# Vetra for HMOs & Insurers ### Operator's guide to running your insurance operation on Vetra > **Vetra** is the operating system for healthcare insurance infrastructure. This guide walks an HMO operator through the modules, day-to-day workflows, and configuration choices that turn the platform into a fully working back-office. --- ## 1. What you get out of the box Vetra ships an HMO portal with the following modules, all sharing a single system of record: | Module | Purpose | | --- | --- | | **Dashboard** | KPIs (claims received, settlement run, loss ratio, fraud flags) at a glance. | | **Clients & Enrollees** | Corporate clients, plan assignments, dependants, enrollee lifecycle. | | **Plans & Benefits** | Plan tiers, benefit limits, copays, exclusions. | | **Providers (Network)** | The provider directory and your in-network relationships. | | **Authorizations (PA)** | Pre-auth queue with urgency, SLA timers, auth codes, appeals. | | **Claims** | Adjudication queue, decisioning, query/attachment workflow. | | **Piles** | Provider + billing-month batches of claims for batch vetting. | | **Finance** | Settlement runs, remittances, payment proofs. | | **Capitation** | Per-enrollee monthly capitation payouts. | | **Reports** | Loss ratio, claims utilisation, provider performance, claims aging, settlement summary, fraud & anomaly, authorisation, enrollee coverage. | | **Approval Limits** | Per-role approval ceilings for claims and settlements. | | **Roles & Users** | RBAC with 55+ permissions; invite staff with scoped access. | | **Settings** | Tenant branding, billing, integrations (where applicable). | --- ## 2. Getting started in 7 steps 1. **Activate your workspace.** Your tenant URL is `app.vetrainsure.com/`. Your initial admin invite comes by email. 2. **Configure roles.** Visit **Settings → Roles**. The system seeds the common HMO roles (Admin, Claims Manager, Adjudicator, Finance, Provider Relations, Read-only). Customize permissions per role from the 55+ permission catalog. 3. **Set approval limits.** **Settings → Approval Limits** controls who can sign off on claims and settlement runs above given thresholds. Keep ceilings tight for new hires. 4. **Onboard plans.** Create plan tiers, benefit limits and exclusions under **Plans**. These power eligibility, PA auto-approval rules, and the enrollee portal coverage view. 5. **Onboard clients & enrollees.** Add corporate clients, then bulk-import their employees and dependants. Each enrollee receives a Vetra Member ID (`---`). 6. **Link providers.** Search the cross-tenant **Provider Directory** under **Network** and send them a "link to network" request. Linked providers can submit claims and PA requests directly to you. 7. **Invite staff.** **Roles & Users → Invite**. Each invitee gets a scoped login and inherits role permissions. --- ## 3. The claims lifecycle ``` SUBMITTED ─► RECEIVED ─► IN_REVIEW ─► APPROVED ─► SETTLED └─► QUERIED ─► RESUBMITTED ─► IN_REVIEW └─► REJECTED ``` ### Submission paths - **Provider portal** — linked providers submit directly. Encounter + line items + attachments captured up-front. - **API** — `POST /v1/claims` for systems integration. - **Manual entry** — your team can enter a claim on behalf of a provider. ### Adjudication - The queue ranks claims by **AI risk score**, **SLA urgency**, **value**, and **payer rules**. - Adjudicators see line items, eligibility verdict, plan benefit limits, and AI-flagged anomalies side-by-side. - A claim can be **queried** (send a question + requested attachments to the provider), **approved** in full or part, or **rejected** with a coded reason. ### Piles Claims belonging to the same provider in the same billing month are grouped into a **Pile**. A pile has its own progress bar, AI-flag summary, and a "Vet next" workflow so a manager can plough through 200+ claims without losing place. ### Settlement Approved claims roll up into a **settlement run** at the cadence you configure (weekly, bi-weekly, monthly). The run produces a remittance advice per provider; uploading the payment proof closes the loop and notifies the provider. --- ## 4. Pre-authorizations (PA) - **Urgency tiers:** ROUTINE / URGENT / EMERGENCY each carry an SLA timer. - **Auto-approval rules:** define per-plan, per-procedure rules; matching requests are approved instantly with an auth code. - **Ghost-patient alerts:** an emergency PA submitted for an enrollee triggers a notification to the enrollee themselves, so the real cardholder catches misuse. - **Appeals:** rejected PAs can be appealed by the provider; appeals re-enter the queue with the original context. --- ## 5. Finance & settlements - **Settlement runs** — group approved claims by provider, produce a remittance, attach the payment proof. - **Capitation** — monthly per-enrollee payouts to designated primary providers. - **Payment proofs** — uploaded by Finance; the provider portal shows them in real time. - **Disputes** — providers can raise disputes against remittances; Finance resolves with audit trail. --- ## 6. AI & fraud intelligence - Every claim is risk-scored on submission. Triggers include duplicate billing, impossible service dates, upcoding patterns, and rapid-fire submissions from the same provider. - **AiRiskEvent** records every flag for auditability. - The **Fraud & anomaly** report aggregates trends by provider, procedure, and enrollee. - **Ask Vetra** (the in-app AI copilot) can summarise a claim, surface similar past cases, and draft a query response. --- ## 7. Reports All eight reports run on live data and ship with KPIs + trend + breakdown + table + filters + CSV export. - Loss ratio - Claims utilisation - Provider performance - Claims aging - Settlement summary - Fraud & anomaly - Authorisation - Enrollee coverage --- ## 8. Notifications A real-time bell over SSE pushes events to staff, providers and enrollees in their respective portals: - PA submitted / decisioned / appealed - Claim submitted / queried / approved / rejected / settled - Settlement run created, payment proof uploaded - Suspicious activity (ghost-patient alerts) --- ## 9. Security & compliance - **Tenant isolation** — every HMO's data is logically isolated and scoped server-side. - **BFF architecture** — the public app talks only to a backend-for-frontend; the core API requires an `x-api-key`. - **Auth** — httpOnly cookies, helmet, throttling, CORS allow-list, environment validation. - **RBAC** — 55+ permissions; approval limits as a second layer of control. - **Audit log** — every permission-sensitive action is append-only and exportable. - **Encryption** — TLS 1.2+ in transit, AES-256 at rest, managed key rotation. --- ## 10. Billing (what you pay Vetra) Vetra charges a per-claim fee at the **RECEIVED** state (not at submission, not at settlement). A pricing hierarchy lets you negotiate tier overrides; subscriptions and invoices are generated automatically. --- ## 11. Day-in-the-life — Claims Manager | Time | Action | | --- | --- | | 09:00 | Open Dashboard → see backlog + SLA breaches. | | 09:15 | Open the heaviest **Pile**, run "Vet next" for batch decisioning. | | 10:30 | Approve a settlement run; route to Finance for proof upload. | | 11:30 | Review **Fraud & anomaly** report; flag two providers to Network team. | | 14:00 | Configure a new auto-approval rule for a plan tier. | | 16:00 | Close out the day's queries via the bell notifications. | --- ## 12. Where to get help - **In-app:** Ask Vetra widget (bottom-right of every screen). - **Docs:** `vetrainsure.com/documentation` - **Email:** support@vetrainsure.com - **Status:** `status.vetrainsure.com` --- *Vetra Health, Inc. — The operating system for healthcare insurance infrastructure.*