Health Plan

Health Plan

Overview of the Health Plan Module

The Health Plan module is closely linked to the Benefits module and is used to process health plan claims.

Claims can be entered directly by HR or submitted by employees (via the Employee Self-Serve module) for updating by HR. Via the Benefits module, employees and their dependants must be registered in the Health Plan before claims can be submitted.



A Guide to Using the Health Plan Module

Pre-requisite steps:


Roles

HR Administrator

Role: Responsible for setting up and managing the Health Plan module within the HRplus system. They define claim types and their limits, add and maintain healthcare provider information, process employee health plan claims, run reports, and manage refunds for settled claims.

Employee

Role: Submits health plan claims for themselves and their dependents through the Employee Self-Serve module. They provide necessary documentation to support these claims and ensure compliance with the health plan requirements.

Dependent

Role: An individual covered under the employee's health plan. Claims are submitted on their behalf by the employee, and they rely on the employee to manage their healthcare benefits.

Health Care Provider

Role: Delivers medical services to employees and their dependents. They may submit claims directly to the insurance company or provide documentation to the employee for claim submission.

Insurance Company

Role: Processes health plan claims submitted by employees or healthcare providers, determines eligibility and coverage for the claimed services, and issues refunds for approved claims.

Steps

Description

Step 1

Setup - Health Plan Base Tables

 

Benefits>>Health Plan>>Claim Types Benefits>>Health Plan>>Health Care Provider

 

 

 

Claim Types

        A request that is raised by the policyholder for compensation of the expenses incurred for the treatment.

 

 

Health Care Provider

        A person or company that provides a healthcare service.

 

Step 2

Employee Health Plan Transactions

 

 

Benefits >> Health Plan >> Health Plan Claims

 

 

Claim

 

·       To enter a new claim, enter the:

 

1.     Claimant Details

2.     Claim Details

3.     Refund Details (once the claim has been processed and refunded)

 

Step 3

Reports

 

 

Benefits>>Health Plan>>Reports

 

 

Reports

 

·       Run relevant Health Plan Reports

 
Glossary of Health Plan Terms

Claim: A request for payment that you or your health care provider submits to your health insurer when you receive items or services you think are covered.

•Medical Claims: Requests for payment for services such as doctor's visits, hospital stays, and surgeries.
•Dental Claims: Requests for payment for dental services.
•Vision Claims: Requests for payment for vision services.
•Pharmacy Claims: Requests for payment for prescription medications.

Health Care Provider: Any individual or organization that provides medical services, such as doctors, hospitals, clinics, and pharmacies.

Claimant Details: Information about the individual who is making the claim, which may include name, contact information, insurance policy number, date of birth

Refund Details: Information regarding the reimbursement of out-of-pocket expenses paid by the claimant.

Settled Claim: A claim that has been processed and for which the insurer has made a payment or has determined that no payment is due. The settlement includes details of the amounts paid and any patient responsibility.

Unsettled Claim: A claim that has been submitted but has not yet been processed or paid. Unsettled claims may be pending due to various reasons, such as waiting for additional information or verification.

Health Plan Module Updates: What's New?
This article provides a summary of recent updates to the HRplus Health Plan module, focusing on key enhancements. These updates include new features, fixes and improvements designed to improve both user experience and the effectiveness of the module.
September 5th – November 29th, 2021
1. Upload Claim Forms: Added functionality for uploading health plan claim forms, simplifying the claim submission process. Read more here.

May 2nd – May 17th, 2021
1. Health Plan Claims: New features for managing and processing health plan claims for employees. Read more here.

November 26th – December 4th, 2020
1.Health Plan Audit: Introduced audit capabilities for tracking health plan claims and ensuring compliance with system regulations. Read more here. 

How do I set up a Claim Type?

Navigation: Benefits>>Health Plan>>Claim Types

Claim Types

A health insurance claim or a medical insurance claim is a request that is raised by the policyholder for compensation of the expenses incurred for the treatment.

A Claim Type categorizes the different types of claims which can be made by employees. E.g. Dental, Vision, Surgical, etc.

Enter New Claim Type



Enter Claim Type details



Claim Type Code: Enter a user defined code which represents the claim description.

Claim Type Description: Enter a user defined claim type based on the schedule of benefits defined by your insurance provider.

YTD Limit - Single: Enter the Year to Date limit for single coverage for the claim type. You should get hsi amount from your health plan administrator.

YTD Limit - Dependant: Enter the Year to Date limit for dependant coverage for the claim type. You should get hsi amount from your health plan administrator.

