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Fig. 2 Manual claim adjudication workflow
Future openIMIS AI-based automatic claim
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adjudication process (vision)
For the AI claim categorization algorithm, the input is represented by a service or item, which has been statically validated by the Rules engine. The output of such a model will be the acceptance or rejection of the item or service. This AI module will allow the Medical Officer to concentrate only on those claims that really need to be reviewed, such as inconsistent or erroneous. Furthermore, in order to detect false positive or false negative cases misclassified by the algorithm, a Quality Assurance module will then select AI-categorized claims to be review by the Medical Officers. This process is illustrated in Fig. 3.
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