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| Excerpt |
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S No | Indicator | Numerator | Denominator |
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| Disaggregation | openIMIS Concept | FHIR Mapping | openIMIS Concept | FHIR Mapping |
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| | | | | Numerator | Denominator |
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1 |
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Value of all claims entered in openIMIS |
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Value of all claims | | | ClaimStatus | claimResponse.processNotexx | | | 2 |
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value claimed per member/HH with claims | Value of all claims | Number of members with claims |
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| RemuneratedAmount | claimResponse.item.adjudication.amount | | | 4 | Incurred |
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Total number of enrolled persons |
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| RemuneratedAmount | claimResponse.item.adjudication.amount | | | 5 | Average claim value | Value of all claims |
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RemuneratedAmount | claimResponse.item.adjudication.amount | | | 6 |
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HHs whose claims add up to 50000 NPR |
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ExceedCeilingAmount | claimResponse.item.adjudication.amount | | | 7 |
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HHs hitting ceiling through families |
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(%) | HHs hitting ceiling up to 50000 NPR during the time period |
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Families with claims during the time period |
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| ExceedCeilingAmount | claimResponse.item.adjudication.amount | | | 8 | Rejected claims | Number |
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ClaimStatus | claimResponse.processNote | | | 9 | Submitted claims | Number |
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11
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Number/value of claims reimbursed by other districts during time period
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Disaggregation by facility type needed
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12
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Total number/value of claims reimbursed during time period
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Disaggregation by facility type needed
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13
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Ratio number/value of claims reimbursed by other districts by total number/value of reimbursed claims during time period
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From total number/value of reimbursed claims subtract total number/value of claims reimbursed by own district (during time period)
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Total number/value of claims reimbursed during time period
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14
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Proportion pending/reimbursed claims of total claims during time period
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Total Number of pending or reimbursed claims during time period
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Total Number of submitted claims during time period
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by facility type needed
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Number of pending claims | | Facility type |
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Disaggregation by facility type needed
ClaimStatus | claimResponse.processNotexx | | | 11 | Pending claims (%) | Number of pending claims | Number of submitted claims | Facility type | ClaimStatus | claimResponse.processNotexx | | |
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12 | Reimbursed claims | Number of reimbursed claims | | Facility type | RemuneratedAmount | claimResponse.item.adjudication.amount | | |
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13 | Reimbursed claims (%) | Number of reimbursed claims | Number of submitted claims | Facility type | ClaimStatus | claimResponse.processNotexx | | |
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14 | Rejection rate of claims (automated/by claims review) | Total Number of rejected claims during the time period | Total number of claims during the time period |
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Type of Claim, emergency, OPD, IPD, Referral | ClaimStatus | claimResponse. |
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| | 15 | Total Revenue in Health Insurance Fund | Premium plus subsidy from public fund/MoF plus other private sources ( |
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17
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Enrollment data, MOF/HIB, | | | | | 16 | HHs revenue contribution (%) | Total premium collected from HHs | Total revenue in Health Insurance fund |
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18
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19
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Total numbers of types of claims
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17 | Government subsidy contribution (%) | Total premium received from MoF | Total revenue in Health Insurance fund |
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to cover the premium for extreme poor and poor
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20
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Rates of types of claims by value/number
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18 | Total claims by types | Total claims by the type (OPD, Emergency, IPD, Referral) |
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VisitType | claim.type | | | 19 | Claim type (%) | Number of claims by each type (OPD, Emergency, IPD, Referral) | Total number/value of all types of claims | | VisitType |
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| Number of claims per diagnosis |
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or longer List? Top 50? Top 100?
ICDID | claim.diagnosis | | | 21 | Trend of Diagnoses-Groups, i.e. NCD | Number of Claims for Treatment of |
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| several possible: Number of Claims for Diagn. |
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A group in year before, an average of several years before |
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Claims need to have indicator for Diagnoses-Group
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| | ICDID | claim.diagnosis | | | 22 | List of number/value of the type of service per period |
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23.1
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Can this be linked to Utilization level?
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Total # of visits or services in defined time period
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Total # of enrolled individuals
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24
item.service | | | 23 | List of Numbers/Value of most prescribed drugs per period |
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| Numbers/Value of most prescribed drugs per period of time |
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24 | List of Numbers/Value of most prescribed drugs per period |
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as % of total Number/Value of claims | List of Numbers/Value of most prescribed drugs per period of time | Total Number/Value of all claims |
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26
List of Numbers/Value of most prescribed drugs per period |
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as % of total Number/Value of claims which |
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prescribed drugs | List of Numbers/Value of most prescribed drugs per period |
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| Total Number/Value of all claims which |
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27
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Number/Value of Claims by public and private Facilities + type of facility
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conditional on quota of number of this type of facility of all facilities?
