Managed Care involves the management of a complex network of providers - doctors, specialists, hospitals, clinics - all of which can be handled within X-GROUP.

Members are assigned in the policy to providers, and during claims processing, the system checks the member has been treated by the relevant provider, or by a provider in the same network. Contracts for the provider are maintained within the system; these can be loaded from an Excel spreadsheet. These contracts are used during the claims process to check the services and rates being billed.

X-GROUP has a specialized component to control the full spectrum of Managed Care operations from Provider Network Administration to Utilization Management.

X-GROUP can be used to set-up Managed Care medical products that a typical insurance company offers its clients. Both inpatient and outpatient benefits can be set up in X-GROUP. These include benefits such as Room & Board, Surgical Procedures and Hospital Fees. Premium tables can be set up according age, gender, occupation and medical history.

The premium information generated for each member movement is fully integrated into the accounting system. Extra premiums and information on medical check-ups, including document listings, can also be captured by the system. Special exclusions and inclusions can be incorporated to avoid covering for pre-existing conditions.

X-GROUP has detailed checks on the benefit usage, which combined with its comprehensive reporting system, provides the insurance company all the needed information to track and control claim expenses.

Provider Network Management in X-GROUP

Allows Provider Classification - Primary Care Physician, Specialist, Hospital, and Clinic etc.
Maintains details of affiliation between providers - Doctors who are part of a clinic.
Provider assignment to Network / Area.
Incorporates various kinds of fee schedules and capitation tables for each provider.
Seamless integration with referral and claims module.
Calculates contributions to the risk pool by the provider.
Tracks plan-matching amounts deposited into the risk pool.