• Scheme registration and management;
• Medical Scheme Rules;
• Option Plan Registration;
• Registration of Contributions;
• Categorising of Members by Category, Scheme and Option Plan.
• The Scheme Management function includes the following functionality: –
• Maintenance of the medical scheme, plan option information and contribution categories of each
• plan option of a medical scheme;
• Service Type maintenance;
• Limit Type maintenance;
• Limit maintenance;
• Service type tariff link maintenance;
• Extension reasons;
• Exclusion Conditions;
• Status codes;
• Fee structures;
• Price structures, and
• Benefit groups

• Registration and maintenance of the member information;
• Registration and maintenance of the member’s dependants;
• Employer maintenance;
• Banking details
• Pre- or Existing condition registration;
• Member and dependant nominations;
• Chronic medication registration;
• Member exclusions;
• Member suspension.
• Ill Health Retirement
• Injury on Duty
• The Member function includes the following functionality:
• Maintenance on the member and dependant information;
• Member types
• Relation file
• Resign reasons
• Suspension reasons
• Authorizations;
• Maintenance on Employer information, and
• Maintenance on Broker Firms.
• Printing of membership cards
• Sick Notes

• Capitation;
• Designated service provider;
• Protocol management;
• Pre-authorization;
• Chronic medicine management;
• Electronic & Paper claims;
• Assesses against scheme and clinical rules or protocol;
• Duplicate checks.
• Authorization types;
• Authorization deny codes;
• Script usage;
• CPT file;
• ICD10 file;
• PMB Management;
• Medicine master;
• Medicine Exclusions;
• MIMS file;
• Clinical protocols/Rules;
• Registering of claims;
• Adjustments (reversal and journal) on claims;
• Member import;
• Claim import, and
• Authorizations file export.

This function provides the following: –  

• Daily operational reports;  
• Billing reports; 
• Claim reports;
• Member reports;  
• Management reports;  
• Financial reports for payments and monthly runs;  
• Specific Client Reports  

Where applicable, default values will be displayed in the fields on entry of the user interface.

• Each claim is checked against the client rules and in house developed clinical rules. The clinical rules can be used by the Client or Client can manage their own clinical protocols

• Client membership rules.
• Client membership benefits.
• Medicine and Tariff rules e.g. exclusions.
• Price checks against medicine master and tariff master depending on different fee and price
• Authorisation validation per claim line.

The clinical rules are set of specialized protocols setup per provider disciplined and client.

After the checking claims are flagged for payment or rejected. All rejected claims are sent for audit where

rejection can be overridden by the Auditor if justified. The clinical rules can be used by the Client or

Client can manage their own clinical protocols.