Provider and Managed Care Information Technology Solutions

Business Philosophy

Our primary focus is to develop, deploy and support software in the healthcare industry. Our success has been derived from the fact that we have extensive industry knowledge that has been obtained throughout our working experience in various sectors within the healthcare industry within our international client base. These skills enable us to render additional services such as administration, consulting and managed care to our clients. We were in the fortunate position to embark on various projects throughout the years and are able to offer these experiences to our customers as a value-added system on top of our core business. Our software design, skills and knowledge of clinical and administrative processes within the various sectors of the healthcare industry has provided us with the unique opportunity to develop and maintain a central medical record per patient, for all our customers. The company is dedicated to supply our clients with leading and innovative healthcare information technology systems which are developed and supported locally.

Our 2 systems

Business Philosophy

View our philosophy

Our primary focus is to develop, deploy and support software in the healthcare industry. Our success has been derived from the fact that we have extensive industry knowledge that has been obtained throughout our working experience in various sectors within the healthcare industry within our international client base. These skills enable us to render additional services such as administration, consulting and managed care to our clients. We were in the fortunate position to embark on various projects throughout the years and are able to offer these experiences to our customers as a value-added system on top of our core business. Our software design, skills and knowledge of clinical and administrative processes within the various sectors of the healthcare industry has provided us with the unique opportunity to develop and maintain a central medical record per patient, for all our customers. The company is dedicated to supply our clients with leading and innovative healthcare information technology systems which are developed and supported locally.

Our 2 systems

Pro-Clin

The system has transformed from a hospital management system to a full fletched Hospital Information Management System (HIMS System).

All development, support and enhancements to the products are developed by our in house support and development team. All development is done locally to ensure that the system adheres and complies with the latest practises and norms in the medical industry.

Pro-Clin has a total of 13 Modules

OUT-PATIENT / CLINIC ADMINISTRATION / PHC

The Clinic Administration Module was developed for an OPD/Clinic environment and enables the user to perform all admission and administration functions for out-patients.

HAART MANAGEMENT

The HAART Management module provides a centralized Dreaded Disease Management functionality and allows for the management of HIV and TB patients with a number of features

WARD ADMINISTRATION MODULE

The Ward Administration menu is used where ward clerks are responsible for all ward administration functions.

ACCOUNT ADMINISTRATION

The Account Administration menu was developed for the debtor’s department. This includes all daily and month-end procedures as well as reporting functions.

OCCUPATIONAL HEALTH MODULE

The Occupational Health module allows for the generation of medical certificates and the recording of occupational health examinations.

 

 

IN-PATIENT ADMINISTRATION

The In-patient Administration caters for the admission and management of Hospital In-patients

 

THEATRE ADMINISTRATION

The Theatre Administration menu is used by theatre clerks responsible for all theatre administration modules.

CASE MANAGEMENT MODULE

The Case Management Module allows for effective in-patient management from the hospitals perspective

MedAdmin

MedAdmin Risk Management System  

SCHEME MANAGEMENT FUNCTION

The function concerns all aspects of the medical scheme company, and should address the following sub-functions:

View Functions
  • 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

 

MEMBER MANAGEMENT FUNCTION

The function concerns all aspects of the members, and should address the following sub-functions:

View Functions
  • 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

 

PROVIDER MANAGEMENT FUNCTION

The function concerns all aspects of the providers, and should address the following sub-functions:

View Functions
  • Registration and maintenance of the provider information;
  • Registration of preferred provider groups;
  • Provider Plan Structures;
  • Capitation arrangements;
  • Payments to providers;
  • Fee Structure and Provider Plan
  • The Provider Management function includes the following functionality:
  • Provider disciplines
  • Provider service types
  • Provider maintenance
  • Provider networks
  • Provider plans

RISK MANAGEMENT FUNCTION

The Risk Management function includes the following functionalities that you need to manage risks

View Functions
  • 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.

PROVIDING REPORTING FUNCTIONS

The reporting function provides a scope of management reports, operational reports, statistical reporting and listings.

View Functions

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.

SECURITY CONSTRAINTS

Appropriate levels of security will be enforced throughout the system on the operating system, program and data levels.

View Levels
  • Operating system – access to the operating system directories containing the data and source code on the server will be restricted;
  • Procedures – a menu structure will be set up for the user according to his/her authorities, and
  • Data – specific data in the system will be accessible only to authorised users.

All transactions which require an audit trail will be logged with a date-time stamp and the user’s ID.

Protection of software will be incorporated through a serial number (compiled, from among other items,

the medical scheme name), required to use the software.

Users will be forced to change their passwords regularly.

CLAIMS PROCESSING

Claims processing is a primary function of the Med-Admin System. The system accepts claims in EDI format from any source and paper claims.

View Functions
  • 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.

PAYMENT RUN

Payment runs can be done daily, weekly etc. depending on the client. Payments are made to providers and members.

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  • Provider and member statements are sent out after each payment run.

    MIS: A number of predefined management reports are available. Any new user defined custom reports can be readily incorporated. A data mining cube of data is also available utilizing Microsoft Analysis Service.

OUR CLIENTS

Digi Group is a South African company with a growing footprint, ensuring that it understands and works within the parameters of local conditions.

The group operates in 6 countries and has a focus on establishing a firm presence in the African continent.

Our clients are located in:

South Africa

Swaziland

Botswana

Namibia

Zambia

DRC

Lesotho

OUR CLIENTS

Digi Group is a South African company with a growing footprint, ensuring that it understands and works within the parameters of local conditions.

The group operates in 6 countries and has a focus on establishing a firm presence in the African continent.

Our clients are located in:

South Africa

Swaziland

Botswana

Namibia

Zambia

DRC

Lesotho

Contact Us

Send us a Message

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Info

R21 Corporate Park
55 Sovereign Drive
Irene
Centurion
0065

Tel: +27 (12) 345 3410
Fax: +27 (12) 345 3660