This page is only an idea of implementation from Patrick Delcroix , not validated nor reviewed by the community
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
11- A insuree got the approval of a review board he has now access to care/episode of care (voucher or pressurization)
12- Scheme administrator want to define bundle of items/services for claims
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)
Coverage extension (might be merged with rights): an insuree can get an exceptional coverage without the need to add a new policy (actually part of the policy or without policy), works with voucher or per-authorization ( result of pre-auth claiming) (US 11)
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) so 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
Complex claim services that can have a variable value based on other parameters (from imisdb or Form, i.e. average contribution for the last 6 months)
Bundle several claim Items and services (12) that can be applied to a claim and then amount of Items/services corrected via pop up (i.e. result not mixed with other items and services) (12)
Invoices (and bills) to be able to deal with many sort of payments (10)
(very low priority) Reinsurance funding and contribution (9)
Real Audit claim process (8)
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 none health/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)
FHIR Questionnaire could be attached based on the type of claims
