Note |
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This specification might evolve based on the development constraints. |
Summary
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):
FHIR Medication fields | FHIR ActivityDefinition fields | FHIR Claim fields | FHIR Patient fields | FHIR HealthcareService fields |
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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) | | |
...
The following module configuration is defined:
Code Block |
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{
'authentication': [string], // Authentication key list. Default: [] String
'claim_response_url': 'http://localhost:8000/claim_ai/ClaimResponse', // URL set in the ClaimResponse. String
'ai_model_file': string"joblib_Voting_Model.pkl", // AI Model file name, relative location withto fullmodule pathfolder. String
Default: ./ai_model.pkl claim'ai_responsescaler_organizationfile': string"scaler.pkl", // ValueAI toScaler build the insurer reference in the ClaimResponse. Default: openIMIS-Claim-AI
}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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Note |
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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
).
...
Plantumlcloud |
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filename | ClaimStatusStateDiagram.png |
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compressed | true |
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revision | 1314 |
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Code Block |
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@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 : Submit Claim
RuleEngineValidation --> RejectedByRuleEngine : Reject\nAll Items
RejectedByRuleEngine : ClaimStatus=Rejected (1)
RejectedByRuleEngine : ClaimItemStatus=Rejected (2)
RejectedByRuleEngine : 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 "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 "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
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 |
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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 (dropdown with options: Show all
, AI-Categorized Claim Only
, Not AI-
processed Categorized Claims
(checkboxOnly
, default checked 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.
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Plantumlcloud |
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filename | openIMIS-AI-Modules-Deployment.png |
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compressed | true |
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revision | 24 |
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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 <<use>>
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>> |
|
Testing
Testing the WebSocket from JavaScript console
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