Content

Preliminary requirements

• Access to the claims entry module is restricted to users with the user role Claims Administrator (same prerequisites as the main page) : Health Facility Claims (User Manual)Preview

• The Complex Product must :

  • be created in the register,

  • be added to the pricelist of medical products of the Health Facility (otherwise it will not be suggested when entering the service).

Navigation

All configuration features (creating a service) can be found in the Administration main menu, under the Medical Services sub-menu.

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Img. 9.2 Creation of Medical Services

To find or add a medical service pricelist for a health facility, the user must go to the Administration menu, under the Health Facilities sub-menu.

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Img. 9.3 Viewing / Attributing a pricelist for health services to a Health Facility

To add a price list, the user must go to the Administration menu, under the Medical Services Price Lists sub-menu

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Img. 9.4 Adding a Medical Service Price List

To enter a claim involving a complex product, the user must go to the Claim menu, under the Health Facility Claims sub-menu.

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Img. 9.5 Entering Claims

To learn more about entering claims, click the link Health Facility Claims (User Manual)Preview

Complex Products : Definitions and Types

A complex product is defined as a health insurance product that combines health services (procedures) and medical items (medicines/consumables) into a single package. It incorporates specific rules such as age and gender restrictions, as well as quantitative caps based on mandatory care protocols. There are two distinct types

Flat-fee bundle (Fixed complex product (flat-rate) / type P): this is a service for which the reimbursement amount is set in advance, with the requirement to provide all associated sub-services, medications, and inputs.

Fee-for-service bundle (Variable complex product (capped) / type F): this is a service for which a total reimbursement amount (a cap) has been set based on the sub-services, inputs, and medications that make up said service.

Creation of a complex medical service

1. Go to Administration → Medical Services.

2. Click on + (Add).

3. Field in the fields for the new Service.

4. In the Type field, choose :

   • Simple/atomic (simple)

   • Flat fee bundle (flat-rate)

   • Fee-for-service bundle (capped)

5. Afer selection, two panels appear to select the linked treatments and products/inputs.

6. Click on theSave icon.

7. Verify the message in the information panel (same logic as other pages).

8. Once the service registration is confirmed, use the back arrow at the top left to return to the list of services and find your entry by its name or code.

Visit the page Claims for more information on data entry and required fields

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Img. 10 Entry of a Complex Medical Service .

View the price list of your Health Facility

This step consists of adding the service that was previously created to a price list in order to be able to carry out claims containing this medical service.

1. Go to Administration, click on Health Facilities.

2. Search by code or name for the health facility in which you want to attribute/view the service pricelist.

3. Open the Health Facility.

4. Locate the service price list field and note it.

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Img.10.2 Viewing the service Price List at Health Facility

Add a complex product to the medical products price list

Once the price list for the health facility's services is known, you must add the complex service(s) we created to this list by following these steps:

1. Go to Administration, click on Medical Services Price Lists.

2. Search for the list by its Name and open it.

3. Search for the previously created medical service by its Code.

4. Check the box for the complex product created to include it in the medical service price list for this health facility.

5. Click on Save. The care service is now included in the medical service price list of this health facility. Uncheck the medical service to remove it.

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Img. 11 Search the List by Name

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Img. 11.1: Add the services to the list by checking the box

Effecting a Claim for a Complex Product

This step consists of entering a new service (claim) for an insured person, by selecting a complex medical product (flat-fee or capped) that groups together sub-services and products/inputs.

1. Go to Administration → Health Facility Claims.

2. Click on + (add) to create a new service.

3. Fill in the required information for the service.

4. In the services entry section, search for the complex medical products (by its Name or Code) and add it to the claim.

5. After selecting the complex product, the system displays (depending on the configuration) the elements linked to the product :

   • the list of sub-services (procedures),

   • the list of products/inputs (medicines, consumables).

6. Complete/adjust the elements (quantities, items actually administered) according to the product type :

   • capped product (type F) : see section below,

   • flat-fee product (type P) : see section below.

7. Click on Save to save the claim (as a draft) and check the message in the information panel.

Case of a capped product (Fee-for-service bundle)

A capped product (type F) corresponds to a care package where the total reimbursement is limited by a ceiling. The service is valued based on the quantities of sub-services and inputs entered, within the limit of the maximum authorized amount.

1. In the claim, add the type F complex product to the list of services.

2. Verify the displayed items (sub-services and inputs) proposed by the complex product.

3. For each sub-service and/or input:

   • Enter the quantity actually used/administered,

   • Add items if the product allows it (depending on configuration),

   • Remove/deactivate unrealized items if the interface allows it (depending on configuration).

4. Control the valuation :

   • The calculated total must remain less than or equal to the ceiling of the product,

   • If the total exceeds the ceiling, a message appears to signal that the threshold has been exceeded and that only the maximum quantity for this product will be reimbursed.

5. Click on Save and verify that the service is correctly saved.

Point of attention : Even if the quantities entered exceed expectations, the reimbursement may remain capped; it is therefore recommended to enter only what was effectively realized and validated by the care protocol.

Case of a flat-rate product (Flat-fee bundle)

A flat-rate product (type P) corresponds to a care package where the reimbursement amount is fixed in advance. In general, the expected logic is that all linked sub-services and inputs are provided in accordance with the protocol.

1. In the claim, add the type P complex product to the list of services.

2. Verify the list of sub-services and inputs linked to the product:

   • Depending on the configuration, these items may be pre-filled and/or non-modifiable.

3. Confirm that the service indeed corresponds to the execution of the full flat-rate package (protocol requirement).

4. Click on Save and verify the message in the information panel.

Point of attention: the valuation of a flat-rate product is generally independent of quantities (fixed amount). The displayed items primarily serve for traceability and compliance with the protocol, depending on the rules applied in your configuration.

For more information on complex products, visit the page Adaptation of openIMIS to an advanced Claim Protocol - Complex Products Adapting openIMIS for Advanced Healthcare Protocols: Complex ProductsPreview

Submission of a service with a complex product

To submit a service using a complex product, proceed as you would for all services in openIMIS:

1. Go to the Claims menu, then click on the Health Facility Claims sub-menu.

2. In the list view, search for the claim using the claim code.

   • The claim must be on the status Entered and an approved amount equal to 0.

3. Select the claim from the list.

4. In the Claim found section, click on the ... icon (three dots) at the top right.

5. Choose the action Submit Selected.

6. Open the information panel and verify that the service has indeed been submitted:

   • If the panel displays Submission 1, the service is correctly submitted.

Verification of the submitted claims

1. On the same page, go to the Search Criteria section.

2. Click on the Claim status field.

3. Select the Verified status.

4. Click on Search.

5. Verify that the claim now appears in the list with the Verified status.

Review of the Claim

The same view as the existing one, with additions from the claims creation:

• Display the health facility (HF) comments during the service review.

• If an authorization exists, the MO (Medical Officer) can increase the quantity to be reimbursed for the specific service/product within the bundle (complex product).

  • If the MO increases the quantity to be reimbursed for a service/product in the bundle, the same validation rules must apply (the MO cannot bypass the validation rules).

Validation of the Claim

During the submission process and during the processing of a claim, two rules must be verified:

• Flat-fee bundle : The bundle must comply with the requirements of the atomic services/items. If the quantities are not exactly identical to those configured in the bundle, the service must be rejected.

• Fee-for-service bundle (Produits complexes Plafonné): The bundle must be monitored to ensure that the ceiling is not exceeded during the review and submission process. The valued price of the service must be recalculated during the validation process.

For more information on bundled services and products (complex products), visit the page Service and Items Module UHC (Medication)Preview .