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This specification might evolve based on the development constraints. |
Summary
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Claim AI-based Adjudication System
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The AI input model is represented by a matrix having on each row one Medical Item/Service from a Claim. If the FHIR Claim Bundle contains multiple Claims then the AI input model will contain all Items/Services from all Claims. Each row contains the following informations (either FHIR Medical OR ActivityDefinition, representing an Item in FHIR Claim):
identifier (ItemUUID) | identifier (ServiceUUID) | identifier (ClaimUUID) | identifier (InsureeUUID, CHFID) | identifier (HfUUID) |
extension.unitPrice | unitPrice | billablePeriod (start, end) | birthDate (to calculate age) | location (HFLocationUUID) |
frequency | frequency | created | gender | category |
extension.useContext (ItemPatCat) | useContext (ServicePatCat) | type | extension.isHead | type |
type (always “Medication”) | type (always “ActivityDefinition”) | item.quantity | extension.povertyStatus | |
item.unitPrice | extension.locationCode (LocationUUID) | |||
diagnosis.diagnosisReference (for icd_0 get ICDID) | extension.group (FamilyUUID) | |||
diagnosis.diagnosisReference (for icd_1 get ICDID) | ||||
enterer (ClaimAdminUUID) |
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In this project, the generated AI Model is only valid for Nepal openIMIS implementation. Any usage in other context/implementation will give wrong categorization responses. For other context/implementation, the retraining of the AI Model, based on already categorized Claims, is mandatory. |
Several data files are to be loaded and saved during the AI Model execution:
encoded fields data file
scalling file
AI model file
The AI Model file name with full path (or relative path) is configured in the modules configuration key ai_model_file
. Each time the model is executed, the model file is loaded, allowing to change the filename on execution in the configuration (hot-reload).
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The following module configuration is defined:
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{ 'authentication': [string], // Authentication key list. Default:String [] ai'claim_modelresponse_fileurl': string'http://localhost:8000/claim_ai/ClaimResponse', // AI Model file name with full path. Default: ./ai_model.pkl claim_response_organization: string // Value to build the insurer reference in the ClaimResponse. Default: openIMIS-Claim-AI }URL set in the ClaimResponse. String 'ai_model_file': "joblib_Voting_Model.pkl", // AI Model file name, relative location to module folder. String 'ai_scaler_file': "scaler.pkl", // AI Scaler file name, relative location to module folder. String 'ai_encoder_file': "Encoder.obj", // AI Encoder file name, relative location to module folder. String 'claim_response_organization': 'openIMIS-Claim-AI', // Organisation name in ClaimResponse. String 'date_format': '%Y-%m-%d', // Date format to use. String 'first_date': '2016-01-01' // First date for date transformation. String } |
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The default AI Model filename will be defined after finalizing the AI Algorithm development. |
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FHIR Contained Resources feature allows to integrate the referred resourced. Because AI-model is requiring information from other resources referenced by the Claim, these resources must to be accessible from the Claim sent by Claim-AI Quality module. In case of FHIR Claim, these are Patient, Condition, Medication, HealthcareService, Practitioner, ActivityDefinition. The mechanism to build Claim resource with Contained Resources is developed in the openIMIS FHIR R4 module. In FHIR R4 module, the inclusion of Contained Resources should be possible based on the query variable contained=true/false
(default false
).
