Health Plan (Introduction and Key Concepts)
Introduction and Key Concepts
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
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.
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.
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.
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.
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 |
Steps | Description | |
Claim Types |
How do I set up a Claim Type? | |
Health Care Provider |
How do I set up a Health Care Provider? | |
Step 2 | Employee Health Plan Transactions | |
Benefits >> Health Plan >> Health Plan Claims | ||
Claim |
Health Plan: How do I enter a Claim? | |
Step 3 | Reports | |
Benefits>>Health Plan>>Reports | ||
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.
Claim Types:
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.
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.
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