Policy Module Documentation
Overview
The Policy Module serves as the central command center for managing insurance policies across your various corporate clients. This module allows you to digitize contracts, configure financial limits, and automate approval rules.
Note: Access to the Policy Module is restricted to Manager level accounts to ensure data integrity and security.
On the main overview page, you will find quick access to essential resources, including the User Guide, Technical Documentation, and direct contact channels for Lnkr Support.
1. Corporate Client Setup
The Lnkr Payer platform supports a wide range of entities providing medical coverage, including TPAs, HMOs, self-funded schemes, and discount card companies. Before creating a policy, you must define the Corporate Client.
To create a new client, navigate to the client creation form and enter the following details:
Entity Details: Client Name, Type, and Contact Information.
Key Personnel: Assign a Representative or Communication Officer to ensure clear lines of correspondence.
2. Creating a Policy
Once the corporate client is established, you can proceed to create a policy. This process is divided into two primary configuration stages:
Step 1: Contract & Terms
Define the high-level attributes of the agreement:
Client: Select the previously created Corporate Client.
Policy Info: Enter a clear Policy Name and Description.
Duration: Set the effective Start Date and End Date.
Step 2: Financial Information & Configuration
Configure the financial constraints and eligibility rules:
Total Ceiling: The maximum coverage limit for the entire policy.
Funding: Select the Funding Type and Pool Amount.
Pool Configuration: Specify if the pool amount is included in the annual maximum.
Inclusion Categories: Define eligible groups (e.g., Employees, Families, Pensioners).
Payment: Set the Payment Frequency.
3. Policy Configuration & Automation
Upon successfully creating the policy, three advanced configuration sections will become available to finalize the setup:
A. Table of Benefits
This section allows you to digitize the hardcopy policy contract into structured data. You can define benefits by:
Service Type: Assign the benefit to a specific category (e.g., In-Patient, Out-Patient, Pharmacy, Pre-Existing, Optical).
Eligibility: Select which Inclusion Categories (e.g., Employees vs. Pensioners) are eligible for this specific benefit.
Limits & Rules:
For each benefit, you can enforce granular controls:
Financial Limits: Annual Limit and Copayment Percentage (%).
Usage Limits: Maximum visits per month/year and visit frequency (in days).
Family Rules: If the "Family" option is selected, you can define Family Coverage %, Out-of-Pocket Maximums, and the maximum number of dependents covered.
B. Auto-Approval Engine
The Auto-Approval Engine streamlines operations by processing approvals in real-time based on your pre-defined logic.
Configuration: Enter a Rule Name, Description, and Effective Date.
Applicability: Select the Service Type and Category the rule applies to (e.g., Medication, Lab Tests).
Denial Conditions: You can flag specific criteria to trigger an automatic rejection (Denial Condition), significantly reducing manual review time for non-compliant requests.
C. Chronic Care Registry
This section manages patients requiring recurring medication dispensation. It automates the monthly approval process for chronic conditions.
Configuration Rules:
Dispense After (Days): Determines the specific day of the month when the approval becomes active/visible to the pharmacy.
Max Duration (Months): The number of months the patient is eligible for the medication (capped by the policy end date).
Patient Mapping:
Once configured, map eligible patients to their specific medications. You can apply item-level restrictions, such as an Annual Maximum Quantity (e.g., 5 bottles per year).
How it Works:
On the designated day of each month, the system automatically generates the chronic approval for the listed patients, ensuring a seamless experience for the beneficiary and the pharmacy.