Netcare Health OS Ecosystem

Payer
Connect

The live coordination layer between healthcare delivery and healthcare funding.

A secure, real-time platform connecting hospitals, clinics, specialists, medical aids, insurers, HMOs, and patients into one operating layer. Verify cover. Approve care. Route patients. Reduce claim friction. All live.

How It Works

One coordination layer. Live.

Eligibility, authorisation, claims, and referrals flow through a single intelligent hub — connecting every provider to every payer in real time. Hover the flow types to explore.

PROVIDER SIDEHospitalsClinicsSpecialistsDay HospitalsLabs & DiagnosticsPAYER SIDEMedical AidsHealth InsurersHMOsScheme AdminsPAYERCONNECTEligibilityAuthorisationClaimsReferrals

Move the patient faster

Approve care smarter

Reduce claim friction

Connect payer & provider live

The Problem

The space between payer and provider is chaos

Every day, millions of healthcare interactions are slowed by manual processes, broken workflows, and zero shared visibility between the people providing care and the people funding it.

Slow eligibility checks

Providers don't know if a patient is active, covered, or in-network until after delays — sometimes hours.

Broken authorisation workflows

Approvals handled through fragmented portals, emails, PDFs, call centres, and endless back-and-forth.

Bad patient routing

Patients sent to the wrong facility, wrong specialist, or non-optimal provider — even when a better covered option exists.

Weak transfer coordination

Moving a patient between facilities or care levels is slow, manual, and badly documented.

Claims leakage & rejection

Claims delayed or rejected from missing codes, bad attachments, missing auth, or benefit misalignment.

Poor payer-provider visibility

Insurers can't see what's happening fast enough. Providers can't see payer logic fast enough. Everyone's blind.

End-to-End Journey

From patient entry to claim resolution

Eight steps. One platform. Complete payer-provider coordination.

01

Patient enters system

Arrives physically, books online, or is referred in

02

Eligibility checked live

Membership, policy, benefits, network, co-pay, exclusions — all verified instantly

03

Best care route determined

Medical need + payer rules + provider network + urgency + cost efficiency

04

Pre-authorisation triggered

Structured request with diagnosis, notes, attachments, urgency

05

Payer reviews & responds

Approve, reject, pend, request info, or escalate — with full context

06

Care proceeds

Patient treated, referred, admitted, scanned, transferred, or discharged

07

Claim readiness checked

Codes, attachments, auth status, benefit alignment, rejection risk — all validated

08

Case timeline stays live

Provider, payer, patient, coordinator, billing — everyone sees progress

10 Product Modules

Every layer of the coordination stack

From eligibility verification to AI-powered decision support — ten modules that turn payer-provider chaos into a single live workflow.

System Architecture

Four layers, ten modules — hover to explore how they connect

INTELLIGENCE LAYERJAI CopilotCSmart RoutingWORKFLOW LAYERAEligibilityBPre-AuthDReferral & TransferEClaims ReadyINTERFACE LAYERGPatient PortalHProvider PortalIPayer PortalDATA LAYERFShared Case Timeline
Intelligence Layer
Workflow Layer
Interface Layer
Data Layer
A

Eligibility & Benefits Engine

Phase 1

The fastest wedge.

Instantly confirms whether a patient is covered and what they're entitled to. Active/inactive status, benefit availability, network match, co-pay warnings, plan limits, authorisation needs — all in seconds.

B

Pre-Authorisation Engine

Phase 2

The approval workflow layer.

Digitises and structures medical approvals between providers and payers. Handles admissions, surgery, radiology, specialist referrals, high-cost treatments, chronic care, maternity, and oncology workflows.

C

Smart Routing Engine

Phase 3

The intelligence layer.

Routes patients to the best covered provider or facility based on specialty, insurer network, distance, urgency, capacity, and cost efficiency. The right care at the right place, every time.

D

Referral & Transfer Engine

Phase 3

The movement layer.

Coordinates patient transfers and referrals safely. Provider-to-provider handoffs, facility acceptance, transfer approvals, care continuation documentation, and receiving facility confirmation.

E

Claims Readiness Engine

Phase 4

The protection layer.

