses this to determine status at time of treatment.
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Membership Event Resultant Status Joined – Regular Active Suspended Suspended Terminated from Plan Terminated Black-Listed Black-Listed Joined – Late Active Reinstated Active Terminated from Fund Terminated -
The system uses the table above for mapping and thus determining what status the member is in at a specific date. This is also dependant on the status of the principal member.A member is changed to another plan by capturing a ‘Joined’ event to the new plan.The system automatically calculates the waiting period depending on whether late-joiner or regular-joiner.
Membership
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This feature enables the system administrator to configure the custom data page of the member data file.
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An unlimited number of details can be so captured under different categories.
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Data field types supported are text, numeric and drop-down.
Member Data Configuration
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This feature enables management of the member tags. These tags distinguish the member and directs how the member is billed. The fundamental tags are:
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Corporate.
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Individual.
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Student.
Member Tags
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The columns of membership reports are user-defined.
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The following filtering parameters are used for each report
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- Fund.
- Current Status (Active, Suspended, Terminated, Black-listed).
- Date of Birth.
- Join-date.
- Principal Members only.
- Date captured.
- Last membership event.
- Card printing status.
- Record verification status.
- Account balance (plus, minus or zero).
Membership Reports
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This shows significance changes to the membership.
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Columns are Join-Date, Activity, Effective-Date, Benefits Date.
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You can filter by specific event types, or by fund.