Benefit Engine
Benefit Engine
Works out healthcare coverage across 13 Thai schemes — cascading, caps, co-payments, discounts and balances — in a fraction of a second.
Key features
- Supports 13 Thai coverage schemes: universal coverage (including out-of-area), civil service benefits, social security and workmen's compensation, local government, state enterprise, private insurance, corporate contracts, foreign patients, welfare, self-pay and others
- Multi-scheme cascade — when a patient holds several schemes, the engine applies them in order, moving to the secondary only once the primary is exhausted
- Caps — per item, per visit, per day or per year, with running totals carried forward
- Co-payments — as a percentage or a fixed amount, deducted automatically
- Mandatory supplemental payments where a scheme covers only part of a service
- Discount policies — staff, elderly and condition-based
- Balance tracking — claimable, used and remaining, per scheme per year
- Simulator — test the numbers before opening a real visit
- Allocation breakdown — every baht attributed to a source, visible to patient and staff
- Audit log — every calculation stored with a snapshot of the policy version used
Overview
The benefit engine is the brain behind billing and coverage. Rather than asking a member of staff to work out what each scheme pays, the engine calculates the whole visit in a fraction of a second and shows the result line by line.
It handles the real conditions of Thai coverage: annual ceilings on particular procedures, mandatory co-payments on certain services, cascading between primary and secondary schemes, and discounts layered on afterwards.
Why it matters
Getting coverage wrong costs real money. Overcharge the patient and you face a complaint; undercharge and the claim is rejected by the scheme. An engine that calculates correctly, shows its working, and can be audited afterwards is what protects a facility’s revenue.
In older systems this knowledge lived in individual staff members’ heads or in personal spreadsheets — and had to be taught again whenever someone left. MorLuang turns it into configurable rules that an administrator can adjust through the interface, with no code change.
Configuring coverage
Four tools let staff manage the rules themselves:
- Coverage policy master — set the conditions per scheme per item: percentage covered, caps, co-pay, cascade order
- Bulk editor — change many items at once, spreadsheet style
- CSV import and export — load scheme data supplied as a spreadsheet
- Simulator — run a hypothetical visit and see the numbers before applying the change
Transparent and auditable
Every visit that passes through the engine carries an allocation breakdown showing which scheme paid what and what the patient owes. Patient and staff see the same figures, which reduces disputes and makes later auditing straightforward.
Each calculation stores a snapshot of the policy version in force at that moment. Even after the rules change, you can still see which version an old visit was calculated under — which matters when a scheme queries a claim months later.
How it connects
The engine sits between charge capture and billing. When a physician orders a test or medication, or staff record a procedure, the engine prices it immediately and returns the split so billing can raise an invoice with coverage already applied. The allocation data then feeds the claim centre for submission in each scheme’s required format.
Who uses this
Related modules
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