Beneficiary Enrollment

This document summarizes the openIMIS features related to beneficiary enrollment. These features are spread into the Persons & Families, Policies and Contributions modules.

Information in this page is a summary of:

current openIMIS documentation (the Web application user guide)
openIMIS functional design specifications (2017, referring to TZ version)
refinements deduced from legacy code readings
general openIMIS training sessions held in 04/2020

Remarks:

This process will be the first in the new platform that requires the foreseen Batch Backend Technology (sysadmin standpoint, claim ‘batch’ processing is in fact an interactive bulk processing but has nothing to do with a scheduled/monitored system batch). Following the TOGAF ADM iteration framework, the chosen technology will be re-considered (looking at django-scheduler plugins as well as openHIM) at the iteration start.
Funding via fictive policy / insuree family will be supported: at least as “filtering out” the funding-related entities (families and policies), at best (depending on budget) by migrating the funding-related screens.

Business Processes

openIMIS aims to support the beneficiary enrollment workflows defined in the Background - Joint Learning Network for UHC . The following table provides the list of current openIMIS features, how they support JLN workflows and which part of the JLN workflows are not (yet) covered.

		JLN Processes Beneficiary Management					JLN Processes Premium Management

		JLN Processes Beneficiary Management					JLN Processes Premium Management
		Enroll beneficiary	Assign beneficiary to PCP	Eligibility inquiry by provider	Eligibility inquiry by beneficiary	Pre-authorization	Premium collection
Policies	Insuree Enquiry Warning: 2 stored procs: `uspPolicyInquiry` and `uspPolicyInquiry2` QUESTION: which one holds the truth ??	x		??? Today, inquiry “by provider” seems to be managed via insurance product scope (down to district only - not HF level) QUESTION: does the openIMIS enquiry take the user’s registered HF (/location) into account??	x (note: openIMIS makes a distinction between medical service and medical item)	NOT COVERED by openIMIS (validation only at claim submission)
Persons & Families	Find Family	x	x
	Family/Group Overview	x	x				x
	Family/Group Page	x
	Adding a Family	x
	Editing a Family/Group	x
	Changing a Head of Family/Group	x
	Moving an Insuree	x
	Deleting a Family/Group
	Find Insuree	x	x
	Insuree Page	x	x
	Adding an Insuree	Partially: not covering medical info identification = photo ? delivery of a “Proof of coverage “ ??	PCP (called FSP in openIMIS) is at insuree level and managed (entered/updated) by clerck/enrolment officer (not the beneficiary himself)
	Editing an Insuree
	Deleting an Insuree
Policies	Find Policy	x
	Policy Page	x
	Adding a Policy	Note: includes policy value (premium composition) calculation Partially: ? delivery of a “Proof of coverage “ ??
	Editing a Policy
	Deleting a Policy
Contributions	Find Contribution						Partially: openIMIS allows to record a contribution (and updates policy status accordingly) Process foresees invoice sending, reports (due premiums,…). Warning about bill sent to beneficiary (not from the web app!)
	Contribution Page
	Adding a Contribution
	Editing a Contribution
	Deleting a Contribution

Background processes

openIMIS also provides some background (without user interaction) features related to Beneficiary Enrollment in scope of this migration:

Policy renewals via SMS/mobile (cfr. Policies module) … note: also includes insuree photo renewal (will be relocated in insuree module ?)
Payment (premium collection) matching (cfr. Contributions modules)

Reports

along Policy renewal via SMS/mobile data, Policy renewal can also be achieved via printout report (with preview in the “Policy renewal screen”) sent to Enrollment officers (QUESTION: via email or real printout ?)

Out of scope of this migration:

reports from the reports menu entry of openIMIS are out of scope: pending insurees, contribution distribution,…
Payments (all sorts of) from payers (insurers) to providers (claims, capitation payments,…)

openIMIS