...

• the default openIMIS Claim adjudication process should be modified as less as possible

• Medical Officers should not be impacted too much by the activation of the openIMIS-AI module

Claim

...

AI-based Adjudication System

Use cases

...

AI-based Claim Adjudication Status

The following state diagram from Figure 1 corresponds to the Claim fields status with the updated adjudication process.

Figure 1. Claim state diagram for the updated claim adjudication process

...

AI-based Claim Adjudication Process

The following activity diagram proposes the updated adjudication process.

...

• Contribute to Claim Review Search with Medical Item/Service and Service filtersListening for <<signal_mutation_module_after_mutating>> SubmitClaimsMutation and prepare AI-categorized filters

• Prepare the new checked claims for AI categorisation by adding custom fields (i.e. was_categorized)

• Contribute to Claim Review Search based on the custom fields (i.e. was_categorized)

• Push the claims Push Claims to Claim-AI module based on scheduled task and/or event-based activation and update claims Claims based on the response

• Reports claim Claim adjudication misclassifications

...

Claim.json_ext.claim_ai_quality.was_categorized = true
Claim.json_ext.claim_ai_quality.request_time = Claim.ValidityFromReview
Claim.json_ext.claim_ai_quality.response_time = Claim.ValidityFromReview
ClaimService.json_ext.claim_ai_quality.ai_result = ClaimService.ClaimServiceStatus
ClaimItem.json_ext.claim_ai_quality.ai_result = ClaimItem.ClaimItemStatus

Module Configuration

Claim-AI Module

Claim-AI Responsibilities

...

Self containing REST API

...

Accepts FHIR R4 Claim and reply with FHIR R4 ClaimResponse

...

Clean the data and prepare it for the AI model

...

The following module configuration is accepted:

{
  claim_ai_url: string // URL of the openIMIS instance running Claim-AI module. Default: ""
  event_based_activation: boolean // True if the checked Claims are sent to Claim-AI module immediatly after check. Default: False 
}

FHIR Contained Resources

FHIR Contained Resources feature (https://www.hl7.org/fhir/references.html#contained) allows to integrate the referred resourced. In our case for FHIR Claim, these are Patient, Condition, Medication, HealthcareService, Practitioner, ActivityDefinition.

Because AI-model is requiring information from other resources referenced by the Claim, these resources must to be accessible in the POST call sent by claim-ai-quality module.

The mechanism to build Claim resource with Contained Resources is to be developed in the openIMIS FHIR R4 module.

The construction based on Contained Resources should be possible based on query variable contained=true/false. Default false.

Custom Claim Review Search Filters - Frontend

The following contributor filters to claim.ReviewsFilter are defined:

• 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, decision if this is hidden or not )

AI Categorisation Misclassification Report

A report is generated that provides the following information (based on manual reviewed Claims ):

• accuracy scores

• number of True Positives results

• number of True Negative results

• number of False Positive results

• number of False Negative results

Decision: should this report be a webpage or a PDF

Claim-AI Module

Claim-AI Responsibilities

• REST API accepting FHIR Claims to categorize them based on a ML model

• AI-model execution

REST API

The Claim-AI module will define one endpoint that will receive the FHIR Claim Bundle to be adjudicated. The base URL for this module is /claim_ai

Call: POST /claim_ai/Claim
Body: FHIR R4 Claim Bundle with Contained Resources 
Response: FHIR R4 ClaimResponse Bundle