Acceptance environment

A test environment that is used to perform (user acceptance) testing on the CarePay system.

Accident

An unforeseen, unexpected and unintended event resulting in bodily injury.

Account

CarePay system term. Beneficiaries are linked to a program through an account:

• By default, an account consists of one principal.

• Optionally, one or more dependents can be added as well.

The principal is an account holder by default. Adult dependents can be designated as account holder as well.

Note that account in this case refers to a user account, not to be confused with an account on a program (policy).

Accreditation

Proof that a program or provider meets certain standards. An independent party decides this through an official review.

Age limit

The age below or above which a payer will not accept enrolment or renewal.

Agency 

Also see Standard Actors.

Agent

Also see Standard Actors.

Agent App

Mobile app used by agents to register beneficiaries on the CarePay platform and/or enroll them in a program.

Agent code

Unique agent identifier used by agents to claim commissions and/or bonuses.

Annual limit

The maximum amount that is covered under a specific program in any given year.

Also see CarePay Master List of Terms and Definitions#Limit. Depending on program settings, various annual limits may apply, for example per beneficiary and/or per account.

B

Beneficiary

Obsolete. See CarePay Master List of Terms and Definitions#Participant.

Benefit

Any service (e.g. consultation, laboratory test, surgical procedure) or supply (e.g. medicine) covered under a program.

Benefit limit

The maximum amount that is covered under a specific program for a specific covered benefit.

Also see CarePay Master List of Terms and Definitions#Limit. Depending on program settings, various annual limits may apply, for example per beneficiary and/or per account.

Billing station

Sub-group of a provider organization (for example some specific department), uses its own invoices (separate from other billing stations) to help identify different forms of care in a treatment record.

Providers are completely free to define billing stations as they want.

Bonus

A monetary reward that is awarded to eligible members.

Eligibility is determined by detailed bonus rules. A bonus could be related to making regular savings, referring new members, et cetera.

C

CALC

Network for financial transactions (commonly referred to as Automated Clearing House or ACH) developed and used by CarePay.

CALC can be used via two portals:

• CALC Admin Portal – used by CarePay employees

• CALC HP Portal – used by Healthcare Provider employees

Capitation

A method of compensation per patient (and per period).

The number of patients used to determine capitation amount is typically defined as the number of enrollees who have set the provider in question as their preferred provider.

Case management

The process of ensuring that health insurance benefits are being properly and fully utilized and that non-covered services are avoided when possible. Case management is the responsibility of the payer, but may be delegated to an Agency.

Case manager

Also see Standard Actors.

Cash advance

A loan product provided to providers following an agreement with CarePay and Medical Credit Fund.

CBP

CarePay Business Processes

CBR

CarePay Business Requirements

CDS

CarePay Database Setup

Chronic condition

A condition that is permanent, recurring or long lasting.

Claim

1. Bill, sent by a provider to a payer, to serve as a basis for compensation on a fee for service basis.

2. CarePay system term. Used to capture and store relevant details of a treatment and the corresponding costs.

A claim can have one of the following statuses in the CarePay system:

• Draft

• Submitted

• Approved

• Rejected

• ReOpened

• ReSubmitted

• Deleted

Also see CBP – CLM: Manage Claims.

Claims management

The process of reviewing and approving submitted claims in line with treatment and payment guidelines.

Claims manager

Also see Standard Actors.

Commission

Transaction of money from a payer to an agency / agent to pay for the execution of tasks by that agency / agent on behalf of the payer.

Compensation

Transaction of money from a payer to a provider to pay for care provided under a specific program.

Types of Compensation include CarePay Master List of Terms and Definitions#Capitation and Fee for service.

Corporate program

A program, in which only employees of some specific employer can enroll as principal. The employer in question may or may not:

• Allow enrolment of dependents.

• Be the (main) payer of the program.

• Provide funds for the program.

D

Data transaction

A transaction in the CarePay system, in which no (mobile) money is involved.

Date of service

The date on which a treatment was provided.

Day case

A treatment without overnight stay.

Dependent

Depending on program settings, different types of dependents may be defined. Spouse and child are the most common types of dependents.

E

Effective cover date

The date on which a health insurance cover comes into effect.

Eligibility

Terms that decide who can get coverage. These terms may include health conditions, age, employment status, et cetera.

Employer

Also see Standard Actors.

Enrollee

Enrolment

The process of enrolling beneficiaries in health programs. This involves capturing and storing account details related to a specific health program. A beneficiary must be registered before he/she can enroll in health programs.