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RejectedByRuleEngine --> [*] RuleEngineValidation --> CheckedIdle : Accept \n Some ItemsCheckedIdle : ClaimStatus=Checked (4) CheckedIdle :
} state "AI Automatic Categorisation" as AICheck { state AIClaimCategorisation <<choice>> CheckedIdle --> AIClaimCategorisation AIClaimCategorisation --> CheckedAIAccepted : Accept\nAll ItemsCheckedAIAccepted :
CheckedAIAccepted :
CheckedAIFlagged : ReviewStatus=SelectedForReview (4) CheckedAIFlagged : ClaimItemStatus=Rejected (2) CheckedAIFlagged : RejectionReason=Rejected by AI (-2) CheckedAIFlagged : json_ext.claim_ai_quality.was_categorized=true CheckedAIFlagged :
note top of CheckedAIFlagged : Rejected Items values } state "Manual Review" as ManualReview { state SelectForReview <<choice>> CheckedAIAccepted --> SelectForReview SelectForReview --> CheckedNotSelected : Select manually\nnot to review SelectForReview --> CheckedSelected : Select manually\nto review state RequireManualReview <<choice>> CheckedSelected --> RequireManualReview CheckedAIFlagged --> RequireManualReview : Selected automatically\nfor review RequireManualReview --> CheckedRejected : Manual Review\nReject All Items CheckedRejected --> [*] RequireManualReview --> CheckedAccepted : Manual Review\nAccept Some Items CheckedAccepted --> CheckedReviewed : Deliver review } state "Processing" as Process { CheckedReviewed --> ValuatedAccepted : Process CheckedNotSelected --> ValuatedAccepted : Process CheckedAccepted --> ValuatedBypassed : Process \nwithout \ndelivering \nreview ValuatedBypassed --> [*] ValuatedAccepted --> [*] } @enduml |
Only the Claims which contains Items/Services rejected by Claim-AI module will have the fields updated. The json_ext fields are always updated, even for the totally accepted Claim.
To ease the conversion from FHIR ClaimResponse to openIMIS Claim and saving into the DB, we have implemented the HTTP PUT method for ClaimResponse resource into openIMIS FHIR R4 Module.
Models
The new Claim-AI adjudication process is executed between Rule-based engine and the manual adjudication (see Getting the ClaimResponse from Claim-AI Module section). Because we decided not to add additional statuses to Claim, requiring to modify the Claim module, we will to use the JSON extensions that can be added and updated from the Claim-AI Quality module.
The following JSON extensions will be created to support the Claim AI-based Categorisation:
to add information on Claim. The field
was_categorized
allow to filter automatically checked Claim that have not been categorized by AI and ‘hide’ them for manual adjudication.Code Block language json "json_ext": { "claim_ai_quality": { "was_categorized": "boolean", // whether the claim has been categorized by Claim-AI module or not "request_time": "datetime", // time when the claim has been sent to Claim-AI module "response_time": "datetime" // time when the claim adjudication response has been received from Claim-AI module } }
to add information on ClaimItem and ClaimService. This is used to store AI categorisation result to allow the misclassification report.
Code Block "json_ext": { "claim_ai_quality": { "ai_result": "integer" // claim adjudication value provided by Claim-AI module (for misclassification report) } }
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@startuml class Claim as "openimis.claim.models.Claim" { class ClaimItem as "openimis.claim.models.ClaimItem" { -- claim_ai_quality extension -- +
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Only the Claims which contains Items/Services rejected by Claim-AI module will have the fields updated. The json_ext fields are always updated, even for the totally accepted Claim.
To ease the conversion from FHIR ClaimResponse to openIMIS Claim and saving into the DB, we have implemented the HTTP PUT method for ClaimResponse resource into openIMIS FHIR R4 Module.
Models
The new Claim-AI adjudication process is executed between Rule-based engine and the manual adjudication (see Getting the ClaimResponse from Claim-AI Module section). Because we decided not to add additional statuses to Claim, requiring to modify the Claim module, we will to use the JSON extensions that can be added and updated from the Claim-AI Quality module.
The following JSON extensions will be created to support the Claim AI-based Categorisation:
to add information on Claim. The field
was_categorized
allow to filter automatically checked Claim that have not been categorized by AI and ‘hide’ them for manual adjudication.Code Block language json "json_ext": { "claim_ai_quality": { "was_categorized": "boolean", // whether the claim has been categorized by Claim-AI module or not "request_time": "datetime", // time when the claim has been sent to Claim-AI module "response_time": "datetime" // time when the claim adjudication response has been received from Claim-AI module } }
to add information on ClaimItem and ClaimService. This is used to store AI categorisation result to allow the misclassification report.
Code Block "json_ext": { "claim_ai_quality": { "ai_result": "integer" // claim adjudication value provided by Claim-AI module (for misclassification report) } }
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@startuml class Claim as "openimis.claim.models.Claim" { class ClaimItem as "openimis.claim.models.ClaimItem" { class ClaimService as "openimis.claim.models.ClaimService" { class Service as "openimis.medical.models.Service" { } class Item as "openimis.medical.models.Item " { } class openimis.core.models.ExtendableModel { class openimis.core.models.VersionedModel { openimis.core.models.BaseVersionedModel ^-- openimis.core.models.VersionedModel openimis.core.models.VersionedModel ^-- Claim Claim "0.." - "0.." Item Service "0.." - "0.." Claim @enduml |
Because currently ClaimItem
and ClaimService
doesn’t support custom fields, these classes will also extend the ExtendableModel
class.
