- Managing Insured and Practitioner lifecycle Open or Close
This module enables management of the entire insured and practitioner lifecycle :
subscribing to the Electronic Health Card service
blocking use of the Electronic Health Card service
removing use of the Electronic Health Card service
- Managing Open or Closed benefits and entitlements (third-party payers) Open or Close
This module enables management of various benefits that the insurer decides to cover through the Electronic Health Card service, as well as of the guarantees linked to each type of policy.
- Real-time benefit processing Open or Close
This module enables real-time processing of the transaction carried out by the insured using her / his Electronic Health Card at the practitioner.
The processing includes several checks, the main ones being:
checking the existence and status of the insuredIf all those checks are positive, the module calculates the guarantee based on the policy, the practitioner’s category, and the nature of the benefit. It sends a real-time answer:
checking the existence and status of the practitioner
identifying the practitioner’s category
identifying the patient
identifying the policy held by the insured
checking risk and suspicion of fraud.
reject, giving the reason for the rejection
accept, giving the guarantee calculated (percentage or ceiling).
- Risk management Open or Close
This module enables risk management linked to use of the Electronic Health Card. The main checks are:
authenticating the card holder (confidential code or fingerprint)
authenticating the terminal
mutual authentication between:
- the card and the terminal
- the card and the electronic-cash server.
The module can also detect irregular and suspicious transactions.
It offers the option to analyse the activities of insured persons and of practitioners by applying pre-defined rules. The insurer has the option of parametering the most suitable decision for any suspicious or irregular transaction (alert, blocking, etc.)
- Administration and traceability of operations Open or Close
This back-office module enables the insurer to:
manage various parameters relating to risk and to the fight against fraud
supervise activity: consult the activities of insured personas and of practitioners; consult the history of access by users and administrators
generate reports and statistics that meet the insurer’s needs, e.g.:
- the list of vouchers issued and payments made
- the type of act performed.