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PNM & Claims Meeting Notes

Date: Friday, October 3rd, 2025
Participants: 8 from Skyconnect, 10 from AIT
AIT Attendees:

  • 2 Management (Faustin Mndolwa and Alex)
  • 2 IT Department
  • 3 PNM
  • 3 Claims

Focus: CLAIMS & Provider Network Management

PNM - Provider Network Management​

By: Dr. Pius Ezekiel

Provider Access & Capabilities​

  • Verify customer identification and status (UR-2301)
  • Post bills/claims (currently manual) (UR-3401, UR-3408)
  • Need integration with local Hospital Management Systems (UR-3401)

Claims Data Entry & Processing​

Presenters: Dr. Mapesa (Vetting and assessment), Pre-approval team member

Current Workflow Detail​

Data Entry Stage (UR-2501, UR-2502, UR-2503)

  • Receive manual claims and electronic claims from providers
  • Receive invoice batch from providers (UR-2401)
  • Manual claims processed from hospitals without systems
  • Prepare claims for vetting

Vetting Process (UR-2504, UR-2505)

  • Vetting Level One: First claims officer reviews
  • Vetting Level Two: Second claims officer confirms (internal policy requires two officers per provider claim to control errors and counter fraud)

Claim Categories (UR-2718)

  • Pending Process
  • Pending Review
  • Pending Processed

Payment Processing (UR-2711)

  • Data entry to payment vouchers
  • Finance team involvement
  • PNM confirms payment to provider

Price Negotiation

  • Currently handled by Claims Department
  • Uses pricelist for negotiation (UR-2101, UR-2102)

Pre-Approval Process​

Notes: Captured by team members (UR-2304, UR-2509)

Member Verification​

Notes: Captured by team members (UR-2301, UR-2302, UR-2303)

System Integrations​

Requirements: Systems must communicate seamlessly from patient visit to treatment completion (UR-3401, UR-3402)

Key Recommendation​

Field Research Required: Travel to at least 10 distinct providers across the country to understand problems and solutions firsthand. (Dr. Pius Ezekiel)

Current Users​

  • Administrators: 5 users
  • Providers (Hospitals): ~500 hospitals with login access (UR-2207)

Current Claims Workflow​

Proposed Claims Workflow​

Major Pain Points​

Claims Processing Issues​

  • Time lag: Delay from provider submission to organization processing (UR-2713)
  • Client claims delay: Some claims delayed up to 90 days or 6 months (very rare/exceptional cases)
  • Long processing tempts fraud: Extended processing times may encourage providers to falsify claims
  • Data integrity issues: Service dates being backdated during manual data entry (UR-2501, UR-2503)
  • Manual data entry: Time-consuming and error-prone (UR-2501, UR-2503)
  • Two-officer requirement: While good for fraud prevention, adds processing time (UR-2504, UR-2505)

Transparency & Eligibility Issues​

  • Lack of upfront eligibility information: Need to display eligibility or denial information initially (UR-2714, UR-2732)
  • Unclear fraud identification: Need clear methods to identify and depict fraud (UR-2728)
  • Verification of services: Need better information on verification of services provided (UR-2301, UR-2302)

Rejection & Post-Processing​

  • High rejection rate: 10-30% of claims rejected monthly (UR-2505, UR-2709)
  • Lengthy justification disputes: Rejection handling creates extended back-and-forth (UR-2709)
  • Claim falsification risk: Longer processing times tempt providers to falsify claims

Process Issues​

  • Paperwork overload: Currently 80%, target is 15% by project end
  • Manual claim submission: Need integration with Hospital Management Systems (UR-3401)
  • Customer processing speed: Patients are sick and need fast service (UR-2301, UR-2303)
  • Failed scanner solution: Previous attempt to scan bills didn't work

Contract Management​

  • Manual contracts (no digital system) (UR-1904)
  • No expiration alerts (UR-1905)
  • No electronic signatures (UR-1904, UR-2107)