Save the record and enter additional claim types as required.

How do I set up a Health Care Provider?

Navigation: Benefits>>Health Plan>>Health Care Provider

Health care Provider

A healthcare provider is a person or company that provides a healthcare service to you. In other words, your healthcare provider takes care of you.

Your health insurance plan will pay your healthcare provider for the services they provide to you, assuming the service is covered and you've met your cost-sharing responsibilities.

Enter new Health Care Provider


Enter Health Care Provider details


Company: Select the company to which the provider is being linked via an employee claim.

Provider ID: This is a user defined ID to identify the provider

Provider Name: Enter the name of the entity or medical personnel provider.

Address Line 1-3: Enter the address of the provider.

Phone No: Enter the phone number of the provider.

Provider Type: Select the provider type from the available options.

Save the record and repeat to add additional health care providers.


Health Plan: How to Enter a Claim

Navigation: Benefits >> Health Plan >> Health Plan Claims

Health Plan Claims

To enter a new claim, enter the:
1.Claimant Details
2.Claim Details
3.Refund Details (once the claim has been processed and refunded)

After you have entered Claimant Details and saved the record, the screen will be refreshed to show the next screen for data entry: Claim Details; and so on.

Enter New Health Plan Claim



1. Enter Claimant Details



Company: Select the Company of the employee making the claim.

Employee: Select the employee for whom the claim is being made.

Dependant: If the claim is for the employee's dependant, select the dependant from the list of the employee's registered dependants. All other dependant details (Date of birth, age, relationship and any medical condition ) will be auto-filled from the dependant's record that is linked to the employee's profile.

Health Plan: Once the employee is selected, the health plan options available for selection are shown based on where the person is enrolled.

2. Enter Claim Details


Claim Type Description: Select the type of claim being submitted. The Single YTD and Dependant YTD will be auto-filled based on the claim type selected.

YTD Refund: The year-to-date refund amount for the respective claim type and employee will be calculated and displayed. This amount represents the total amount refunded to date for the respective employee and claim type e.g. the total refund for all ‘Medical’ claim types for the employee. You are not allowed to edit this amount.

Claim Date: Enter the date that the claim was submitted by the employee.

Provider Name: Select the provider name from the list of available options.

Amount Claimed: Enter the full amount being claimed as entered on the claim form submitted by the employee.

Dispatch Date: The date the claim was sent to the insurance company for processing.

Status: The status of the claim will default to NOT SETTLED.

You may save the record at this point and when the refund has been received for the claim then you can re-open the record and update the Refund Details as explained below.

Record showing Claim Not Settled



Upload Claim Documents

The Document Type field defaults to CLAIM when adding a claim.



3. Enter Refund Details

Credit Payment: Click Yes if the refund amount is to be paid to the employee’s company rather than the employee. This will apply in cases where the company has already refunded the employee in respect of the claim. Otherwise click No.

Refund Date: Enter the date of the refund.

Cheque No: Enter the cheque no of the refund cheque.

Refund Amount: Enter the amount of the refund as displayed on the refund cheque.

Collected By: Enter the name of the person who collected and signed for receiving the refund cheque.

Once you have entered all refund details and there are no pending issues with the claim, then you can update the Claim details to SETTLED
 as shown below.

Save the record.

Record showing Settled Claim



    • Related Articles

    • Health and Safety

      Glossary of Terms found in the Health and Safety Module 1. Accident Reasons: The underlying causes or factors leading to an incident, including unsafe conditions, human error, or equipment failure. 2. Body Part: Refers to the specific area of the ...

    • Benefits

      Overview of the Benefits Module OVERVIEW The HRplus Benefits Module is designed to streamline the management of employee benefits programs within an organization. It allows employees to easily view, their enrollment in benefits such as health ...

    • How to Import Cycle Changes?

      NB*HR users will need to be granted access to the relevant permissions to make the changes via cycle changes in the Powerpay module.  Please see an example of the permissions required below: From there you will need to ensure that the User has the ...

    • 2. HRplus Release Notes 2020 01 02 25th Jan to 18th Feb 2020

      RELEASE NOTES Release Number:   2020.01.02 (Year.Quarter.Month) Development Periods: 25th January to 18th February 2020 Release Closed:   18th February 2020 NOTE:  The numeric ID that is used to identify each item is of no significance to the client ...

    • What are User Groups and Permission Description

      The following tables show brief descriptions of each of the User Groups (Table 1.1) and some examples of typical users (Tables 1.2 to 1.5): Click here for instructions on how to view/edit employees in a user group. Table 1.1 - Description of User ...