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Contribute to Claim Review Search with Medical Item/Service and AI-categorized filters
Prepare the new checked claims for AI categorisation
Push Claims to Claim-AI module on scheduled task and/or event-based activation and update Claims based on the response
Reports Claim adjudication misclassifications
Models
The new Claim-AI adjudication process is executed between Rule-based engine and the manual adjudication. Because we decided not to add additional statuses to Claim, requiring to modify the Claim module, we propose to use the JSON extensions that can be added and updated from the Claim-AI Quality module.
The following JSON extensions will be created to support the Claim AI-based Categorisation:
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{
claim_ai_url: string // URL of the openIMIS instance running Claim-AI module. Default: ""
event_based_activation: boolean // True if the checked Claims are sent to Claim-AI module immediatly after check. Default: False
} |
Claims Preparation
Claim-AI Adjudication Activation Methods
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This activation is based on the openIMIS mutation signal signal_mutation_module_after_mutating on SubmitClaimMutation mutation (red AcceptSignalAction in AI-based Claim Adjudication Process). First, this event allows to prepare the Claims for the Claim-AI adjudication processing. Second, it would allow to push the Claims to Claim-AI module for the actual adjudication. Because we are interested to activate the processing using this event, we propose to define the module configuration variable event_based_activation, allowing to push the checked Claims immediately after Rule Engine check. not actually an activation because
The event-based activation allows a continuously communication flow between the openIMIS implementation and the Claim-AI implementation.
Schedule Task activation
This activation is using the DjangoScheduler to schedule the sending of Claim to Claim-AI module (pink AcceptSignalAction in AI-based Claim Adjudication Process). As the Event-based activation, this trigger is also pushing the checked Claims to Claim-AI module.
In case the Event-based activation is activated (event_based_activation=True), the triggering of the Schedule Task will not do anything because all the checked Claims have already been sent during
Claims Preparation
AI-based Claim Adjudication Process
Pushing Claims to Claim-AI Module
Build FHIR Claim Bundle
FHIR Contained Resources
FHIR Contained Resources feature (https://www.hl7.org/fhir/references.html#contained) allows to integrate the referred resourced. In our case for FHIR Claim, these are Patient, Condition, Medication, HealthcareService, Practitioner, ActivityDefinition.
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