Also see CBP – REG: Manage Registrations.

Exclusion

Specific medical condition or circumstance that is not covered under a program.

F

Facility

A term commonly used to designate any healthcare provider, whether a doctor, a hospital or clinic.

Fee for service

A method of compensation based on the costs of services provided.

Financial transaction

A transaction in the M-TIBA platform that undergoes financial implications on the system (e.g. MTIBA fees, Safaricom fees).

G

Grace period

A period after the premium payment due date, during which insurance coverage remains in force and the policyholder may make a payment without penalty. The user might be able to access or not access the benefit depending on the program rules.

H

Health insurance

A contract that requires a health insurer to pay some or all of a member’s health care costs in exchange for a premium.

Healthcare organization

Health Provider with one or more healthcare facilities.

Hospitalization

Services related to staying at a hospital for either scheduled procedures, accidents or medical emergencies. Hospitalization services typically do not include hospital stays for giving birth to a child.

I

Inpatient

A term used to describe a person admitted to a hospital for at least 24 hours. It may also be used to describe the care rendered in a hospital when the duration of the stay is at least 24 hours.

Inpatient insurance

Insurance intended to provide coverage in case of hospitalization, including benefits for room and board and miscellaneous expenses, within certain limitations.

Inpatient service

Services provided when a member is registered as a bed patient and is treated as such in a health care facility such as a hospital (see Hospitalization).

In-progress treatment

A treatment with the status in-progress refers to a treatment where the provider has started billing but not yet submitted.

Insured person

The person who a contract holder (an employer, individual or Insurer) has agreed to provide coverage for, often referred to as a member/subscriber.

Insurer

The insurance company that offers health insurance plans.

Invoice

Group of invoice items, part of a treatment record.

Every treatment record contains at least one invoice. Invoices can be used (optionally) by a provider for internal accounting purposes

Invoice item

Predefined element of care, can be selected by a provider from the Product List to capture details of care provided, forms the basis for subsequent claims.

J

J

K

K

L

Lapse 

The termination of insurance coverage due to lack of payment after a specific period of time.

Length of stay

The total number of days that a patient stays in a facility such as a hospital.

Life

Refers to a single person in the system who has an active benefit(program) attached to them with a status enabled.

Limit

Any maximum that a health insurance plan imposes on specific benefits.

M

Maternity (inpatient)

Typically, inpatient maternity services include hospitalization and physician fees associated with the birth of a child.

Maternity (outpatient)

Typically, outpatient maternity services include antenatal and postnatal services.

Member

An individual who is registered on the CarePay platform.

Also see Standard Actors.

Member App

Mobile app used by beneficiaries to self-register on the CarePay platform and/or enroll in a health program.

M-PESA

Mobile payment service provided by Safaricom.

M-TIBA

Mobile payment service provided by Safaricom where money is earmarked for healthcare payment only.

N

Next of kin

A person, usually a spouse who can claim on behalf of the member in case of death/incapacitation. This is mostly applicable for Afya Kamili product.

O

Outpatient

Outpatient procedure

Some procedures can be done in a hospital, surgery centre or doctor’s office. The person goes home after the procedure. There is no overnight stay. This is also called Day case.

Outpatient service

Treatment that is provided to a patient who can return home after care without an overnight stay in a hospital or other inpatient facility.

P

Partial disability

A condition in which, as the result of an illness or injury, a group health insurance member cannot perform all the duties of his or her occupation but can perform some.

Participant

An individual who can register on the CarePay platform and enroll in one or more programs.

This term replaces beneficiary, which was used before and still appears in many places.

Partner user

A user who administers a benefit on a payer’s behalf.

Patient

Person seeking treatment at a provider, can be either a principal member or a dependent.

Payer

Also see Standard Actors.

PIN

Personal Identification Number

Policy (contract)

This is a legal agreement between a customer (an individual or group) and an insurance plan. It lists all details of the plan’s coverage.

Pre-auth treatment

A treatment with the status ‘pre-auth’ has been submitted to the case manager to authorise treatment.

Pre-authorization

The process by which members or provider notifies the health plan administrator of treatment plans, such as a hospital admission or a complex diagnostic test.

Pre-existing condition

A condition, disability or illness that you have been treated for before applying for new health coverage. A health problem that existed or was treated before the effective date of your health insurance coverage.

Preferred provider

A provider who has a contract with your health insurer and who a member selects to use from a list.