Provider Pricing​

  • Price lists change frequently and vary widely (UR-2101, UR-2206)
  • No automated upload/approval system (UR-2101, UR-2106, UR-2107)
  • Price negotiation currently manual (UR-2101, UR-2102)

Infrastructure Gaps​

  • Some providers lack internet access
  • Previous scanner solution for bills failed

Provider Management​

  • Need accreditation functionality (UR-1901)
  • Provider information editing needs audit trail (UR-1902)
  • Status modification (suspension, termination) (UR-1903, UR-1907)
  • Special notes and documentation (UR-1906)
  • No predictions for future incidents (e.g., expiring customers) (UR-1905)

Required Features​

Claims Processing & Data Entry​

  • Automated claim registration (UR-2501, UR-2502, UR-2506)
  • Support for manual and electronic claims (UR-2503)
  • Scanned claims visibility (UR-2503)
  • Link claims to verification records and approval numbers (UR-2506)
  • ICD-10 code incorporation (UR-2507)
  • Multiple diagnosis code capture (UR-2508)
  • Provider invoice acknowledgement system (UR-2401)
  • Classification into Inpatient/Outpatient (UR-2502)
  • Claim categories tracking (Pending Process, Review, Processed) (UR-2718)

Vetting & Validation​

  • Two-level vetting workflow (UR-2504, UR-2505)
  • View member demographics and special notes (UR-2501)
  • Display items by internal tariff and brand names (UR-2504)
  • Reject claims with coded rejection reasons (UR-2505)
  • Additional notes entry capability (UR-2505)
  • View approval/authorization and approver (UR-2509, UR-2606, UR-2702)

Auto-Processing & Settlement​

  • Auto-process against policy clause conditions (UR-2601)
  • Check preset price lists (UR-2601)
  • Gender specificity validation (UR-2601)
  • Waiting period enforcement (UR-2601, UR-2714)
  • Flag rejected claims for reprocessing (UR-2602)
  • Partial admissibility processing (UR-2603)
  • Auto-process excess through SBP/Buffer (UR-2604)
  • Multiple settlement channels (UR-2602, UR-2703, UR-2704, UR-2705, UR-2706)

Fraud Prevention & Transparency​

  • Upfront eligibility/denial display (UR-2714, UR-2732)
  • Clear fraud identification methods (UR-2728)
  • Exception reports for data extremes (UR-2728, UR-3301)
  • Service date validation to prevent backdating (UR-2501)
  • Claim exception reports (high amounts, repeat visits) (UR-2728)
  • Flag exclusions during verification (UR-2714)
  • Pop-up notification of waiting period services (UR-2732)

Rejection & Reconciliation Management​

  • Link reconciliation to original claim (UR-2701)
  • Multiple channels for rejected claims (UR-2703, UR-2704, UR-2705, UR-2706)
  • Levels of approval for rejected claims (UR-2709)
  • Ability to cancel/reject claims with controls (UR-2605)
  • Claim reversal with controls (UR-2707, UR-2717, UR-2738)
  • SMS notification to clients on utilization (UR-2710)
  • Invoice generation for indemnity claims (UR-2711)

For Providers​

  • Financial reports accessible in their accounts (UR-2211)
  • Reports aggregatable over time periods (yearly, etc.) (UR-2211)
  • Faster customer processing (patients are sick - priority!) (UR-2301, UR-2303)
  • Provider portal for services (UR-3408)
  • Member verification capability (UR-2301, UR-2302, UR-2303)
  • Claims submission interface (UR-3401, UR-3408)
  • Provider reports access (UR-3408)
  • Advanced verification methods (fingerprint, facial recognition, OTP) (UR-2301)

