Corporate Credit & Private Insurance Pre-Authorization

1. Overview & Business Value#

This comprehensive operational guide details the architecture, business workflows, configuration parameters, and execution steps for Corporate Credit & Private Insurance Pre-Authorization within SmartERP.

Configure corporate employer contracts, credit ceiling limits, co-pay rules, and pre-authorization approvals for insured employees.

{screenshot:corporate-credit-company-preauthorization-overview-dashboard}

2. Prerequisites & Security Access Groups#

• Required Modules: smarterp_healthcare, smarterp_clinical_core, smarterp_pharmacy
• Security Groups:
  • Healthcare Receptionist (Technical ID: smarterp_healthcare.group_medical_receptionist)
  • Physician / Attending Doctor (Technical ID: smarterp_healthcare.group_medical_doctor)
  • Pharmacy Dispenser (Technical ID: smarterp_healthcare.group_medical_pharmacist)
• Master Data Dependencies: Patient master registry (Medical Record Number - MRN), EFDA drug formulary, Ethiopian Ministry of Health (MoH) HMIS disease codes, and EHIS insurance tariffs.

3. Step-by-Step Configuration & Execution#

Step 1: Navigating to the Module Interface#

1. Log into your SmartERP instance at https://smarterp.et/odoo.
2. Open the main App Switcher (grid icon in the top-left corner).
3. Select the Healthcare app icon.
4. From the top navigation bar, open Healthcare → Clinical Dashboard → OPD Triage / Inpatient ADT / EMR / Pharmacy Dispensing.

{screenshot:corporate-credit-company-preauthorization-app-switcher-navigation}

Step 2: Creating and Parameterizing Records#

1. Click the New button in the top-left control panel.
2. Complete the mandatory fields in the record form:
   • Medical Record Number (MRN) (Mandatory): Unique national health identifier or generated hospital record code
   • Patient Demographics (Mandatory): Full legal name, gender, date of birth, and Kebele residential location
   • Encounter Type (Mandatory): Outpatient (OPD), Inpatient (IPD), Emergency, or Triage consultation
   • Attending Physician (Mandatory): Licensed healthcare practitioner responsible for clinical encounter
3. Configure optional operational parameters and localized tags as required:
   • Insurance Provider & Policy (Optional): EHIS CBHI/SHI policy or corporate credit contract
   • Triage Vital Signs (Optional): Blood pressure, pulse rate, respiratory rate, temperature, and SpO2
   • ICD-11 / HMIS Diagnosis Code (Optional): Standardized diagnosis category for statutory health reporting
4. Click the Save icon in the control bar to commit the record.

{screenshot:corporate-credit-company-preauthorization-record-creation-form}

Step 3: Validating and Processing Transactions#

• State Transitions: Execute operational state progression (Reception / Triage → Consultation → Lab / Radiology → Prescription → Billing / Discharge).
• Ledger & System Impact: Patient billing registers medical service revenue, debits patient or insurance accounts receivable, and debits pharmaceutical inventory upon prescription dispensing.
• Audit Verification: Automated recording of author ID, timestamp, and immutable revision history.

{screenshot:corporate-credit-company-preauthorization-transaction-processing-state}

Corporate Partner Master Configuration#

Hospitals frequently enter direct credit agreements with corporate employers, embassies, and private insurance companies (e.g., Ethiopian Airlines, Ethio Telecom, Commercial Bank of Ethiopia, Nyala Insurance).

To configure a corporate credit partner:

1. Open Healthcare > Configuration > Insurance & Corporate > Corporate Partners.
2. Select or create the company partner record (res.partner).
3. Set credit parameters:
   • Credit Ceiling Limit (ETB): Maximum allowable outstanding unbilled receivable (e.g., 5,000,000 ETB).
   • Payment Terms: e.g., Net 30 or Net 60 Days.
   • Discount / Markup Schedule: Contractual percentage adjustments on standard hospital tariffs.
   • Exclusion List: Services requiring cash payment (e.g., Dental cosmetics, optical frames exceeding limit).

Enrolling Corporate Employees and Setting Benefit Caps#

1. Under the corporate partner record, click Beneficiary Roster.
2. Import or create employee records specifying:
   • Employee ID Number and Full Name.
   • Eligible Dependents (Spouse and Children).
   • Annual Medical Benefit Ceiling (e.g., 50,000 ETB per beneficiary per fiscal year).
   • Co-Payment Percentage (e.g., 10% employee cash co-pay, 90% company invoice).

Electronic Pre-Authorization for High-Cost Procedures#

When a physician orders procedures exceeding a defined monetary threshold (e.g., MRI scan, major surgery, ICU admission):

1. The system displays a Pre-Authorization Required banner.
2. The Corporate Billing Officer generates an electronic Pre-Authorization Request:
   • Clinical summary authored by attending specialist.
   • Proforma estimate of hospital, diagnostic, and surgical costs.
3. The request transmits via email or insurer API portal.
4. Upon receiving approval, the officer enters the Authorization Code and approved monetary cap.
5. The clinical service unlocks immediately for execution.

Periodic Corporate Invoicing & Statement Reconciliation#

1. At the agreed billing cycle (bi-weekly or monthly), open Healthcare > Insurance > Corporate Invoicing.
2. Select the employer and period.
3. The system generates a single consolidated corporate invoice with itemized patient encounter attachments.
4. Post the invoice to Accounts Receivable.

4. Advanced Configuration Points#

• Automated Actions & Scheduled Tasks (Crons):
  • Healthcare: Generate daily MoH HMIS aggregate tally (smarterp_healthcare.ir_cron_hmis_sync): Runs daily at 23:00 to prepare DHIS2 health data summaries
  • Pharmacy: Flag expiring EFDA medicine batches (smarterp_healthcare.ir_cron_fefo_expiry): Runs daily at 06:00 to alert dispensers of lots expiring within 60 days
• Custom Print Templates & Reports:
  • Official Patient Encounter Summary & Medical Certificate
  • Electronic Prescription Order Form (Model 19 Compliant)
  • Ethiopian Health Insurance Service (EHIS) Claim Dossier
  • Daily MoH Outpatient / Inpatient Morbidity Tally Sheet
• Multi-Company Rules: Record-level security isolation under Company 1 (Ashewa Technology Solutions S.C.), preventing cross-company ledger leakage across parent and subsidiary legal entities.

5. Comprehensive Troubleshooting Matrix#