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Automated Claims Adjudication
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Technical Requirements
The claims review engine should align with the modularization roadmap of openIMIS. It is envisioned that the improved claims review engine would be written as a standalone service that utilizes a HL7 FHIR data store as the data input for the claim engine, in particular the FHIR Financial Module resources. This service would include the rules engine as well as user interfaces. This service would then be integrated in the openIMIS software as well as be available for the management of insurance schemes that do not use openIMIS but wish for advanced claim management functionality (e.g. PhilHealth). The claims review engine should be written so that future iterations can make use of advances in Machine Learning and Artificial Intelligence to improve the accuracy of identification of misfiled claims and to reduce the time involved by health workers in resolving claims.
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