Financial Management Module
Comprehensive financial management including actuarial analysis, medical loss ratio tracking, payment processing, premium billing, and rate table maintenance.
Organization Relevance
How It Works
The Financial module integrates with claims, enrollment, and provider modules to provide real-time financial visibility. Actuarial models project medical costs and reserve requirements. MLR calculations ensure ACA compliance. Payment processing handles provider reimbursement, premium collection, and capitation disbursement. Rate tables drive pricing across all financial transactions.
Requirements
- General ledger integration
- Actuarial modeling capability
- MLR calculation engine per ACA requirements
- Banking/EFT connectivity for payments
- Premium billing and collection infrastructure
Target Audience
CFO/Finance Leadership, Actuaries, Accounts Payable/Receivable, Premium Billing Teams, Financial Analysts
Pages (8)
| Page | Purpose | Key Features |
|---|---|---|
| Financial Dashboard | Financial KPI overview with revenue, expense, and profitability metrics | Financial KPIs, Revenue/expense tracking, Trend analysis, Budget comparison |
| Actuarial Analysis | Actuarial cost projections, reserve calculations, and risk modeling | Cost projections, Reserve modeling, Risk analysis, Trend factors |
| Financial Adjustments | Process financial adjustments, write-offs, and reconciliation entries | Adjustment entry, Approval workflow, Reconciliation, Audit trail |
| Grace Periods | Manage premium grace periods and coverage continuation rules | Grace period tracking, Notification management, Coverage status, Reinstatement rules |
| Invoicing | Generate and manage invoices for premiums, employer groups, and services | Invoice generation, Payment tracking, Aging analysis, Dunning management |
| Medical Loss Ratio | Calculate and monitor Medical Loss Ratio for ACA compliance | MLR calculation, Component tracking, Rebate estimation, Regulatory reporting |
| Payment Processing | Provider payment generation and disbursement management | Payment runs, Check/EFT generation, Payment reconciliation, Remittance creation |
| Rate Tables | Maintain rate tables for premium rating, provider reimbursement, and fee schedules | Rate table management, Version control, Effective dating, Rate comparison |
API Integrations
Payment processing API (ACH/EFT)X12 820 Premium PaymentGeneral ledger sync APIFinancial reporting APIRate table management API
Referenced Resources
ACA Medical Loss Ratio RequirementsNAIC Statutory Accounting PrinciplesCMS Rate Review GuidelinesASC 944 Insurance Accounting
Expected Results
Financial transparency with accurate MLR compliance, actuarial soundness, timely provider payments, and comprehensive financial reporting for all stakeholders.