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Claim.ReviewStatus: updated to “Selected for Review” (value 4) if the ClaimResponse contains rejected items
ClaimItem.Status/ClaimService.Status: updated to “rejected” (value 2) for each ClaimResponse.item where adjudication.category equal to 1
ClaimItem.RejectionReason/ClaimService.RejectionReason: updated to “rejected by AI” (value -2) for each ClaimResponse.item where adjudication.category equal to 1
json_ext.claim_ai_quality.was_categorized: updated to True
json_ext.claim_ai_quality.ai_result: updated to ClaimResponse.item.adjudication.category + 1 (DB values 1-Accepted, 2-Rejected)
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@startuml state "Enter Claim" as ClaimEntering { Entered --> Entered : Edit\nClaim state "Rule Engine Checking" as RuleEngineCheck { state RuleEngineValidation <<choice>> Entered --> RuleEngineValidation : Submit Claim RuleEngineValidation --> RejectedByRuleEngine : Reject\nAll Items RejectedByRuleEngine --> [*] RuleEngineValidation --> CheckedIdle : Accept \n Some Items } state "AI Automatic Categorisation" as AICheck { state AIClaimCategorisation <<choice>> CheckedIdle --> AIClaimCategorisation AIClaimCategorisation --> CheckedAIAccepted : Accept\nAll Items AIClaimCategorisation --> CheckedAIFlagged : Reject\nSome Items note top of CheckedAIFlagged : Rejected Items values } state "Manual Review" as ManualReview { state SelectForReview <<choice>> CheckedAIAccepted --> SelectForReview SelectForReview --> CheckedNotSelected : Select manually\nnot to review SelectForReview --> CheckedSelected : Select manually\nto review state RequireManualReview <<choice>> CheckedSelected --> RequireManualReview CheckedAIFlagged --> RequireManualReview : Selected automatically\nfor review RequireManualReview --> CheckedRejected : Manual Review\nReject All Items CheckedRejected --> [*] RequireManualReview --> CheckedAccepted : Manual Review\nAccept Some Items CheckedAccepted --> CheckedReviewed : Deliver review } state "Processing" as Process { CheckedReviewed --> ValuatedAccepted : Process CheckedNotSelected --> ValuatedAccepted : Process CheckedAccepted --> ValuatedBypassed : Process \nwithout \ndelivering \nreview ValuatedBypassed --> [*] ValuatedAccepted --> [*] } @enduml |
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A PDF report is generated that provides the following information (output based on manual reviewed Claims):
total number of Claims
accuracy scores
number of True Positives results
number of True Negative results
number of False Positive results
number of False Negative results
Table with Claim that were fixed (
ClaimItem.json_ext.claim_ai_quality.ai_result != ClaimItem.ClaimItemStatus- same for ClaimService)ClaimCode
CHFID (Insuree number)
ICDID (check if name can be entered)
Date from-to (DateFrom - DateTo)
Total items (ClaimItems + ClaimServices)
Fixed items
Reviewed date (ValidityFromReview)
Reviewed by (AuditUserIDReview → Username)same format as Claim Overview report with additional
json_ext.claim_ai_quality.ai_resultcolumn for each Item and Service
To generate this report, the user will have have to filter through the Review Claims search form and trigger the report through a button (label is “AI Misclassification Report”). Only the filtered Claims will be considered for the report.
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