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12- Scheme administrator want to define bundle of items/services for claims
Features requires:
Rights (management + claiming)More generic management of the benefit package, a benefit package cannot only use the Health insurance coverage models, other model such as one time payment or right must be supported (both can be linked, a pension coverage can lead to a pension benefit ) each model should be a set of modules: ability to add “rights“ to an insuree that will ensure that he will get benefits/payment for a given period of time (US 1,3,6)
Coverage extension (might be merged with rights): an insuree can get an exceptional coverage without the need to add a new policy (actually part of the policy or without policy), works with voucher or per-authorization ( result of pre-auth claiming) (US 11)
Customizable claim valuation so the value of service/cash transfert can be calculated based a specific information (US 1,2,3,6,8)
Configurable Workflows So the claiming can be reviewed by the right team depending on the type of claim (also some process will require multiple approvals which are not yet supported) so additional steps can be added in the claim to ensure that all the required parties did their parts (US 3, 4, 7)
Form attached to the claim to collect the additional information required to handle the case
Complex claim services that can have a variable value based on other parameters (from imisdb or Form, i.e. average contribution for the last 6 months)
Bundle several claim Items and services (12) that can be applied to a claim and then amount of Items/services corrected via pop up (i.e. result not mixed with other items and services) (12)Invoices (and bills) to be able to deal with many sort of payments (10)
(very low priority) Reinsurance funding and contribution (9)
Real Audit claim process (8)
On the modeling parts:
The cash payment and the rights should be linked to a product in order to know which issuree are “cover“ for the right and to get contributions (alike product service and Item)
Claim cash payment and claim right should be linked to a claim meaning that the claim screen should allow adding such right or none health/cash payment (may depend on the claim type)
Active rights would be a instance of their own, still linked to the product through the right they implement
Claim/Active Rights Audits should also be dedicated object that might change the status of the claim or rights (put it as suspended for example)Grievance to manage grievance from insuree
The insuree object must become more generic : Person Model
the HF models must have a module on their own so Geo location could be deployed stand alone
managing beneficiary ('potential') listing and its curation
On the modeling parts:
FHIR Questionnaire could be attached based on the type of claims
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