Digital Square D1 proposal: Support for Formal Sector schemes and Configurable Claims Workflow in openIMIS

Teams:

Swiss TPH (@Patrick Delcroix @Dragos Dobre @Siddharth Srivastava)
SolDevelo (@Kamil Madej (Deactivated) @Damian Borowiecki (Deactivated), @Beata Komorowska (Deactivated) , @Rafał Stencel (Deactivated) , @Seweryn Niedzielski , @Joanna Bebak (Deactivated) )

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Incubator: Support for formal sector schemes (openIMIS)
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Calculation rules (openIMIS)
- formal-sector-project
- payment-layer-project
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Calculation rule: Input relevance and validation (openIMIS)
- formal-sector-project
- account-receivable-rule
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contribution plan calcrule : percentage of income (openIMIS)
- account-receivable-rule
- formal-sector-project
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Formal Sector Beneficiary API in Nepal (openIMIS)
- formal-sector

Concepts and interaction with openIMIS

The goal of this development is to reuse the openIMIS people and family registration, claim management and the logic to extend the coverage to the family members.

This module will add a new enrollment methods, the Group enrollment: A Policy Holder (a enterprise in case on Nepal) will take policy on the behalf of its employee and their famillies.

the relationships will be:

Every period (monthly in case of Nepal), a contract will be created between the policy holder and each enterprise.
- The periodicity will depend on the contribution plan and therefore will be configuration
- The same insurance product could have different contribution plan therefore different contribution periodicity
Every covered employee will be mentioned in the contract along with the list of insurance product that will be part of their coverage.
once the contract validated and paid, the policy of the emöployee and their family will be activated for the period covered by the contract
- the period of the contract doesn’t have to be the period of the policy: this will enable having coverage limits (max amount, max surgery …) that could be shared for several periods

In case of a insuree have multiple employers, the system will activate only one policy per product.

insuree should be able to move between the formal and informal sector

Objectives

This project aims to develop the "Formal Sector" features requested by institutions in charge of developing health financing schemes in Nepal, in particular the management of enrolment of the insuree as part of an insurance group.
Here are the high-level use cases to be covered by this design:

Manage group insurance
- UC1 - The Scheme Administrator wants to manage the policy holder insurees and their policy entitlement. (includes UC2 from the proposal)
- UC3 - The Scheme Administrator wants to manage the policy holder contract.
- UC4 - The Scheme Administrator wants to manage the policy holder contract payment.
- UC5 - The Scheme Administrator wants policy holders insuree policies covered by a contract to auto activate based on policy holders contract payment.
- UC7 - The Scheme Administrator wants to manage policy holders.
Contribution Plan and Contribution Plans Bundle to manage the Policy Value
- UC8 - The Scheme Administrator wants to add a Contribution plan (pricing rules linked to an insurance product).
- UC9 - The Scheme Administrator wants to be able to configure the calculation parameters in the Contribution plan.
- UC10 - The Scheme Administrator wants to add a Contribution Plan Bundle.
- UC11 - The Scheme Administrator wants to enable some Contribution Plan Bundles per policy holder.
Policy holder Portal
- UC12 - The policy holder wants to manage its policy holder insurees and their policy entitlement.
- UC13 - Policy holder wants to manage its users.
- UC14 - Policy holder wants to manage its contracts.
Not Functional
- UC15 – Administrator wants to assign group insurance authorities (rights) to openimis role
- UC16 – Manage the calculations
- UC17 – add “nepal” calculations for policy value on income and contract rejection when important change are detected

Modules

The following module are part of the Formal Sector scheme management:

General topics (compitation accross modules)

Authorities

To manage the group insurance several authorities will be added, the existing authorities have a "*" :

PolicyHolder
- C/R/U/D (4 authorities)
- Portal R
PolicyHolderInsuree
- C/R/U/D (4 authorities)
Approve (TBC)
- Portal C/R/U/D (4 authorities)
PolicyHolderContract
- C/R/U/D (4 authorities)
- Submit
- Approve/ask for change
- Amend
- Portal Submit
- Portal Amend
PolicyHolderContractDetails
- C/R/U/D (4 authorities)
- Approve
- Portal C/R/U/D (4 authorities)
PolicyHolderUser
- C/R/U/D (4 authorities)
- Portal C/R/U/D (4 authorities)
Payment
- C*/R*/U*/D*(4 authorities)
- Submit (TBC)
- Validate
- CreditNote
ContributionPlanBundle
- C/R/U/D(4 authorities)
- replace
- Portal R
ContributionPlan
- C/R/U/D(4 authorities)
- repalce
- Portal R
Profile
- C/R/U/D(4 authorities)
- Duplicate

Roles

To manage the group insurance several roles will be added, the existing roles have a "*" :

