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SAP Modules for Health Insurance

Former Member
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Dear SAP community,

we are currently working on a software that might need to communicate with SAP-Systems of health insurance companies sooner or later. Regarding this, I have a few open questions:

  1. Which modules are typically used by german health insurcance companies?
  2. Which module is resposible for the accounting part of the process which means checking and processing the incidents that are billed by the hospitals?
  3. Are there SAP functions that allow the user to check if the bills are correct?
  4. Are there existing workflows that can be performed by the user when certain bills are incomplete, wrong or suspicious?
  5. Are there existing interfaces which can be used to communicate with the the accounting part of the module?

I hope these questions are clear. If there is anything unclear, please do not hesitate and ask for extra information.

I am looking forward to your reply.

Yours sincerely

M. Hartwig

3 REPLIES 3

Former Member
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All your 5 points will be addressed when Nan-Shan Health Insurance become go live.

MichaelHilberg
Explorer
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Hi Mattis,

I am not aware of SAP's installed base in Germany for health insurance companies.


From the processes you are looking for, you'd be mostly looking at SAP Claims Management (FS-CM). FS-CM has extensive functionality for health insurance and should cover these processes. Check out the health insurance-related documentation for FS-CM here: Health-Specific Concepts in Claims Processing - SAP Library


Best regards,

Michael


PS: Manish, Nan Shan's health insurance is quite different from the German health insurance business.

Former Member
0 Kudos

Hello Mattis,


Referring to your below questions, please find some remarks which are maybe of assistance to you. In general I recommend to check the following link http://help.sap.com/insurance


Please proceed as follows:

1. select on the right side any of the SAP Insurance solutions you’re interested in

2. select the most recent EhP of this solution

3. select the topics you’re interested in (release notes, application help, master guide, etc.)

4. select the language you like (EN/DE)

5. from there you can navigate through lines of business (Health Insurance, P&C, Life, …) as well as general topics of insurance business management


1. Which modules are typically used by German health insurance companies?

There’s no “typical” module usage. The reason therefore is, that German statutory health insurance companies also use other software than SAP Insurance solutions, i.e. that functionalities which are needed to follow the regulations of SGB (Sozialgesetzbuch) are sometimes in other applications than SAP Insurance. From business perspective the customer relationship management, collections & disbursements, claims management (Leistungsmanagement), business partner master data management, finance management, and business intelligence solutions are in the focus of managing health insurance business. Just to give you an overview on how a leading German health insurer manages the business with SAP solutions, please refer to this link http://www.aok-systems.de/produkte/oscare-highlights.html


2. Which module is responsible for the accounting part of the process which means checking and processing the incidents that are billed by the hospitals?

Checking and processing incidents billed by hospitals is part of the SAP Claims Management (please refer to the link of SAP Help, where you find detailed information about the processes and how they are supported by SAP solution. Once the checks of incoming hospital invoices is finalized and approved, outgoing payments can be made via accounts payable or collections & disbursement.


3. Are there SAP functions that allow the user to check if the bills are correct?

Yes, you can implement checks on data consistency and data correctness. With business rules you can also define individual check criteria. By activating the difference log report you can check if accounted positions and amounts are in accordance with previously given treatment approvals.


4. Are there existing workflows that can be performed by the user when certain bills are incomplete, wrong or suspicious?

Yes, you can use some standards like task management and alert notification. That’s a functionality which is available within SAP Claims Management. Depending on selected functionality when implementing the software, the user can decide individually whom to involve in the workflow, or select from a drop down menu possible choices, or the workflows are started automatically in the background involving pre-defined persons or groups for investigation.


5. Are there existing interfaces which can be used to communicate with the accounting part of the module?

Yes, there are interfaces which can be used. For detailed description please refer to above mentioned SAP Help. http://help.sap.com/erp2005_ehp_08/helpdata/en/ca/87cb53f0f67314e10000000a174cb4/content.htm?framese...


Hope it answers your question. If you feel comfortable with my reply please mark this question as "answered".


Best regards

Karsten Tecklenburg

Industry Principal Insurance

SAP MEE