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the default openIMIS Claim adjudication process should be modified as less as possible
Medical Officers should not be impacted too much by the activation of the openIMIS-AI module
Claim adjudication process
Updated Claim Status
The following state diagram from Figure 1 corresponds to the Claim fields status with the updated adjudication process.
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Figure 1. Claim state diagram for the updated claim adjudication process
Updated Claim Adjudication Process
The following activity diagram proposes the updated adjudication process.
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| filename | openIMIS-AI-Modules-Interaction.png |
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| revision | 19 |
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Claim-AI Quality Module
Claim-AI Quality Responsibilities
Contribute to Claim Review Search with Medical Item/Service filter
Listening for <<signal_mutation_module_after_mutating>> SubmitClaimsMutation
Prepare the new checked claims for AI categorisation (not to be selected by reviewers)
Convert openIMIS Claims to FHIR Claims and POST to Claim-AI
Receive FHIR ClaimResponse
Update Claim Status and ReviewStatus
Reports claim adjudication misclassifications
Models
The following model is created to support the Claim AI-based Categorisation:
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| filename | ClaimAIExec.png |
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| revision | 161 |
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Claim-AI Module
Claim-AI Responsibilities
Self containing REST API
Accepts FHIR R4 Claim and reply with FHIR R4 ClaimResponse
Clean the data and prepare it for the AI model
Categorize the claim (AI model execution)