Health Assurance System

Workcube Health Assurance System is a module that enables the organization to manage and pay for the health risks of an organization's employees and employees' relatives. It works integrated with other functions such as Health Assurance System, HR, Accounting, Finance.

The health insurance system is described below with a case study:

Necessary steps will be followed for the requests entered by the employee and the conversion of contracted institution invoices into requests in order to make the payments for health expenses;

Employee Health Expense Requests will be entered,

Contracted institution invoices will be converted into expense requests.

Transactions

Preliminary Transactions

1. Payroll Flow Parameters definitions should be made. (Payroll Rules)
2. Process definition should be made. (BPM > Processes)
3. Process Type definitions should be made. (BPM > Process Categories)
4. Assurance Type definitions should be made to limit usage control and details. (System > Parameters > Health Assurance Types)

Main Transactions

1. Employee health expense request
   
   1. The employee must enter the health expense request into the system. (HR Transactions > Health Expense Request)
   2. The employee can control all the health expense requests entered into the system and edit them if they are not approved. (HR Transactions > Health Expense Request)
   3. The approval unit must view and control the entered health expense requests. (Medical and Social Security Transactions > Health Expense)
   4. After checking the health expense request, the approval unit should approve it and update the process to the accounting and payment steps.
   5. Here, the health expense can also be updated on a record basis, or the requests controlled by the batch approval process can be included in the process flow.
2. Converting contracted institution invoices to health expenses
   
   1. The authorized unit is directed to the health expense screen by clicking the 'Control Spending' button in the detail of the relevant invoice in order to check the contracted institution invoices and convert them to health expenses. (Medical and Social Security Transactions > Health Expenditure Receipts)
   2. The redirected add page opens with the relevant fields in the invoice detail field. The approval unit completes the registration by filling in the required fields here.
   3. The approval unit must view and control the entered health expense requests. (Medical and Social Security Transactions > Health Expense)
   4. After checking the health expense request, the approval unit should approve it and update the process to the accounting and payment steps.
   5. Here, the health expense can also be updated on a record basis, or the requests controlled by the batch approval process can be included in the process flow.

Post-Transactions

1. Check the accounting records of health expenses.
2. Check the budget records of health expenses.
3. Check current records of health expenses.

Case Study: Health Expense Request and Approval

ROUTE: E-Profile Card > HR Transactions > Health Expense Request

Process: The process should be selected to direct the expense request to the relevant units. What needs to be considered here is the correct definition of authorizations when defining processes. Mandatory field.

Employee, Branch Office and Department: If the employee enters his own health expense request, employee information is automatically filled in these fields and cannot be changed.

Document Date: It contains the date information on which the expense request was recorded.

Document Type: The document types you have added to your system appear here. It is not mandatory. You can add document types under System > General Settings > Document Types. (fuseaction : settings.form_add_document_type)

Treatment Institution: It can be entered in invoices coming from outside the contracted institution, for example, it can be a pharmacy name. It is not a required field.

Invoice No: It can be entered for expenses coming from outside the contracted institution, such as a receipt number. It is not a required field.

Patient: The field where the employee must indicate whether the expense is for himself or for someone else.

Coverage Type: Indicates for which coverage type the treatment is performed. It doesn't have to be chosen. On the right side, the details of the previous expense on this type of coverage are shown. Depending on the type of work for which the coverage type is selected, it should be used if the limit is specified in the range of limb, treatment, medicine and material and amount.

Treatment Types: Its content varies depending on the type of coverage chosen and indicates the type of treatment applied.

Description: It is used to write a note about the disease or a different situation. It is not required to be filled.

Invoice Total: The Total Amount in the document showing the amount given, such as an invoice, must be entered here.

From the settings under System > XML, if "Does the employee pay his share during the treatment?" If yes option is selected, the "Treatment Base Amount" ratio field will be 100% and the "Share of Institution" ratio will be equal to the ratio from the coverage type detail. As the coverage type changes, a new ratio comes and this is written in the "Share of Institution" ratio field. If there was a Contracted Institution Invoice and the yes option was selected, since the invoice amount from the institution would also be equal to the institution's share, the ratio distributions would be equal to the ratio from both the "Treatment Base Amount" ratio and "Share of Institution" ratio Coverage Type detail and the calculations would be reflected in the relevant fields accordingly.