Validates claims before submission. Checks authorisation presence, code alignment, benefit match, documentation completeness, policy validity, and rejection risk. Stops bad claims before they happen.

F

Shared Case Timeline

Phase 2

The visibility layer.

A single live journey for every case — registration, eligibility, authorisation, referral, transfer, admission, treatment, discharge, claim status. Every party sees what they need, nothing more.

G

Patient Portal

Phase 2

The patient-facing layer.

Keeps patients informed. Cover status, approval progress, required documents, where to go, next steps, transfer instructions, out-of-pocket warnings, and current case stage. No more confusion.

H

Provider Portal

Phase 2

The provider operations layer.

Used by front desk, case managers, doctors, admissions, finance, and transfer coordinators. Verify cover, submit authorisation, upload documents, track responses, initiate referrals, validate claims.

I

Payer Portal

Phase 2

The funder-side layer.

Used by authorisation teams, medical officers, claims teams, and case managers. Review requests, manage approvals, monitor urgent cases, track network usage, flag suspicious patterns.

J

AI Copilot

Phase 4

The Visio intelligence layer.

Summarises clinical requests and benefit logic, flags missing items, suggests covered options, explains payer responses, identifies claim risks, recommends best next provider, surfaces delays and bottlenecks.

Who It Connects

Every party in healthcare financing

Provider Side

HospitalsPrivate clinicsSpecialist groupsGP networksDay hospitalsDiagnostic centresPharmaciesLabsEmergency/ambulanceRenal/oncology/maternity centres

Payer Side

Medical aid schemesHealth insurersHMOsScheme administratorsManaged-care orgsTPAs / claims administratorsPublic-financing bodies
Go-to-Market

Five phases to infrastructure

Start with the easiest wedge. End as the coordination layer for African healthcare.

Phase 12026Eligibility & Benefits...Phase 22026–2027Pre-Auth + Provider & ...Phase 32027Smart Routing + Referr...Phase 42027–2028Claims Readiness + AI ...Phase 52028+Network Intelligence +...
Phase 12026

Eligibility & Benefits Verification

The easiest wedge. Fast ROI. Easy to demo. Easy to understand. Providers see value in minutes.

Revenue Model

Eight revenue streams. One product.

Provider SaaS fee
Payer enterprise fee
Transaction-based fees
Premium AI usage
25%

Provider SaaS fee

Monthly subscription per facility

20%

Payer enterprise fee

Annual contract per insurer/scheme

8%

Implementation & setup

Onboarding, training, integration

10%

Integration fees

Per-connection to existing systems

15%

Transaction-based fees

Per eligibility check or auth request

12%

Premium AI usage

Advanced copilot features

5%

Analytics & reporting

Network intelligence dashboards

5%

White-label licensing

Branded deployments for large groups

Compliance by Design

Built for regulated healthcare

Not a feature set. Part of the product foundation. Every module is built for healthcare and insurance compliance from day one.

COMPLIANCEBY DESIGN
Access Control
Role-based access control
Consent management
Encryption at rest & in transit
Data Protection
Secure API gateway
Full audit logs
Activity tracking
Audit & Tracking
Breach handling workflows
Document-level permissions
Retention controls
Operations
Cross-border transfer controls
Least-privilege access
MFA / strong authentication
The Investment Thesis

This product sits in the middle of the money

Before vs After

Measurable operational transformation

Every metric that matters — red bars (before) vs coloured bars (with Payer Connect)

Metric
Before
Improvement
After
Gain
Eligibility Check Time
2–4 hours
< 3 seconds
0.0%
Pre-Auth Turnaround
3–5 days
< 30 minutes
0.0%
Claim Rejection Rate
15–25%
< 3%
0.0%
Admin Overhead
40% of staff time
< 10%
0.0%
Patient Routing Errors
30%+ misrouted
< 2%
0.0%
Payer Visibility Lag
Days behind
Real-time
0.0%
Average operational improvement
92%reduction in
friction points

The coordination layer
healthcare has been missing

Payer Connect is where healthcare delivery meets healthcare funding. One platform. Live. Secure. Intelligent.

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