Migrations
Because the Claim-AI modules are activated after Claims have been adjudicated (the data used for the training), a migration script needs to be created to insert the JSON fields into the available data. The following initializations will be used:
If Claim.ClaimStatus == Entered (Value 2) Then don’t add Claim.json_ext.claim_ai_quality
If Claim.ClaimStatus == Checked (Value 4) Then add
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Claim.json_ext.claim_ai_quality.ai_result: integer = 0 } class Service as "openimis.medical.models.Service" { } class Item as "openimis.medical.models.Item " { } class openimis.core.models.ExtendableModel { class openimis.core.models.VersionedModel { openimis.core.models.BaseVersionedModel ^-- openimis.core.models.VersionedModel openimis.core.models.VersionedModel ^-- Claim Claim "0.." - "0.." Item Service "0.." - "0.." Claim @enduml |
Because currently ClaimItem
and ClaimService
doesn’t support custom fields, these classes will also extend the ExtendableModel
class.
Migrations
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was_categorized = false
Claim.json_ext.claim_ai_quality.request_time = null
Claim.json_ext.claim_ai_quality.response_time = null |
If Claim.ClaimStatus == Rejected (Value 1) Then add
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Claim.json_ext.claim_ai_quality.was_categorized = false
Claim.json_ext.claim_ai_quality.request_time = Claim.ValidityFrom
Claim.json_ext.claim_ai_quality.response_time = Claim.ValidityFrom
ClaimService.json_ext.claim_ai_quality.ai_result = ClaimService.ClaimServiceStatus
ClaimItem.json_ext.claim_ai_quality.ai_result = ClaimItem.ClaimItemStatus |
If Claim.ClaimStatus in [Reviewed/Processed (Value 8), Valuated (Value 16)] Then add
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Claim.json_ext.claim_ai_quality.was_categorized = true Claim.json_ext.claim_ai_quality.request_time = Claim.ValidityFromReview Claim.json_ext.claim_ai_quality.response_time = Claim.ValidityFromReview ClaimService.json_ext.claim_ai_quality.ai_result = ClaimService.ClaimServiceStatus ClaimItem.json_ext.claim_ai_quality.ai_result = ClaimItem.ClaimItemStatus |
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ClaimFilterMedicalItem
allows Medical Officers to filter the Claims list based on a specific Medical Item (only one from autocomplete list)ClaimFilterMedicalService
allows Medical Officers to filter the Claims list based on a specific Medical Service (only one from autocomplete list)ClaimFilterAIProcessed
allows Medical Officers to display or hide the non AI-processed Claims (checkbox, default checked)dropdown with options:Show all
,AI-Categorized Claim Only
,Not AI-Categorized Claims Only
, defaultAI-Categorized Claim Only
)
Custom Claim Review Search Results - Frontend
The following column will be added to the claim.Searcher
result list:
ClaimResultsAIProcessed
will display the value ofClaim.json_ext.claim_ai_quality.was_categorized
as True/False.
AI Categorisation Misclassification Report
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total number of Claims
accuracy scoresscore ( Accuracy = (TP+TN)/(TP+TN+FP+FN) )
number of True Positives results
number of True Negative results
number of False Positive results
number of False Negative results
Table with Claim that were fixed (
ClaimItem.json_ext.claim_ai_quality.ai_result != ClaimItem.ClaimItemStatus
- same for ClaimService)same format as Claim Overview report with Scope as ‘Claim and All Details’ and with additional
For each Item and Service will be added:
json_ext.claim_ai_quality.ai
_result
columnMedical Officer name from AuditUserIDReview (same as for ClaimAdmin)
To generate this report, the user will have have to filter through the Review Claims search form and trigger the report through a button (label is “AI Misclassification Report”). Only the filtered Claims will be considered for the report.
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database openIMISDB node openIMISImplementation as
ClaimAIQualityModule --^ ClaimModule } openIMISImplementation
} ClaimAIModule
ClaimAIAlgorithm
ClaimAIAlgorithm
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Testing
Testing the WebSocket from JavaScript console
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