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This document summarizes the openIMIS features related to beneficiary enrollment. These features are spread into the Persons & Families, Policies and Contributions modules.

...

Remarks:

  • This process will be the first in the new platform that requires the foreseen Batch Backend Technology (sysadmin standpoint, claim ‘batch’ processing is in fact an interactive bulk processing but has nothing to do with a scheduled/monitored system batch). Following the TOGAF ADM iteration framework, the chosen technology will be re-considered (looking at django-scheduler plugins as well as openHIM) at the iteration start.

  • Funding via fictive policy / insuree family will be supported: at least as “filtering out” the funding-related entities (families and policies), at best (depending on budget) by migrating the funding-related screens.

Business Processes

openIMIS aims to support the beneficiary enrollment workflows defined in the Background - Joint Learning Network for UHC . The following table provides the list of current openIMIS features, how they support JLN workflows and which part of the JLN workflows are not (yet) covered.

JLN Processes

Beneficiary Management  

JLN Processes

Premium Management

Enroll beneficiary

Assign beneficiary to PCP

Eligibility inquiry by provider 

Eligibility inquiry by beneficiary 

Pre-authorization  

Premium collection

Policies

Insuree Enquiry

Warning:

2 stored procs:

uspPolicyInquiry and uspPolicyInquiry2

QUESTION: which one holds the truth ??

x

???

Today, inquiry “by provider” seems to be managed via insurance product scope (down to district only - not HF level)

QUESTION:

does the openIMIS enquiry take the user’s registered HF (/location) into account??

x

(note: openIMIS makes a distinction between medical service and medical item)

NOT COVERED by openIMIS

(validation only at claim submission)

Persons & Families

Find Family

x

x

Family/Group Overview

x

x

x

Family/Group Page

x

Adding a Family

x

Editing a Family/Group

x

Changing a Head of Family/Group

x

Moving an Insuree

x

Deleting a Family/Group

Find Insuree

x

x

Insuree Page

x

x

Adding an Insuree

Partially:

  • not covering medical info

  • identification = photo

  • ? delivery of a “Proof of coverage “ ??

PCP (called FSP in openIMIS) is at insuree level and managed (entered/updated) by clerck/enrolment officer (not the beneficiary himself)

Editing an Insuree

Deleting an Insuree

Policies

Find Policy

x

Policy Page

x

Adding a Policy

Note:

includes policy value (premium composition) calculation

Partially:

Editing a Policy

Deleting a Policy

Contributions

Find Contribution

Partially:

openIMIS allows to record a contribution (and updates policy status accordingly)

Process foresees invoice sending, reports (due premiums,…).

Warning about bill sent to beneficiary (not from the web app!)

Contribution Page

Adding a Contribution

Editing a Contribution

Deleting a Contribution

...

  • along Policy renewal via SMS/mobile data, Policy renewal can also be achieved via printout report (with preview in the “Policy renewal screen”) sent to Enrollment officers (QUESTION: via email or real printout ?)

Out of scope of this migration:

...