Briefing session Presentation - Online Real Time Claims Processing

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On-Line Real Time
Briefing Session
30 January 2012
ROAD ACCIDENT FUND
BRIEFING SESSION – On Line Real Time / EDI Service.
GAUTENG
RAF/2012/00007
DATE: 30 JANUARY 2012
RAF - MENLYN
AGENDA
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Welcome
Introduction of the RAF members
Circulation of Attendance Register
Presentation By RAF - BAU/Medical Bills
Presentation by Procurement
Q&A
Closing
RAF Overview
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Established through an act of Parliament in 1996.
Started operating in 1997.
National Public entity in accordance with schedule 3A of the PFMA.
Governance: Parliament through SCOPA; Ministry of Transport; Board of
RAF
Provide compulsory cover to all users of South African roads, both citizens
and foreigners, against injuries sustained or death arising from MVA within
the borders of South Africa.
Rehabilitate and compensate persons injured in a timely and caring
manner.
Promote safe use of all South African Roads
Social responsibility to re-integrate victims of road accidents to society.
Pays medical and related services costs; general damages; loss of income;
loss of support and funeral expenses.
RAF pro-actively reaching out to communities by expanding the footprint,
enhancing processing capability buy improving business processes and
systems.
Values: Ubuntu; Freedom to succeed and Pride in what we do.
ZIMBABWE
NORTHERN
PROVINCE
BOTSWANA
Pietersburg
MPUMALANGA
Pretoria
Mmabatho
NORTH WEST
NAMIBIA
MOZAMBIQUE
Johannesburg
GAUTENG
Welkom
Upington
Kimberley
FREE STATE
KWAZULU
NATAL
Bloemfontein
Pietermaritzburg
LESOTHO
Durban
NORTHERN CAPE
Umtata
ATLANTIC
OCEAN
EASTERN CAPE
Stellenbosch
Cape Town
RAF PowerPoint Toolkit and Instruction Guide
WESTERN CAPE
Page 5
Grahamstown
East London
Port Elizabeth
INDIAN OCEAN
BACKGROUND
• Current transformation process.
• Envisaged nine provincial offices for origination of claims.
• All claims to be processed centrally at the Benefit Administration Unit
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(envisaged).
Claimed benefits include Medical; General Damages; Funeral; LOE and
LOS.
Medical Unit is responsible for payment of past medical expenses;
rehabilitation services; life care and supplier claims.
In 2010/2011 financial year 195,634 Medical claims lodged and 187,168
finalised.
126,486 of the finalised are supplier claims.
2010/2011 - Medical payments close to 800 million rand.
Estimated/expected to increase by 8-10%.
Rehabilitation and Life Care Services are pre-authorized.
Payments are made to service providers, attorneys and claimants.
SYSTEMS AT RAF
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Currently two systems run parallel
In-house built Old Claims system/legacy system
Fineos claims processing system introduced in 2009/2010.
Manual/electronic processing of claims
Document storage at SharePoint (back up)
Payment control via SAP for both systems.
Need for thorough duplicate checks before processing
OPERATING ENVIRONMENT AT RAF
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Windows
IBM AIX
HP UNIX
DATABASES : Oracle and MSSQL
CLAIMS PROCESS ON FINEOS
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Lodgement
Scanning
Indexing/intake/Verification
Merits Assessment
Benefit Assessment
Payment request/approval
Payment control with SAP
Settlement and/or Undertaking Certificate
Rehabilitation and/or Life Care
EDI SPECIFICATIONS
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On-Line Real Time Healthcare technology to facilitate processing and payment of medical claims.
On Line Real Time link between service provider systems and RAF
Direct Link with HPCSA and BHF
Medical Intelligence
Pricing (tariffs) and service validation technology.
Built-in billing rules.
Payment response messaging
Automatic updates
System driven quantity and quality checks for pre-authorised treatment.
Centralised patient records for RAF.
The system should have robust audit trails.
On site and remote technical support.
Seamless integration regardless of service provider system or RAF.
Enable direct submission for pre-authorized services
Give solutions to the supplier’s claim challenge
Configuration to all communication methods ( e.g. 3G, ADSL, etc).
Adequate Storage Capacity
Training of super users / train the trainer
Training manual
Technical Mandatory Requirement
The service provider must have full local solution support.
Please provide the structure of the support team to the RAF
Technical / Functional Requirements
Technical /functionality will be evaluated against the following detailed
requirements:
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Project plan and methodology
Experience
Standard Operating Procedures
Security Features
Training plan
Report Generation
Site visit
Details of the Bid
Request for proposals: Appointment of a service provider to provide
On-Line Real Time Healthcare Claims processing technology system
• Closing date 9 February 2012.
• All questions / enquiries outside this forum will be via email to:
[email protected] not later than 11:00 on 2nd February 2012.
• Questions/ Answers will be published on the RAF website by 3rd
February 2012.
Details of the Bid
Documents can be couriered or hand delivered at the reception during:
Mondays - Fridays
Working hours
7h45 a.m. – 16h00 p.m.
Please ensure that register is signed at the reception
Closing date and time should be strictly adhered to:
9 February 2012 at 11h00 a.m. sharp
Compliance
• Compulsory Documents (Valid original Tax Clearance Certificate)
• Page 5-Checklist of documents to be submitted
• Please ensure that document is signed where required
• Complete proposal should be submitted
Evaluation
• Functionality
 Bidders who score less than 60% out of 85% on functionality will not
be considered for site visit
 Bidders who score less than 80% out of 100% will be not be
considered for further evaluation on price and BEE
Evaluation
90/10 principle will be used.
Price and BEE
QUESTIONS
THANK YOU
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