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The functionality allows reviewing and adjustments of claims from medical point of view. Reviewing of claims is restricted to users with the system role of Medical Officer or with a role including an access to |
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The register of Users defines who can login to openIMIS and under what constraints. The register of Locations defines administrative division of the territory, on which a health insurance scheme is operated. The register of Payers allows specification of institutional payers that can pay contributions on behalf of policyholders (households, groups of persons). The register of Enrolment Agents specifies all persons (either employed or contracted) by the scheme administration that are entitled to distribute/sell policies to population. The register of Claim Administrators specifies all employees of health facilities that are entitled to submit claims to the scheme administration. The register of Health Facilities contains all contractual health facilities that can submit claims to the scheme administration. The register of Medical Items specifies all possible medical items (drugs, prostheses, medical devices etc.) that can be used in definitions of packages of insurance products and in pricelists associated with contractual health facilities. The register of Pricelists that splits into two divisions for Medical Services and for Medical Items contains pricelists valid for individual health facilities or their groups reflecting results of price negotiations between contractual health facilities and the scheme administration. Finally, the register of Products includes definitions of all insurance products that can be distributed/sold within the health insurance scheme.
Claims/Claim/Review. Pre-conditionsA claim has been already submitted. NavigationAll functionality for use with the administration of claim overview can be found under the main menu Clicking on the sub menu Claims Overview PageThe Claims Overview Page is the central point for all claim review administration. By having access to this panel, it is possible to review, feedback, amend and process claims. The panel is divided into five sections (Img. 30). Search PanelThe search panel allows a user to select specific criteria to minimise the search results. In the case of claims the following search options are available, which can be used alone, or in combination with each other. Region Select the District Select the HF Code Select the HF Name Type in the beginning of; or the full Claim Administrator Select the Insurance Number Enter the insurance number of the patient. When the field is selected, the search insuree popup(:refnum:’insuree_picker’) will be display and will allow the claim administrator to search the insuree based on its insurance number, or/and last name, or/and other(first) name Claim No Type in the beginning of; or the full Review Status Select the Feedback Status Select the Claim Status Select the Main Dg Select the Batch Run Select the Visit Date From Type in a date; or use the Date Selector (Tab. 12), to search for claims with a Visit Date To Type in a date; or use the Date Selector (Tab. 12), to search for claims with a Claim Date From Type in a date; or use the Date Selector (Tab. 12), to search for claims with a Claim Date To Type in a date; or use the Date Selector (Tab. 12), to search for claims with a Visit Type Select type of out-patient visit or in-patient admission from the list of types of visit to search for claims made on specific visit/admission type. Claim Selection Update PanelThis panel is basically for functionality of updating multiple claims which are currently loaded in the Result Panel at once basing on the claim filter criteria available on this panel. The update on the claims is basically changing Feedback Status and Review Status of a claim from Idle to Selected for Feedback or Selected for Review respectively. The filters in this panel work on the claims which are currently loaded on the result panel. The combination of filters is either Select A selection dropdown box to select between Review Select and Feedback Select to filter only claims whose review status is Idle or feedback status is Idle respectively from among claims currently in the Result Panel. Random Accept a number which is considered to be a percentage of the claims in the Result Panel. Check the random checkbox and enter a number on the text field next to checkbox. The default is 5%. Value Accept a number which is considered to be claimed value. This will filter claims from the Result Panel by taking claims whose claimed value is equal or greater than the entered number in the Value text field. Check the value checkbox and enter a number on the text field next to checkbox. Variance Enable to set a variance arround the Filter button Once desired criteria have been set and after clicking this button (Img. 36), then the claims currently displayed in the result panel which satisfy the criteria, a reduced number of claim will be dispalyed in the result panel Bulk updates One can select them all (Img. 35) then by clicking on the 3 dots (Img. 37) more advanced actions (Img. 38) will be displayed. A notification will be displayed to confirm display the action result (Img. 32) Result PanelThe Result Panel displays a list of all claims found, matching the selected criteria in the search panel. The currently selected record is highlighted with light blue, while hovering over records changes the highlight to yellow (Img. 33). Per default 10 records can be displayed at one time in a scroll panel but this number can be changed (Img. 42, the default value can also be changed in front end configuration), Further records can be viewed by changing pages (Img. 41). The Feedback and Review Status Columns in each row contain a drop down list with options for claim feedback status and claim review status. A user can change the claim feedback and review status to Idle to Not Selected or Selected or Bypass. the change will take effect directly in an asynchronous mode, a notification will indicate the result of the update (Img. 34) Deliver Review Clicking on this button (Img. 40) re-directs a user to the Claim Review Page, where a claim with review status Selected for Review can be reviewed and its current review status changed to Reviewed. If the claim is not in the status Selected for Review then the claim can be only loaded and shown to the user without any subsequent action. Deliver feedback Clicking on this button (Img. 39) re-directs a user to the Claim Feedback Page, where a claim with feedback status Selected for Feedback can be feed backed and its current feedback status changed to Delivered. Actions MenuThe Action menu is used in conjunction with the current selected record (highlighted with light grey). The user should first select a record by clicking on any position of the record or by clicking on
Clear Selection Unselect the selected claims Select For Feedback set the feedback status of the selected claims to Selected Skip feedback set the feedback status of the selected claims to Not Selected Select For Review set the review status of the selected claims to Selected Skip Review set the review status of the selected claims to Not Selected Process selected Process the selected claim with the status Checked, once processed the claims will have the status Processed this means that the valutation will be done against the cieling and deductible configure on the product page Information PanelThe Information Panel is used to display messages back to the user. Messages will occur once a claim has been reviewed, updated, feedback added on claim or if there was an error at any time during the process of these actions. Claim Review PageData Entry
Read-only information of the current claim:
Editable information of the current claim:
Services and Items data entry grids.
Saving / ReviewingOnce appropriate data is entered, clicking on the data entry validationIf inappropriate data is entered at the time the user clicks the BackBy clicking on the Claim Feedback PageThe Claim Feedback page will show -only information of the current claim selected for feedback, on the top section of the page it has input boxes where a user with the system role Medical Officer or with a role including an access to Claims/Claim/Feedback can enter feedback on the current claim or where the user can read a feedback delivered by enrolment officers. Data EntryRead-only data of the feedback includes in the section **Claim the following:** Health Facility The health facility code and name which the claim belongs to. Insuree Patient/beneficiary names and insurance number Date Claimed The date on which the claim was prepared by the claiming health facility Visits Date From The date on which the patient visited (or was admitted by) the health facility for treatment on which the claim is basing on Visit Date To The date on which the patient was discharged from the health facility for treatment on which the claim is basing on Visit Type Type of visit covered by the claim (emergency, referal, other) Claim No. The unique identification of the claim within the claiming health facility. Guarantee No. Identification of a guarantee letter for prior approval of provision of claimed health care. Claim Status The status of the claim. Review Status The status of the claim with respect to reviewing. Feedback Status The status of the claim with respect to feed backing. Claim Administrator The administrator’s code and name, who was responsible for submission of the current claim.
SavingOnce all mandatory data is entered, clicking on the BackBy clicking on the |
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