For Administrators​

  • User activity reports (UR-3104, UR-3105, UR-2715)
  • Financial reports (UR-2206, UR-2211)
  • Price list management system (upload & approve) (UR-2101, UR-2105, UR-2106, UR-2107)
  • Prediction system for incidents (e.g., expiring customer coverage) (UR-1905)
  • Contract expiration alerts (90 days) (UR-1905)
  • Provider accreditation (UR-1901)
  • Provider grouping and management (UR-2201, UR-2202, UR-2203)
  • Client-to-provider group linking (UR-2204, UR-2205, UR-2209)

Provider Management​

  • Edit provider information with audit trail (UR-1902)
  • Modify provider status (UR-1903)
  • Terminate/suspend with effective dates (UR-1907)
  • Upload contracts (UR-1904)
  • Upload special notes (minutes, memos) (UR-1906)
  • Configure capitation arrangements (UR-2108)
  • Provider status tracking (active/inactive/suspended) (UR-2207)

Price List Management​

  • Upload with effective date tracking (UR-2101)
  • Map provider items to internal tariff (UR-2102)
  • Deactivate items (UR-2103, UR-2104)
  • Download existing pricelists (UR-2105)
  • Add single items with approval (UR-2106)
  • Upload signed scanned copies (UR-2107)

Member Verification & Pre-Authorization​

  • Advanced verification methods (fingerprint, facial recognition, OTP) (UR-2301)
  • Verification exception handling (UR-2302)
  • Offline verification mode (UR-2303)
  • Online authorization request channel (UR-2304)
  • Pre-authorization for specific services (maternity, dental, optical, chronic medication, hospitalization) (UR-2304)
  • View authorization and approver (UR-2509)
  • Reverse approved pre-authorization (UR-2717)

Claims Processing Integration​

  • API for interfacing with provider systems (UR-3401)
  • HMS integration for automated claims (UR-3401)
  • Integration with Teammate system (UR-3402)
  • Seamless communication from patient visit to treatment completion (UR-3401, UR-3402)

Reporting Requirements​

  • Claims register (UR-2712)
  • Claims transmittal report (summary and detailed) (UR-2713)
  • Claims status report (UR-2718)
  • Member balance report (UR-2719)
  • Member/Family utilization report (UR-2720)
  • Corporate utilization report (UR-2721)
  • Hospitalization list (UR-2722)
  • Member/Scheme analysis report (UR-2723)
  • Claim ratio (UR-2724)
  • Average visit cost (Overall/IP/OP) (UR-2725)
  • Claim experience per provider (UR-2726)
  • Benefit utilization (UR-2727)
  • SBP/Buffer/Indemnity/Ex-gratia report (UR-2729)
  • Exceeded benefits report/dashboard (UR-2730)
  • Fund utilization report (UR-2733)
  • Claim experience per age band (UR-2734)
  • Claim experience by region (UR-2735)
  • Claim experience per product (UR-2736)
  • Overall claim cost (IP/OP) (UR-2737)
  • Price list per provider as at date (UR-2206)
  • Active/inactive/suspended providers with addresses (UR-2207)
  • Providers per provider group (UR-2208)
  • Clients assigned to provider groups (UR-2209)
  • Provider distribution by region (UR-2210)
  • Provider statements as at date (UR-2211)

Special Claims Processing​

  • Process claims of different categories (UR-2716):
    • Funnel claims
    • Reimbursement claims
    • Rescue and evacuation
    • International claims
    • Other exceptional claims
  • Process claims for terminated members (UR-2731)
  • Exclude ineligible benefits per member (UR-2739)

System Improvements​

  • Reduce manual processes from 80% to 15%
  • Electronic contract management with alerts (UR-1904, UR-1905)
  • Integration with Hospital Management Systems (UR-3401)
  • Better rejection handling workflow (UR-2505, UR-2709)
  • Real-time dashboards (UR-3403)
  • Serial controls on claim forms and registration numbers (UR-3201)

Critical Insights​

Customer Processing Speed: "Customer processing speed should be a priority. They are sick." - Emphasizes need for fast, efficient workflows

