Note
This specification might evolve based on the development constraints.

Summary

Table of Contents

Claim AI-based Adjudication System

...

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):

FHIR Medication fields	FHIR ActivityDefinition fields	FHIR Claim fields	FHIR Patient fields	FHIR HealthcareService fields
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)

...

Note
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).

...

The following module configuration is defined:

Code Block

language	json

{
    '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: stringURL set in the ClaimResponse. String
    'ai_model_file': "joblib_Voting_Model.pkl", // Value to build the insurer reference in the ClaimResponse. Default: openIMIS-Claim-AI
}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
}

Note
The default AI Model filename will be defined after finalizing the AI Algorithm development.

...

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).

...

Plantumlcloud

filename	ClaimStatusStateDiagram.png
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width
compressed	true
revision	914

Expand

title	Diagram source

Code Block
@startuml



state "Enter Claim" as ClaimEntering {


 [*] --> Entered : Enter Claim


 
 Entered --> Entered : Edit\nClaim


 Entered : ClaimStatus=Entered (2)


 Entered : ReviewStatus=Idle (1)


 Entered : ClaimItemStatus=Accepted (1)


 Entered : RejectionReason=Accepted (0)



state "Rule Engine Checking" as RuleEngineCheck {



 state

RuleEngineValidation <<choice>>Entered

 RuleEngineValidation <<choice>>

 Entered --> RuleEngineValidation : Submit Claim



 RuleEngineValidation --> RejectedByRuleEngine : Reject\nAll Items


 RejectedByRuleEngine : ClaimStatus=Rejected (1)


 RejectedByRuleEngine : ClaimItemStatus=Rejected (2)


 RejectedByRuleEngine :

RejectionReason=[1-19]

RejectedByRuleEngine --> [*]

RuleEngineValidation --> CheckedIdle : Accept \n Some Items
CheckedIdle : ClaimStatus=Checked (4)
CheckedIdle :

 RejectionReason=[1-19]
 RejectedByRuleEngine : json_ext.claim_ai_quality.was_categorized=false
 RejectedByRuleEngine : json_ext.claim_ai_quality.request_time=ValidityFrom
 RejectedByRuleEngine : json_ext.claim_ai_quality.response_time=ValidityFrom
 RejectedByRuleEngine : json_ext.claim_ai_quality.ai_result=Rejected (2)


 RejectedByRuleEngine --> [*]

 RuleEngineValidation --> CheckedIdle : Accept \n Some Items
 CheckedIdle : ClaimStatus=Checked (4)
 CheckedIdle : json_ext.claim_ai_quality.was_categorized=false

}

state


 
}

state "AI Automatic Categorisation" as AICheck {



 state AIClaimCategorisation <<choice>>



 CheckedIdle --> AIClaimCategorisation

 

 AIClaimCategorisation --> CheckedAIAccepted : Accept\nAll Items


 CheckedAIAccepted : json_ext.claim_ai_quality.was_categorized=true


 CheckedAIAccepted : json_ext.claim_ai_quality.ai_result=Accepted (1)



 AIClaimCategorisation --> CheckedAIFlagged : Reject\nSome Items


 CheckedAIFlagged : ReviewStatus=SelectedForReview (4)


 CheckedAIFlagged : ClaimItemStatus=Rejected (2)


 CheckedAIFlagged : RejectionReason=Rejected by AI (-2)


 CheckedAIFlagged : json_ext.claim_ai_quality.was_categorized=true


 CheckedAIFlagged : json_ext.claim_ai_quality.ai_result=Rejected (2)



 note top of CheckedAIFlagged : Rejected Items values

}

state

 

}

state "Manual Review" as ManualReview {



 state SelectForReview <<choice>>



 CheckedAIAccepted --> SelectForReview



 SelectForReview --> CheckedNotSelected : Select manually\nnot to review


 CheckedNotSelected : ReviewStatus=Not Selected (2)


 CheckedNotSelected : RejectionReason=Accepted (0)



 SelectForReview --> CheckedSelected : Select manually\nto review


 CheckedSelected : ReviewStatus=Selected (4)


 CheckedSelected : RejectionReason=Accepted (0)



 state RequireManualReview <<choice>>



 CheckedSelected --> RequireManualReview

 

