...
Example
If a claim for providing a Normal Delivery service to a Female of 25 yrs of age (who is covered by a product that includes all services in the National Health Insurance of Nepal) is entered by Health Facility A, openIMIS will check against a few criteria automatically before presenting the claim for manual review for the scheme operator.
Claim entered by Health Facility A Beneficiary Definition Product Definition Service Definition Item Definition
- Female patient
- Only 1 service claimed
- Normal Delivery
- Date of claim:
- Female
- 25 yrs of age
- No claims for delivery service before
- Active Policy
- Ceiling amount remaining: Rs. 30,000
- All services in the openIMIS instance included
- All items in the openIMIS instance included
- Normal Delivery Service
- Female only
- Once every calendar year
- Price: Rs. 10,000
N/A Assumptions of some definitions are presented in Table 1. In this case, the claim would be accepted as the beneficiary has an active policy, has an available credit covering the cost of the service claimed, is a Female, and this is the first time a delivery service is claimed for this beneficiary. This claim would now appear on the screen of the claim review team of the scheme operator for manual review.
However, if the same claim (or similar, but including the delivery service) is entered again before 01 Jan 2020, the claim will be rejected as it will not meet the criteria defined under Service Definition - Once every calendar year.
...