Overview
TOSHFA-is a comprehensive ERP solution for Insurers & Third-Party Administrators for Health Insurance Quotation Engine, policy administration module and claims management module, hospital network module, analysis module, accounting module, Reinsurance module as well as 360-degree reporting to TPA, Insurers, Hospital, Corporate, Individuals, and Brokers & Agents.
TOSHFA has gone through various functional and technological revolutions over the years. It is a web-based application along with integrated portals for Hospital Portal, Corporate Portal, broker Portal, Agent Portal and customer Portal to view the details and claim’s status and reports from the website login section.
In brief, it can notify policyholders about policy renewal date, it can manage all policy details received from insurers, preparation of ID cards, tracking of ID cards, dispatches of the cards, endorsement of employees and import policy data from excel files.
Maintains the record of network hospitals which includes hospitals detail entry, tracking suspended hospitals, record details of discount offered and claim analysis. Manage all aspects of claims related to Health, Adjudication, Billing, Settlement, preparation and dispatch.
The Quotation Module auto-calculates the total Premium Rates for different networks and different Rate Plans for number of Insured by considering Insurer underwriting guidelines including but not limited to standardizing the data that would give the Interface flexibility for the Underwriters to expand their Rating Parameters (viz. Rate Plans/ Network Plans) and allows in calculating the premium. This innovative tool enables Insurance Company to generate the Quotations for a new prospect client (called as tool rating based on market utilization factors) or client having coverage from other insurance company (Experience rating based on Claims experience).
This Engine is seamlessly integrated with the other system modules from Policy Administration, Approvals and Claims Management to the processing of the regulatory mandatory data submissions flow. TOSHFA has a comprehensive reporting engine that allows to extract the reporting of various process in the dynamic formats as required by the Stakeholders. This Product innovation has made clientele to reach pinnacle in their insurance needs and also assisted them in expand their business with the flexible rating parameters. The module is seamlessly automated with increased user & business experience that saves data entry at many places and allows as many number of quotations and renewals to happen by a click in no time.
Key Features
- Toshfa integrated with configurable third-party services
- Toshfa has fully automated with maker checker workflow management
- Toshfa is secured with AES 256 for all the sensitive data
- Option to define if an insured requires Health Declaration Letter
- Provision to create various Business Categories
- Flexibility to connect with Oracle Fusion system
- Mapping Nationality with Country to check Territory Coverage
- Ease of auto triggering emails on various business processes
- Option to show Digital Signature across the system
- Configuration of Key functions, that does not require vendor support
- Automated TPA Endorsements
- Automated TPA Claims Processing.
- Capitation option to insure lower level / HMO plans
- Flexibility to capture Burning Cost of a TPA
- Option for fronting HMO plans by charging Fronting Fee
- Commission Setup option for an Intermediary/ Broker
- Flexible option for various Intermediary Level configurations
- Configuration of various Regulatory conditions
- Quote Approval Authority Matrix based on user profile
- Broker Requirement Letter Configuration
- Customizable Table of Benefits creation option
- Option to setup the RI Rates and applying Insurer Exp Loading
- Configuration of various loading/ discount factors as applicable
- Provision to define Document Setup (Doc Type/ Size)
- Configuration for printing TOB components
- Option to make various Voucher Adjustments
- Locking Expired Policy to stop making any endorsements further
- Option to make ACTIVE policy to TOBERENEWED policy
- Option to view total number of claims on HASH TOTAL basis
- Option to apply Other Charges on Approved Claim amount
- Option to cut the receipt based on Gross/ Net Commission Basis
- Option to key-in AR/ AP code for a sub account
- Option for grouping the main accounts
- Voucher – Accounting Entries view provision
- View Insured Information based on Member ID/ Policy ID/ Email ID/Staff ID/ TPA ID/ Mobile No/ Emirates ID/ Member Name
- Option to Hold the cover until getting Insured details
- Booking the reserve for Holding Covers / Active Policies
- Booking UPR for Policies
- Reversal option for various accounting postings
- Accounts Reconciliation between Operations & Finance
- Cheque to Credit Note option and vice versa
- Cheque Tracker
- Option to make the Payment/ RI Payment/ HMO Payment
- RI / RI Broker Creation option with all the necessary details
- Option to create a Treaty with Capacity & all other parameters
- Option to run Premium Register & download if the data is huge
- Option to run Claim Register & download if the data is huge
- Provision to encrypt / decrypt the password
- All FAQs at one place for review
- Summarized System Exceptions with their count
- Flexibility for Third Party Integrations.
- Provision to upload ICD & Dental, Medicine, or CPT codes directly
- Provision to adjudicate the claims based on coverages
- Provision to classify the providers based on a territory
- Grouping all the providers into one
- Mechanism to define a plan template for each Insurer
- Issuing the quote based on loading/ discount factors
- Setting-up the restriction / limit for approval/ claim processing
- Has an intelligent system for audit trialing
- Has flexibility to make policy endorsements
- Provision to restrict / limit the Carrier user for claim processing
- Crystalline reports facility
- Accounting system (defined based on basic chart of account)
- Pre-approvals, Claims processing along with Customer Service
- Automatic Client Group Creation with all the necessary details
- Automatic Client Creation with all the necessary details
- Direct Interface for complaints lodge & Resolution
Key Benefits
- User Management System
- Insurance Administration Management System
- Insurance Quote Management System
- Insurance Agents / Brokers Management System
- Internal workflow automation
- Automation of claim processing
- Claim and policy management platforms
- Personalized insurance pricing
- Endorsements Management System
- TPA Management- Automated Endorsements & Claims
- Insurance Accounting and Automation
- Chat-bots for Insurance
- Provision to create various industry specific Business Categories
- Ease of auto triggering emails on various business processes
- Quote Approval Authority Matrix based on user profile
- Configuration of various Regulatory conditions
- Customizable Table of Benefits creation option
- Insured details 360-degree view
- Intelligent system for audit trailing