This document summarizes which the features are in scope :of the Claim module.
- it naturally references the current openIMIS documentation (the Web application user guide)
- provides some refinements deduced from current code readings
- lists taken hypothesis (whenever ambiguity or incomplete description was encountered) and attention points for the new claim module
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The claim module supports several Business processesProcesses, documented in another wiki section. Background - Joint Learning Network for UHC (claim management section).
The following table summarizes which features are in use in which Business Process:
| JLN Process - Claims processing | JLN Process - Claims status inquiry | JLN Process - Claims dispute and appeals | JLN Process - Claims adjustment and voids | |
|---|---|---|---|---|
Claim control (overview) | x | x | ||
| Verify patient data | x | |||
| Enter (new) claim | x | |||
| Edit claim | x | |||
| Print claim | x | |||
| (Bulk) Delete claim(s) | x | |||
| (Bulk) Reject claim(s) | x | |||
| (Bulk) Submit claim(s) | x | |||
| Claim review and feedback control (overview) | x | |||
| Bulk claim modifications | x | |||
| Review claim | x | |||
| Enter claim feedback | x | |||
| (Bluk)Move claim(s) to Processed status | x | |||
| (Bulk) Delete claim(s) | x | |||
| (Bulk) Reject claim(s) | x | |||
| Claim Valuation Batch Processings | x | |||
| Claim operational report | x | |||
| NOT COVERED STEPS | Aggregate, merge and batch claims data Flag for fraud and abuse Update beneficiary(note: beneficiary = patient?) Claims status sent to provider, beneficiary and other appropriate authorities Explanation of Benefits sent to provider and/or beneficiary Timeliness of claims processing First time claim pass rate | Is this business process covered in current openIMIS at all ?? | Is this business process covered in current openIMIS at all ?? |
Access rights
A claim is attached to a location (HF). Besides role-based feature access control (cfr. Actors and Roles here below), all claim management actions (entering, submitting,...) are limited by user’s location(s) scope: users can only access/manage claims related to his registered locations.
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- Enter/Submit claims
- Query eligibility service
- List claims
Claim control (overview)
The claim control feature provides a set of claim search capabilities.
It also gives access to the following features:
- Enter (new) claim
- Edit (existing) claim
- (bulk)Submit claim(s)
- (bulk)Reject claim(s)
- (bulk)Delete claim(s)
Claim Entry Features
Verify patient data
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The claim forms are not printed from openIMIS claim module. The receptionists receive them printed from a central printer.
Claim entry control (overview)
The claim control feature provides a set of claim search capabilities.
It also gives access to the following features:
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Enter (new) claim
Claims can be entered by end users or other IT systems.
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