Premium

Amount to be paid for a specific account on a specific program.

This amount is typically dependent on account composition (number and type of beneficiaries) and the cover/insurance package. Premium payments may be due monthly, quarterly, or annually.

Price

Costs associated with a product.

Price List

List of the specific products offered by a provider and the associated prices under a specific program.

For every program, there is one Product List, defined by the payer. There could be many different Price Lists, one for every provider. Different Price Lists may contain different products (usually, providers don’t offer all products on the Product List) and may also contain different prices (unlike the products in the Product List, which are defined by the payer, the associated prices in the Price List are negotiated between payer and provider).

Principal

Also see Standard Actors.

Product

Predefined element of care (drug, procedure, lab test, et cetera).

Product List

List of products that are covered under a specific program.

Production environment

The live environment that is used to run the CarePay system.

Program

System of benefits, with predefined rules for eligibility and coverage. Eligible beneficiaries must enroll in a program before they can enjoy its benefits. The following types of programs exist:

• Savings

• Insurance

• Donor

Also referred to as Health Program. Other common terms include (Health) Plan and (Health) Scheme.

Provider

Also see Standard Actors.

Provider network

A group of providers that have signed a joint agreement on the services they offer under a specific program, and the costs they charge for those services.

Typically, the network provides services at a special rate. In some programs, coverage is more extensive when patients seek treatment at a provider in the network.

Q

Q

R

Registration

The process of registering beneficiaries on the CarePay platform. This involves capturing and storing personal details, irrespective of health programs.

Reimbursement

Restitution by a payer of costs that are covered under a particular program, but were paid by an enrollee in that program.

Not to be confused with compensation, which is paid by a payer to a provider.

Remittance

Transaction of money into a savings account by someone who is not an account holder.

Not to be confused with saving.

Remitter

A person who sends a remittance.

Renewal

Continuation of an account beyond the original duration of the contract.

Accounts are typically created and renewed for a period of one year.

Renewal date

The date on which a member’s health insurance plan benefit year renews.

Re-opened treatment

Status of a treatment that has been submitted by a provider but the claim manager re opens it for the provider to make adjustments to the claim.

Risk

The chance or likelihood of loss.

S

Saving

Transaction of money into a savings account by an account holder.

Not to be confused with remittance.

Sponsor

This is a group that sets up and manages a health plan or group insurance plan. It can be an employer, labour union, government agency or non-profit group.

Spouse

Partner (in a marriage) of the principal.

Submitted claim

A status of a claim that the healthcare provider has submitted to the claim manager and the healthcare provider has finished billing.

Submitted treatment

A treatment with status ‘submitted’ has been submitted to the claim manager to work on the claims contained in it.

T

T&C

Terms and Conditions

May refer to CarePay T&C related to personal data or program T&C related to program specific data. Beneficiaries must accept the CarePay T&C to register on the CarePay platform, and accept program T&C to enroll in a program.

Tariffs

Signed off agreed service specific charges by CarePay with contracted Health providers.

Temporary partial disability

This term is used to describe the condition of a person who due to injury is unable to work at full capacity but who is able to work at reduced efficiency and is expected to fully recover.

Temporary total disability

This term describes the condition of a person who due to injury is unable to work, but who is expected to fully recover.

Testing environment

Environment used by the development team when building the system.

Till

Service from Safaricom that allows merchants, including providers, to accept payments by M-PESA for services offered.

Training environment

Environment used for demos / training.

Transaction code

Unique identifier associated with every transaction at a provider.

Treatment

1. Interaction between patient and provider to provide care, may range from a simple consultation to elaborate surgery.

2. CarePay system term. Used to capture and store details of a medical appointment. These may include diagnoses, prescribed medicines, physician notes, et cetera.

U

Underwriter

Company that performs underwriting and takes the risk on the submitted claims.

Underwriting

The process by which an insurer determines whether it will accept an application for insurance based upon risks and projections, and through which a determination on monthly premium is made.

USSD

Unstructured Supplementary Service Data

Users can access the CarePay platform via (amongst others) USSD.

Utilization

This term refers to how frequently a group uses the benefits associated with a health insurance plan or healthcare program.

V

Voucher

A text message or printout that entitles the holder to a discount or free access to health care.

Waiting period

A period after the cover start date during which an enrollee is not allowed to access services on that cover.

Withdrawal

A request from a provider on CALC to transfer money to their M-PESA account or bank account as payment for services offered.

X

X

Y

Y

Z

Z