 CheckedAIFlagged --> RequireManualReview : Selected automatically\nfor review



 RequireManualReview --> CheckedRejected : Manual Review\nReject All

Items

 Items
 CheckedRejected: ClaimStatus=Rejected (1)
 CheckedRejected: ClaimItemStatus=Rejected (2)


 CheckedRejected : RejectionReason=Rejected by MO (-1)



 CheckedRejected --> [*]



 RequireManualReview --> CheckedAccepted : Manual Review\nAccept Some Items


 CheckedAccepted : ClaimItemStatus=Accepted (1)


 CheckedAccepted : RejectionReason=Accepted (0)



 CheckedAccepted  --> CheckedReviewed : Deliver review


 CheckedReviewed : ReviewStatus=Reviewed (8)



state "Processing" as Process {



 CheckedReviewed --> ValuatedAccepted : Process


 ValuatedAccepted : ClaimStatus=Valuated (16)



 CheckedNotSelected --> ValuatedAccepted : Process



 CheckedAccepted --> ValuatedBypassed : Process \nwithout \ndelivering \nreview


 ValuatedBypassed : ClaimStatus=Valuated (16)


 ValuatedBypassed : ReviewStatus=Bypassed (16)



 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.

...

Code Block
Claim.json_ext.claim_ai_quality.was_categorized = false Claim 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

Code Block

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.requestai_timeresult = nullClaimService.ClaimServiceStatus
ClaimClaimItem.json_ext.claim_ai_quality.responseai_timeresult = nullClaimItem.ClaimItemStatus

If Claim.ClaimStatus in [Rejected (Value 1), Reviewed Reviewed/Processed (Value 8), Valuated (Value 16)] Then add

...

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, default AI-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 of Claim.json_ext.claim_ai_quality.was_categorized as True/False.

AI Categorisation Misclassification Report

...

total number of Claims
accuracy score ( 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 column for each Item and Service
  - ai_result column
  - Medical 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.

...

Plantumlcloud

filename	openIMIS-AI-Modules-Deployment.png
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width
compressed	true
revision	24

Expand

title	Diagram source

Code Block
@startuml

database openIMISDB

node openIMISImplementation as



node openIMISImplementation as "openIMIS Implementation" {



component ClaimModule as "Claim Module"


component ClaimAIQualityModule as "Claim AI Quality Module"


component FHIRR4Module as "FHIR R4 Module"



FHIRR4Module -[dashed]-> ClaimModule: <<use>>


ClaimAIQualityModule -[dashed]-> FHIRR4Module : <<use>>

ClaimAIQualityModule --^ ClaimModule

}

openIMISImplementation


ClaimAIQualityModule --^ ClaimModule

database openIMISDB

ClaimModule -[dashed]-> openIMISDB:

<<use>>node openIMISClaimAIImplementation as "openIMIS

 <<use>>

}


node openIMISClaimAIImplementation as "openIMIS Claim-AI Implementation" {



component ClaimAIModule as "Claim-AI Module"


artifact ClaimAIModel as "Claim-AI Model"


ClaimAIModule -[dashed]-> ClaimAIModel: <<use>>

}

ClaimAIModule



}


ClaimAIModule -0)- ClaimAIQualityModule: FHIR Claim


ClaimAIModule -(0- ClaimAIQualityModule: FHIR ClaimResponse



node ClaimAITraining as "openIMIS Claim-AI Training" {



component ClaimAIAlgorithm as "Claim-AI ML Algorithm"

ClaimAIAlgorithm


artifact openIMISDBReplica as "openIMIS Claim Data"

ClaimAIAlgorithm -[dashed]-> ClaimAIModel:

<<generates>>
ClaimAIAlgorithm

 <<generates>>
openIMISDBReplica -[dashed]-> openIMISDB: <<replicates>>
ClaimAIAlgorithm -[dashed]->

openIMISDB

 openIMISDBReplica: <<use>>



@enduml

Testing

Testing the WebSocket from JavaScript console

...

Versions Compared

Old Version 55

New Version Current

Key

Summary

Claim AI-based Adjudication System

Custom Claim Review Search Results - Frontend

AI Categorisation Misclassification Report

Testing

Testing the WebSocket from JavaScript console

Page Comparison

Versions Compared

Old Version 55

New Version Current

Key

Summary

Claim AI-based Adjudication System

Custom Claim Review Search Results - Frontend

AI Categorisation Misclassification Report

Testing

Testing the WebSocket from JavaScript console