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his page is only an idea of implemention from Patrick Delcroix , not validated nor reviewed by the community |
In order to go beyong health openIMIS need to gain some features:
Basic user stories not covered by openIMIS today:
1- a woman is 8 months pregnant and is allowed to not work anymore until the 3 month the child , she claim wage compensation for the 4 coming months, the compensation should match with 80 % of the mean income of the previous 6 months
2- an insuree is eligible for a cash payment and claims it
3- a worker is getting retired and claims his retirements funds to be paid monthly, but not all of his working history is in openIMIS
4- a insuree have a work related accident, he claim is wage compensation but before approving it a committee must review the case so the board ca take the decision
5- a insuree got treated in an hospital(resp. lab analysis) without agreement with the scheme operators, he claim the reimbursement of the paid fees
6- a familly with 3 children below 16 is eligible for familly benefit so she enter the right form to collect the information required to handle her case
7- before any real assessment of the claim, the admin department ensure that all the required prood are present in the claims, each region has an admin department and there is different team for each team of claim
8- a controlling body is auditing claims and wants to used imis to follow the cases
9- following a disaster the insurance is bankrupt but it call its reinsurance for helps, the reinsurance will provide funding because the scheme dully paid all its past contributions
10- once the claims are validated, the payment is sent to financial services so the claimee will get the financing claimed
Features requires:
Rights (management + claiming): ability to add “rights“ to an insuree that will ensure that he will get benefits/payment for a given period of time (US 1,3,6)
Customizable claim valuation so the value of service/cash transfert can be calculated based a specific information (US 1,2,3,6,8)
Configurable Workflows So the claiming can be reviewed by the right team depending on the type of claim (also some process will require multiple approvals which are not yet supported)
Payment and accounts to be able to deal with many sort of payments
Rights management: to define the different right possible (salary replacement, pension, accident compensation ….) and to manage active rights
Claim/Active Rights Audits : to validate the veracity of the claim, current feedback process is too weak)
claim cash payment: be able to claim a cash payment (new born, COVID one time support … )
claim rights: to claim the activation of a right
(nice to have) reinsuranceso additional steps can be added in the claim to ensure that all the required parties did their parts (US 3, 4, 7)
Form attached to the claim to collect the additional information required to handle the case
Non health services that can have a variable value based on other parameters (from imisdb or Form)
Invoices (and bills) to be able to deal with many sort of payments (10)
On the modeling parts:
the cash payment and the rights should be linked to a product in order to know which issuree are “cover“ for the right and to get contributions (alike product service and Item)
claim cash payment and claim right should be linked to a claim meaning that the claim screen should allow adding such right or cash payment (may depend on the claim type)
active rights would be a instance of their own, still linked to the product through the right they implement
Claim/Active Rights Audits should also be dedicated object that might change the status of the claim or rights (put it as suspended for example)
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FHIR Questionnaire could be attached based on the type of claims
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