SchemeClerk( Clerck)
- PolicyHolder*
  - C/R/U
- PolicyHolderInsuree
  - C/R/U/D
  - Approve (TBC)
- PolicyHolderUser
  - C/R/U/D
- PolicyHolderContract
  - C/R/U
  - Submit
  - Approve
- ContributionPlanBundle
  - R
- ContributionPlan
  - R
- PolicyHolderContributionPlan
  - R
SchemeAdmin*
- PolicyHolder
  - C/R/U/D
- PolicyHolderInsuree
  - C/R/U/D
  - Approve (TBC)
- PolicyHolderUser
  - C/R/U/D
- PolicyHolderContract
  - C/R/U/D
  - Submit
  - Approve
- ContributionPlanBundle
  - C/R/U/D
  - replace
- ContributionPlan
  - C/R/U/D
  - replace
- PolicyHolderContributionPlan
  - C/R/U/D
PolicyHolderClerk
- PolicyHolderInsuree
  - C/R/U
- PolicyHolderContract
  - R/U
  - Submit
- ContributionPlanBundle
  - R
- ContributionPlan
  - R
- payment
  - submits
accountant*
- Payment
  - Validate

Database Versioning

The entities will have different versioning in place:
Entity related to a specific date (contract …) no versioning will be in place only logging/audition, the code or reference will be used to differentiate them on a business level.
Configuration item (Product, plans, bundle, calculation, policy holder, policyholders insuree): those could be replaced by another version at a given time therefore no CI could have the same code and overlapping validity dates; they will have

DateValidFrom (date)
DateValidTo (date)
isDeleted
Code (this stays the same across version)

Sub tables won't have any versioning because a new version of the parent table will create a new row in the sub tables.

Drop down list

The configuration of the the droip down list won’t be on the database but on the module configuration, in case a configuration is required across al module, the code will be updated to accept this configuration

