This page presents the analysis of AI algorithm’s input data model. First, we analyse the openIMIS data structure and extract the minimal required openIMIS entities and fields representing the information used by the Medical Officer to adjudicate a claim. Second, we look at the openIMIS-FHIR mapping and extract the minimal required FHIR resources and fields to feed the AI algorithm during the learning, development and test processes. Because the openIMIS FHIR module do not map all openIMIS fields to FHIR resources, we are limited by the current FHIR-openIMIS R4 mapping.
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Claim adjudication - openIMIS entities and fields
As are looking Based on the openIMIS claim adjudication process, we are interested to identify the entities/tables and their fields that are used by the Medical Officers to review and categorise the items and services present in a claim.
openIMIS Claim Review Web Page
openIMIS Database Tables
Diagram
The following database diagram displays openIMIS tables and their relations. The analysis is centred on Claim and identifies other entities in relation to a Claim and used in the adjudication process.
Fields definition
From all the fields that the Medical Officers are using when reviewing claims, we mainly need to identify entities in relation to the claimClaim. From some entities (Claim, Insuree), we required more than the identification fields. We also show through → the links to follow to extract the information.
tblClaim
ClaimUUID: Unique identifier of the Claim
In the following tables, we list only the minimum required information that we judge to help us in the adjudication process.
Field | Type | Description |
|---|---|---|
ClaimUUID | uniqueidentifier | Unique identifier of the Claim |
DateFrom | smalldatetime | |
DateTo | smalldatetime | |
DateClaimed | date | |
ClaimStatus | tinyint | |
Claimed | decimal(18, 2) | |
Approved | decimal(18, 2) | |
VisitType | char(1) | Emergency, Referral, Other |
ClaimCategory | char(1) | Automatically defined in checking process: Surgery, Delivery, Antenatal, Hospitalisation, Consultation, Visit |
last visit to the same hospital (how many days) |
tblClaim → tblHF
Field | Type | Description |
|---|---|---|
HfUUID | uniqueidentifier |
tblClaim → tblClaimAdmin
Field | Type | Description |
|---|---|---|
ClaimAdminUUID | uniqueidentifier |
tblClaim → tblClaimServices
Field | Type | Description |
|---|---|---|
ClaimServiceStatus | tinyint | Service accepted or rejected |
QtyProvided | decimal(18, 2) | |
PriceAsked | decimal(18, 2) |
tblClaim →tblClaimServices → tblServices
Field | Type | Description |
|---|---|---|
ServiceUUID | uniqueidentifier |
tblClaim → tblClaimItems
Field | Type | Description |
|---|---|---|
ClaimItemStatus | tinyint | Item accepted or rejected |
QtyProvided | decimal(18, 2) | |
PriceAsked | decimal(18, 2) |
tblClaim →tblClaimItems→ tblItems
Field | Type | Description |
|---|---|---|
ItemUUID | uniqueidentifier |
tblClaim → tblICDCodes (Main and Secondary Diagnosis)
Field | Type | Description |
|---|---|---|
ICDUUID | uniqueidentifier |
tblClaim → tblInsuree
Field | Type | Description |
|---|---|---|
InsureeUUID | uniqueidentifier | |
DOB | date | Date of birth |
Gender | char(1) | Gender in codded format: e.g. M/F, 0/1 |
HFID | int | First Point of Contact |
tblClaim → tblInsuree → tblFamilies
Field | Type | Description |
|---|---|---|
FamilyUUID | uniqueidentifier |
tblClaim → tblInsuree → tblInsureePolicy → tblPolicies
Field | Type | Description |
|---|---|---|
PolicyUUID | uniqueidentifier |