From the settings under System > XML, if "Does the employee pay his share during the treatment?" If no option is selected, the "Treatment Base Amount" ratio field will be 100% and the "Share of Institution" will be equal to the ratio from the coverage type detail. As the coverage type changes, a new ratio comes and this is written in the "Share of Institution" ratio field. But if there was a contracted institution invoice, this time the invoice sent would reflect the amount without deducting the employee share, compared to the other option. This time, the ratio of the "Treatment Base Amount" field is 100%, and the "Share of Institution" ratio is equal to the ratio entered in the detail of the Coverage Type and the relevant calculations are made. In other words, "Employee Share" will be deducted from the invoice amount and the amount to be paid by the Institution will be reflected.

Health Expense Institution Share, Employee Share Calculation Settings

1. How does the XML-set employee pays his/her share option work in contracted institution invoices?

If Yes is selected;

Treatment Base Amount = Invoice Amount It is calculated with the Ratio of 1 * 100 / Treatment Base Amount.

If no is selected;

Treatment Base Amount = Invoice Amount is calculated as 1 * Ratio / 100.

2. If he has been treated in a non-contracted institution and requesting for expense request how does the XML setting the employee pays his/her share option work? 

If No is selected;

Institution share + Employee Share = Invoice amount.

3. How does the employee pays his share option in XML setting to determine the coverage type in non-contracted institution invoices?

If Yes is selected, the ratio from the coverage type is assigned to the "Treatment Base Amount" ratio.

If No is selected, 100 is assigned to the "Treatment Base Amount" ratio.

4. If the employee has been treated at the non-contracted institution and requesting for expense request, how does the employee pay his/her share option to determine the coverage type in XML setting?

Regardless of yes or no, 100 is assigned to the treatment base amount ratio.

The Institution share ratio is always the ratio from the coverage type.

Here, the previous limit controls of the selected coverage type of that employee are shown. The coverage type in the example is selected as Emergency Treatment - SSI.

In this field on the right, Year and Employee or Employee Relative are selected and all previous expenses to the relevant person are displayed. At the bottom, the total expenses made for each type of coverage are shown.

This area on the same page contains the details of the treatment;

• In the field of Treatment, Medications and Limbs, the treatment procedures applied to the patient, the drugs taken or the limbs treated can be selected.
  • In the Treatment Procedures Table;
    • Treatment: It is the type of treatment applied.
    • Explanation: It can be used as a note field, any status explanation can be written.
    • Limb: In this treatment, it can be selected for which limb the treatment is made.
    • List Price: Indicates the amount determined by the Medical Association.
    • Purchase Price: The amount requested by the health institution for this treatment.
    • Discount: It is the discount area. It is used in cases where the entire amount requested by the health institution should be paid with a discount. Value must be entered in percent.
    • Unit Price: The amount to be paid to the employee. It is multiplied by the number and the Amount field is filled.
    • Currency: The currency of the amount to be paid is selected.
  • Medicine and Supplies;
    • The common fields in the Treatment Procedures table are used for the same purpose.
    • Indicates only drugs obtained as a result of treatment in the Medicine and Supplies field.
  • In the Table of Limbs;
    • If a limb was treated, it must be selected here.
    • Max: The coverage type is specified in detail and means the maximum number of times that treatment can be performed on this limb.
    • Payment Limit: It specifies the treatment that can be done on this limb and the maximum amount that the institution can afford.
    • %(Percentage): Specifies the percentage of the invoice amount that the institution will pay.
• In the Use of Coverage field, the total number of Treatments, Medications and Limbs and usage details of the relevant Employee in that Coverage Type are listed. The lines drawn in red are the usages where the limit is exceeded.

Health Expense Accounting

If a transaction type definition is made for the Health Expense from the transaction categories, if this transaction type is selected and updated in the expense detail, accounting records will be created. By clicking on the icon showing the details of the accounting receipts in the tab menu, you can examine the popup as shown in the picture.

Health Expenses Batch Approval

Approval units can come to the list of health expenses and list the Employee or Contracted institution invoices from the Sorting field in the filter field and give batch approval, and the process can be carried out in an easy and short way.

After making a list, health expenses to be sent for approval are selected from the far right column of the list. The total amounts of the selected expenses are shown in the field below.

Process: The processes of health expenses are updated with the selected stage.

Document No: It is automatically assigned by the system and this document number is displayed as batch approval in "Notifications and Approvals".

Document Date: Indicates the date of the transaction.

Template: Specifies the template to be used when previewing in Workflow.

Documents submitted for Batch Approval can be managed from Workflow.