Two-Officer Vetting Policy: Internal control mechanism requires two claims officers to vet one provider's claim to control human errors and counter fraud

Time Measurement: The timeframe is measured from provider submission to organization (not from provider entry) - revealing hidden delays

Rare but Critical: Client claims delayed for up to 90 days or 6 months in exceptional cases - unacceptable wait times for patients

Action Items from Meeting​

To be shared for Monday, October 6th, 2025:

  1. List of providers/hospitals (from AIT)
  2. List of system users (from AIT)
  3. SOPs or operations guidelines
  4. Example of pricelist used for negotiation from claims

Next Steps​

Immediate Actions​

  • Plan field visits to 10+ providers (Dr. Pius's recommendation)
  • Review provider list, user list, and SOPs shared by AIT
  • Analyze example pricelist for negotiation workflow

Claims Processing Improvements​

  • Design two-level vetting workflow with fraud controls (UR-2504, UR-2505)
  • Implement upfront eligibility display (UR-2714, UR-2732)
  • Build fraud detection methods (UR-2728, UR-3301)
  • Create service date validation to prevent backdating (UR-2501)
  • Setup claim category tracking system (UR-2718)
  • Implement automated claim registration (UR-2501, UR-2502, UR-2506)
  • Build claims transmittal reporting (UR-2713)

Integration & Automation​

  • Design integration approach for HMS systems (UR-3401)
  • Setup seamless system communication from visit to treatment completion (UR-3402)
  • Implement API for provider systems (UR-3401)
  • Build auto-processing engine (UR-2601, UR-2602, UR-2604)
  • Configure multiple settlement channels (UR-2603 to UR-2706)

Provider Management​

  • Implement provider portal (UR-3408)
  • Setup contract management with alerts (UR-1904, UR-1905)
  • Configure price list management workflow (UR-2101 to UR-2107)
  • Develop provider accreditation module (UR-1901)
  • Build provider grouping functionality (UR-2201 to UR-2205)

Verification & Authorization​

  • Setup verification methods (fingerprint, facial recognition, OTP) (UR-2301)
  • Implement offline verification mode (UR-2303)
  • Build pre-authorization workflow (UR-2304)
  • Create verification exception handling (UR-2302)

Reporting & Analytics​

  • Setup comprehensive claims reporting (UR-2712 to UR-2737)
  • Create capitation calculation framework (UR-2108)
  • Build rejection handling workflow (UR-2505, UR-2709)
  • Setup provider reporting system (UR-2206 to UR-2211)
  • Implement real-time dashboards (UR-3403)
  • Build prediction system for expiring customers (UR-1905)

Process Optimization​

  • Map detailed process flows at each provider type
  • Reduce paperwork from 80% to 15% target
  • Optimize claim processing timeframes to reduce 90-day delays
  • Prioritize features based on field research findings
  • Implement serial controls on claim forms (UR-3201)

Summary Statistics​

Current State:

  • 500 providers
  • 5 administrators
  • 10-30% monthly claim rejection rate
  • 80% paperwork (target: 15%)
  • Up to 90-180 day claim delays (exceptional cases)
  • Two-officer vetting requirement for fraud control

Key Processes Identified:

  1. Provider Network Management (PNM)
  2. Claims Data Entry
  3. Two-Level Vetting
  4. Pre-Approval Process
  5. Member Verification
  6. System Integrations

Critical Success Factors:

  • Fast processing for sick patients
  • Fraud prevention and detection
  • Upfront eligibility transparency
  • Seamless HMS integration
  • Reduced manual processes
  • Effective rejection handling capitation configuration module (UR-2108)
  • Develop rejection handling workflow (UR-2505, UR-2709)
  • Setup provider reporting system (UR-2206 to UR-2211)
  • Build prediction system for expiring customers (UR-1905)
  • Reduce paperwork from 80% to 15% target