ClaimItemID

int (PK)

YES

ClaimID

int

YES

FK tblClaim

ItemID

int

YES

FK tblItems

ProdID

int

NO

FK tblProduct

ClaimItemStatus

tinyint

YES

1

1: Accepted | 2: Rejected

Availability

bit

YES

1

If the medical item is available or not in the HF.

QtyProvided

decimal(18, 2)

YES

Quantity provided by HF.

QtyApproved

decimal(18, 2)

NO

Quantity approved by Medical Officer when reviewing manually. If NULL then same as QtyProvided.

PriceAsked

decimal(18, 2)

YES

Price per unit asked by HF.

PriceAdjusted

decimal(18, 2)

NO

Price calculated automatically based on Product configuration when Processing the Claim.

PriceApproved

decimal(18, 2)

NO

Price approved by Medical Officer when reviewing manually. If NULL then same as PriceAsked.

PriceValuated

decimal(18, 2)

NO

Total price calculated automatically for the item: PriceAdjusted * QtyApproved

Explanation

ntext

NO

Explanation from HF (text).

Justification

ntext

NO

Justification from Medical Officer when reviewing manually (text).

RejectionReason

smallint

NO

0

One of the values (value: meaning):
-1: Rejected by a medical officer
0: Accepted
1: Item/Service not in the registers of medical items/services
2: Item/Service not in the pricelists associated with the health facility
3: Item/Service is not covered by an active policy of the patient
4: Item/Service doesn’t comply with limitations on patients (men/women, adults/children)
5: Item/Service doesn’t comply with frequency constraint
6: Item/Service duplicated
7: Not valid insurance number
8: Diagnosis code not in the current list of diagnoses
9: Target date of provision of health care invalid
10: Item/Service doesn’t comply with type of care constraint
11: Maximum number of in-patient admissions exceeded
12: Maximum number of out-patient visits exceeded
13: Maximum number of consultations exceeded
14: Maximum number of surgeries exceeded
15: Maximum number of deliveries exceeded
16: Maximum number of provisions of item/service exceeded
17: Item/service cannot be covered within waiting period
18: N/A
19: Maximum number of antenatal contacts exceeded

ValidityFromReview

datetime

NO

ValidityToReview

datetime

NO

AuditUserIDReview

int

NO

LimitationValue

decimal(18, 2)

NO

Limitation

char(1)

NO

PolicyID

int

NO

RemuneratedAmount

decimal(18, 2)

NO

DeductableAmount

decimal(18, 2)

NO

ExceedCeilingAmount

decimal(18, 2)

NO

PriceOrigin

char(1)

NO

ExceedCeilingAmountCategory

decimal(18, 2)

NO

ValidityFrom

datetime

YES

Current date

ValidityTo

datetime

NO

LegacyID

int

NO

AuditUserID

int

YES