AdMedika CoB

Coordination of Benefits

About National Health Insurance

jknbpjs

As per 1st of January 2014 Indonesia started the National Health Insurance Program (JKN: Jaminan Kesehatan Nasional) as a realization of the National Social Security as mandated by Law Number 40 of 2004 on National Social Security System (SJSN). The JKN program is managed by the Health Social Security Management Agency (Badan Penyelenggara Jaminan Sosial /BPJS Kesehatan). The JKN benefits are based on Managed Care healthcare scheme and provide benefits for those who follow the required procedure using primary health facility, mostly at primary public health centers. Through this program, every citizen will get comprehensive health care covering promotive, preventive, curative and rehabilitative services with affordable cost through the insurance system.

According to the JKN roadmap, the whole population in Indonesia are obliged to register to BPJS by 1st January 2015 for employees and 1st January 2019 at the latest for others categories of the population. Formal workers or employees will be enrolled in the JKN by their employers, while people working in the informal sector should register themselves if they wish to be covered by the JKN program.

About Coordination of Benefits

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With the implementation of JKN, every citizen are covered by the program and for those who are already have a health insurance coverage, those coverage will be considered as a “top-up payer” or additional insurance coverage. As per Presidential Decree Number 12 of 2013 on Health Insurance, states that BPJS Kesehatan and supplemental health insurance program providers / commercial insurance (Top-Up payer) must be able to coordinate in providing health insurance benefits to participants.

Coordination of benefits (CoB) is a practice used to determine the responsibility of payment for a healthcare claim when there is more than one health plan coverage. The benefits payable under JKN plan can be determined without a CoB. A CoB can apply to the top-up payer and the payable benefits could be reduced in such a way that the total of the payable benefits for all the plans will not exceed 100% of the real costs paid by the insured person. Coordination of benefits helps ensure that members covered by more than one plan will receive the benefits they are entitled to while avoiding overpayment by either plan.

AdMedika Coordination of Benefits

admedika cob

AdMedika CoB is an integrated solution developed specifically to support the JKN Program. With AdMedika CoB, the plan benefits and health insurance costs can easily be detected and divided among the Health BPJS and Top-Up Payer.

AdMedika CoB solution can generate periodic reporting such as reports on diagnosis such as the top 10 diseases based on sex and age, costs indicators based on hospitalization duration, the number of visits based on the number of patients, referred cases and provider types, and alert for Unusual Occurrence (epidemics). This reports can be utilize to analyze and validate the participants health provider, reviewing the agreed capitation fee with the provider, analyze the reference cases, and much more.

AdMedika CoB solution can be used by healthcare providers, private insurance, State-own enterprises (BUMN) and Health Foundation of self-insured private enterprises.

admedika cob

Case Study

A member covered by both the JKN plan and private insurance is referred to a secondary healthcare provider. The member wish to be treated in the VIP class but the JKN plan that he enrolled in, only cover up to second class hospitalization.

As the primary payer, BPJS will only cover the bill of second class while the balance difference between second and VIP class will be covered by the private insurance as the top-up payer according to his plan benefits. The benefits are thus "coordinated" among all of the health plans, and payments do not exceed 100% of charges for the covered services.

Flexible Collaborative Scheme

AdMedika COB Solution is one of the key features of an e-Health Application for Hospital Infomation System that are built by Telkom Indonesia & AdMedika. This application are built with cloud computing technology and comprehensive modular system is designed to support web eligibility, tiered referral (e-referral), INA-CBG & Capitation based accounting management and comprehensive reporting system that are required by the implementation of JKN.

admedika cob

For healthcare providers that currently do not have a Hospital Information System, can use the e-health application with embedded AdMedika CoB system. And for healthcare providers that already have a Hospital Information System can utilize the AdMedika CoB as a bridging program.

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