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In the process of data cleaning, several exclusion conditions were defined and are mainly related to the defined adjudication workflow.
Exclusion conditions
Condition 1
All the medication and activity definition items with a ClaimStatus ‘Entered’ (the claim was entered but not submitted, so not yet checked by the RuleEngine) were excluded from the analysis: corresponding to 201’402 records (83’986 medication and 117’416 activity definition items) and respectively to 40’393 claims with date of submission of the claim between 05-12-2017 and 29-09-2020.
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Fig 4. Number or claims related to the status of the claim, as well as the review status
Condition 2
All items rejected by the Rule Engine, were excluded from the analysis: 209’210 records, corresponding to 78’289 claims.
Condition 3
Missing values in the ClaimAdminID, PolicyID, ProdID, VisitType columns will be excluded: 1’451 records corresponding to 578 claims.
Condition 4
Inconsistency with respect to the values in the ClaimItemStatus, ClaimStatus, ReviewStatus, RejectionReason, PriceValuate: 145 records corresponding to 74 claims.
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Records where ClaimStatus is Rejected and RejectionReason is Accepted;
Condition 5
Inconsistency in terms of status and PriceValuate: rejected item, but with positive valuated price: 33 records corresponding to 24 claims.
Condition 6
Inconsistencies in terms of date fields in the DateFrom, DateTo, DateClaimed or DOB: 6’199 records corresponding to 1’340 claims.
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