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HFLevel/LegalForm | type | | | 26 | Number/Value of Claims reviewed/valuated |
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Disaggregation down to Claim reviewer Level needed
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29
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| | | Claim reviewer | HFLevel/LegalForm/Valuated | type | | Facility Type, Gender | 27 | Number/Value of Claims reviewed/valuated (%) | Total Number/Value of claims reviewed/valuated |
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| Total Number/Value of all claims submitted |
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30
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Total Value/number of (valuated- already paid for?) reviewed claims by gender
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Value/Number of claims concerning female patients and vice versa
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Total Value/Number of claims
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should show conditional on male/female quota of enrollees, otherwise statistic only meaningful if enroled people are exactly 50% female, 50% male - also: costs for gender specific costs like maternal health care to be included or excluded?
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31
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Total Value/number of (valuated- already paid for?)reviewed claims by age group
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32
| HFLevel/LegalForm/Valuated | type | | Facility Type, Gender, Age Group | 28 | Valuated Value of claims as a share of total value of submitted claims |
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Aggregated Value of claims after being revised (include rejected claims?) | aggregated Value of all submitted claims |
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| | | | 29 | Incurred administration expense ratio |
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Total value of collected contributions |
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34
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Total value of incurred claims |
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Total value of earned contributions |
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value to the beneficiaries and programme viability
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Total sum of OOP spending |
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36
Total sum of health expenditure = OOP + claims |
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measures impact on target population. To measure this, treatment costs which patients pay for by themselves would have to be entered into OI
32 | Benefit coverage rate | Number of accepted claims |
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Total number of reported medical cases |
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Quality of the programme indicator. To measure this, hospitals would have to send data accordingly/ OI would need to register other cases
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| | Approved | claimResponse.totalBenefit | | | 33 | Complaint ratio |
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Total number of complaints |
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Total number of covered individuals |
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importance for OI?
34 | Promptness of claim approval |
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Period of time between submission and approval of a claim |
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/
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DateClaimed - DateProcessed | claim.created - claimResponse.created | | | 35 | Health infrastructure |
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40
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Waiting time for procedures
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40.1
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Should we include average waiting perid and proportion of people waiting delays out of total enrolled individuals
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41
Number of health facilities/health personnel |
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number of population
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OI doesnt know total number of population but can provide number of health personnel and so on
Population | | | | | | 36 | Average cost per (inpatient) visit | Total Value of all (inpatient) claims |
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Total number of inpatients |
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42
Number of cases for specific diseases |
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42.1
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HIV, DM, measles, DTP,…
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claim.diagnosis | | | 38 (a) | Payment allocation by diseases and its severity/Inpatient admissions/Primary health care sensitive diagnosis/tracer conditions | Total payments in the defined time period | Total enrolled population in the defined time period |
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RemuneratedAmount | claimResponse.item.adjudication.amount | | | 39 (b) | Ratio of highly complex to |
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fewer complex patients. | Total |
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number of highly complex patients seen in the defined area during the defined time period | Total |
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number of low complexity patients seen in the defined area during the defined time period |
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| | | | | 40 | Net income(profit) ratio | Total Value of collected (premiums + subsidies) - paid claims |
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Total amount of collected premiums + subsidies |
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viability - negative indicator shows that programme will not be viable, poisitive indicator means programme is viable. Largely positive indicator means re-evaluation of contributions and benefits.
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Additional Indicators Proposed based on review of all indicator sources
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Provider payment related indicators
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Do we also need to consider payments made to each practitioner/provider/ or Total payments made to practtioner/provider will do?
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Promptness of payment to providers
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Time taken in payment to the providers from the date claim was incurred
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Referral Rate
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Total referrals made by providers in a defined time period
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Total visits in the defined time period
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Patient satisfaction rate
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# of individuals who report that they are satisfied with the services they receive in the defined time period
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Total # of individuals receiving services
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Expansion of provider network
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Percentage of previously accredited facilities that renew or retain their accreditation
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Expansion of provider network
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Percentage of newly accredited facilities
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Accessibility of provider network
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Health facilities per 10,000 beneficiaries
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Quality of care
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Average number of readmissions within 30 days
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Quality of care
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Number of deaths per 1,000 hospital admissions
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