Content

Summary

Some schemes require that a health facility requests a pre-authorization of a treatment from the insurer before they administer it to the client in order to have the assurance that the costs will be covered. For eg. expensive treatments like certain type of heart surgeries might require a pre-authorization request to be approved by the insurer (including indication of amount to be blocked from the patients ceiling) before the hospital undertakes the surgery. Request is derived from Service Desk issue reported by users in Egypt captured in OSD - 42

Discussion

At the moment, this is out of scope of openIMIS as normally benefit packages are pre defined etc. Might become relevant again when looking at formal sector.

Requirement

1.1           Goals/Scope

1.2           Background

Draft specification of pre-determination workflow as special case of a claims workflow:

• OpenHIE: https://guides.ohie.org/arch-spec/introduction/openhie-finance-and-insurance-services-workflows/hfw-004-claiming

• IHE: http://build.fhir.org/ig/IHE/ITI.Finance/ITI-YY5.html

1.3           Assumptions

1.4           User stories

1.5 Implementation Cases

Technical Specification

2.1     Impact on the general architecture

2.2    Impact on the database structure

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