Vertical

Health & Provider Network

A medical scheme administrator built on iqava's connected core: benefits, members, real-time eligibility and adjudication — over a shared provider network, with portals for members and providers.

Two platform capabilities + a flagship vertical

A shared Provider Network and real-time medical scheme administration, with member and provider portals on top. LOB-agnostic underneath — the same network serves motor (garages, assessors) and general (advocates, valuers), and the benefit engine is configuration, not a hardcoded medical schema.

The Provider Network

One shared directory of service providers — hospitals, garages, assessors, advocates — that any insurer on iqava can empanel. A provider is entered once and shared: the second insurer to empanel a hospital does zero data entry. Facilities can be ticked from a registry rather than typed, and each insurer sets their own panel tariffs.

Where to find it

Console → Service delivery → Provider Network — search or add a provider, tick facilities from the registry, and manage your panel (status + tariffs).

Medical scheme administration

Design a scheme's benefit structure — inpatient, outpatient, dental, optical and more — with annual limits, sub-limits (e.g. maternity within inpatient), waiting periods, co-pays, exclusions, and whether a limit is a shared family pool or per member. Enrol members and their dependants, then check eligibility and adjudicate claims in real time.

Benefit structureMembers & dependantsEligibilityAdjudicationUtilization

Eligibility, in real time
Is the member active, past any waiting period, and with limit remaining? The answer is a live query against the scheme's benefits and the member's (or family's) utilization this year.
Benefit-level adjudication
A billed service is decided as pass, partial or reject — walking eligibility → exclusions → co-pay → sub-limit cap → annual-limit cap — returning exactly what the insurer pays and what the member bears, with reasons. Pre-authorize (preview) or book the claim, which advances utilization for the next decision.

Where to find it

Console → Service delivery → Medical Schemes— create a scheme (with a standard benefit structure to tune), manage members, and run the live eligibility & adjudication tool.

Member & provider portals

Members see their cover in their iqava wallet at my.iqava.com/cover — a digital member card and, per benefit, how much of the limit is left this year, updated in real time.

Providers get their own portal at iqava.com/provider: a hospital claims its facility, then verifies a member's eligibility and submits pre-authorizations and claims — but only for insurers that have actively empanelled them. Each submission is adjudicated in real time against that insurer's benefits.

To confirm the person holding the card is the member, the provider can send a one-time codeto the member's phone and have them read it back. The confirmation is recorded on the insurer's audit trail, so a later claim is known to have been presented in person. A member with no phone on file is verified by the card and national ID as before. The member's digital card also carries a QR code, so a desk can scan it with a phone camera and land straight on that member's lookup instead of typing the number.

What's coming

Available today: the provider network (with a registry sample), scheme benefits, members, eligibility, adjudication, one-time-code and scannable-QR card verification, an employer portal with member self-registration, corporate scheme import, and the member & provider portals. On the roadmap: loading the full national facility registry.

Related: the Integration Hub (sync members and providers from an insurer's existing systems) and Claims.