...
The following table summarizes which features are in use in which Business Process:
| JLN Process - Claims processing | JLN Process - Claims status inquiry | JLN Process - Claims dispute and appeals | JLN Process - Claims adjustment and voids | |
|---|---|---|---|---|
Claim control (overview) | x | x | ||
| Verify patient data | x | |||
| Enter (new) claim | x | |||
| Edit claim | x | |||
| Print claim | x | |||
| (Bulk) Delete claim(s) | x | |||
| (Bulk) Reject claim(s) | x | |||
| (Bulk) Submit claim(s) | x | |||
| Claim review and feedback control (overview) | x | |||
| Bulk claim modifications | x | |||
| Review claim | x | |||
| Enter claim feedback | x | |||
| (Bluk)Move claim(s) to Processed status | x | |||
| (Bulk) Delete claim(s) | x | |||
| (Bulk) Reject claim(s) | x | |||
| Claim Valuation Batch Processings | x | |||
| Claim operational report | x | |||
| NOT COVERED STEPS | Aggregate, merge and batch claims data Flag for fraud and abuse Update beneficiary(note: beneficiary = patient?) Claims status sent to provider, beneficiary and other appropriate authorities Explanation of Benefits sent to provider and/or beneficiary Timeliness of claims processing First time claim pass rate | Is this business process covered in current openIMIS at all ?? Batch processing for valuations. Not flagged as fraud, but services & items are rejected if they don't meet certain pre-defined conditions (defined during defining services/items) Once claims are submitted, immediate feedback is provided in terms of services/items rejected, claims processed etc. Detailed status can be viewed via reports. Can be done via Feedback app. Needs human intervention to go to beneficiary to ask questions. No - planning on adding these to analytics module (HISP India) | Is this business process covered in current openIMIS at all ?? |
Access rights
A claim is attached to a location (HF). Besides role-based feature access control (cfr. Actors and Roles here below), all claim management actions (entering, submitting,...) are limited by user’s location(s) scope: users can only access/manage claims related to his registered locations.
...