The following requirements were considered when updating openIMIS’s Claim adjudication process:

• 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 adjudication process

Use cases

Updated Claim 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

Updated Claim Adjudication Process

The following activity diagram proposes the updated adjudication process.

Deployment architecture

Claim-AI Quality Module

Claim-AI Quality Responsibilities

• Contribute to Claim Review Search with Medical Item and Service filters

• Listening for <<signal_mutation_module_after_mutating>> SubmitClaimsMutation

• Prepare the new checked claims for AI categorisation by adding custom fields

• Contribute to Claim Review Search based on the custom fields

• Defines a scheduled task to convert openIMIS Claims to FHIR Claims and POST to Claim-AI

• Receive FHIR ClaimResponse

• Update ClaimItem and ClaimServices status

• Reports claim adjudication misclassifications

Models

The following JSON extensions will be created to support the Claim AI-based Categorisation:

• claim_ai to add information on Claim. The field was_categorized allow to filter automatically checked Claim that have not been categorized by AI and ‘hide’ them for manual adjudication.

  "json_ext": {
    "claim_ai_quality": {
      "was_categorized": "boolean", // whether the claim has been categorized by Claim-AI module or not
      "request_time": "datetime", // time when the claim has been sent to Claim-AI module
      "response_time": "datetime" // time when the claim adjudication response has been received from Claim-AI module
    }
  }

• claim_ai_item to add information on ClaimItem and ClaimService. This is used to store AI categorisation result to allow the misclassification report.

  "json_ext": {
    "claim_ai_quality": {
      "ai_result": "integer" // claim adjudication value provided by Claim-AI module (for misclassification report)
    }
  }

Because ClaimItem and ClaimService doesn’t support custom fields, these classes need to be extended with ExtendableModel class.

Migrations

Because the Claim-AI modules are activated after Claims have been adjudicated (the data used for the training), a migration script needs to be created to insert the JSON fields into the available data. The following initializations will be used:

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

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

• Categorize the claim (AI model execution)