Requirement Traceability Matrix

Scope	platform	#	sub	details	steps	SOP/MODULE	Requirement closing date	ETA
general	any	UC1		The Scheme Administrator wants to manage the policy holder insurees and their policy entitlement. (includes UC2 from the proposal)		SOP#001b	30/10/20	28/02/21
general	any	UC3		The Scheme Administrator wants to manage the policy holder contract.		SOP#001a	31/12/20	28/02/21
general	any	UC4		The Scheme Administrator wants to manage the policy holder contract payment.			31/12/20	28/02/21
general	any	UC5		The Scheme Administrator wants policy holders insuree policies covered by a contract to auto activate based on policy holders contract payment.			31/12/20	28/02/21
general	any	UC7		The Scheme Administrator wants to manage policy holders.			30/10/20	31/12/20
general	any	UC8		The Scheme Administrator wants to add a Contribution plan (pricing rules linked to an insurance product).			30/10/20	31/12/20
general	any	UC9		The Scheme Administrator wants to be able to configure the calculation parameters in the Contribution plan.			30/10/20	31/12/20
general	any	UC10		The Scheme Administrator wants to add a Contribution Plan Bundle.			30/10/20	31/12/20
general	any	UC11		The Scheme Administrator wants to enable some Contribution Plan Bundles per policy holder.			30/10/20	31/12/20
general	any	UC12		The policy holder wants to manage its policy holder insurees and their policy entitlement.			31/12/20	28/02/21
general	any	UC13		Policy holder wants to manage its users.			31/01/21	28/02/21
general	any	UC14		Policy holder wants to manage its contracts.			31/01/21	28/02/21
general	any	UC15		Administrator wants to assign group insurance authorities to openimis role			31/12/20	28/02/21
general	any	UC16		Manage the calculations			30/09/20	31/10/20
calculation	backend	UC16	1	add a new Calculation rule (needs to change the openimis.json).		calculation	30/09/20	31/10/20
calculation	webapp	UC16	2	use the frontend contribution to select a calculation rule.		calculation	30/09/20	31/10/20
calculation	webapp	UC16	3	use the fronend contribution to display the parameters required by multiple calculation for an object.		calculation	30/09/20	31/10/20
calculation	backend	UC16	4	replace a calculation rule.		calculation	30/09/20	31/10/20
calculation	backend	UC16	5	remove a calculation rule.		calculation	30/09/20	31/10/20
calculation	backend	UC17	1	have a calculation rule to calculate the policy value based on policyholderInsuree income		calculation	31/12/20	28/02/21
calculation	backend	UC17	2	have a calculation rule to set contract as to-be-reviewed when the expected value is 15% more or less than submitted		calculation	31/12/20	28/02/21
contribution plan bundles	webapp	UC10	1	Search	contribution plan bundles List > use the search box > search, the default list will show only the active contribution plan bundle	contribution plan	30/10/20	31/12/20
contribution plan bundles	webapp	UC10	2	Add	contribution plan bundle List > 'add' contribution plan bundle > fill the details on the contribution plan bundle page > save	contribution plan	30/10/20	31/12/20
contribution plan bundles	webapp	UC10	3	Update	contribution plan bundles List > "Select" contribution plans bundles > update the details on the contribution plan bundle > save	contribution plan	30/10/20	31/12/20
contribution plan bundles	webapp	UC10	4	Delete	contribution plan bundle List > "Select" contribution plan bundle > "Delete (this role should be only available to admin, others should only archive by setting the DateValidTo)	contribution plan	30/10/20	31/12/20
contribution plan bundles	webapp	UC10	5	Replace	contribution plan bundle-> List contribution plan bundle List > "Select" contribution plan bundle > update the details on the contribution plan bundle, update the contribution plan > replace version > add ValidityTo (DateValidTo of the to-be-replace CPB will be set are the Validity from the new CPB )	contribution plan	30/10/20	31/12/20
contribution plan bundles	backend	UC10	6	Replacing / removing propagation to policyholder contribution plan bundle		contribution plan	30/10/20	31/12/20
contribution plan bundles	backend	UC10	7	Replacing / removing propagation to policyholder insure contribution plan bundle		contribution plan	30/10/20	31/12/20
contribution plan	webapp	UC8	1	Search	contribution plan List > use the search box > search, the default list will show only the active contribution plan	contribution plan	30/10/20	31/12/20
contribution plan	webapp	UC8	2	Add	contribution plan List > 'add' contribution plan > fill the details on the contribution plan page > save	contribution plan	30/10/20	31/12/20
contribution plan	webapp	UC8	3	Update	contribution plan List > "Select" contribution plan > update the details on the contribution plan > save	contribution plan	30/10/20	31/12/20
contribution plan	webapp	UC8	4	Delete	contribution plan List > "Select" contribution plan > "Delete (this role should be only available to admin, others should only archive by setting the DateValidTo)	contribution plan	30/10/20	31/12/20
contribution plan	webapp	UC8	5	Replace	contribution plan bundle List > List contribution plan > "Select" contribution plan > update the details on the contribution plan > create a new version > add ValidityTo (DateValidTo of the to-be-replace CPB will be set are the Validity from the new CPB )	contribution plan	30/10/20	31/12/20
contribution plan	backend	UC8	6	Replacing / removing propagation to contribution plan bundle		contribution plan	30/10/20	31/12/20
Policy holder	webapp	UC7	1	Search	PolicyHolder List > use the search box > search, the default list will show only the active policy holder	Policy holder	30/09/20	31/10/20
Policy holder	webapp	UC7	2	Add	PolicyHolder List > "add" PolicyHolder > fill the details on the Policy holder page > save	Policy holder	30/09/20	31/10/20
Policy holder	webapp	UC7	3	Update	PolicyHolder List > "Select" PolicyHolder > update the details on the Policy holder page > save	Policy holder	30/09/20	31/10/20
Policy holder	webapp	UC7	4	Delete	PolicyHolder List > "Select" PolicyHolder > Delete (this role should be only available to admin, others should only archive by setting the DateValidTo)	Policy holder	30/09/20	31/10/20
Policy holder users	webapp	UC7	5	search users	PolicyHolder List > "Select" PolicyHolder > UserList > > search, the default list will show only the active policy holder users	Policy holder	30/09/20	31/10/20
Policy holder users	webapp	UC7	6	add users	PolicyHolder List > "Select" PolicyHolder > UserList > add user	Policy holder	30/09/20	31/10/20
Policy holder users	webapp	UC7	7	update user	Select PolicyHolder > UserList > (Search user) >Select User > change details > Save	Policy holder	30/09/20	31/10/20
Policy holder users	webapp	UC7	8	Delete user	Select" PolicyHolder > UserList > (Search user) >Select User > change details > Delete	Policy holder	30/09/20	31/10/20
Policy holder insuree	webapp	UC1	1	Search	PolicyHolder List > "Select" PolicyHolder > Insuree tab > use the search box > search, the default list will show only the active policy holder insuree	Policy holder	30/09/20	31/10/20
Policy holder insuree	webapp	UC1	2	Add	PolicyHolder List > "Select" PolicyHolder > Insuree tab > 'add' insure > fill the details on the Policy holder insuree page > save	Policy holder	30/09/20	31/10/20
Policy holder insuree	webapp	UC1	3	Update (error)	PolicyHolder List > "Select" PolicyHolder > Insuree tab > update the details on the Policy holder page > save	Policy holder	30/09/20	31/10/20
Policy holder insuree	webapp	UC1	4	Replace	(new version) PolicyHolder List > "Select" PolicyHolder > Insuree tab > update the details on the Policy holder page > create new version à add ValidityTo	Policy holder	30/09/20	31/10/20
Policy holder insuree	webapp	UC1	5	Delete	PolicyHolder List > "Select" PolicyHolder > Insuree tab > "Select" an insuree> Delete (this role should be only available to admin, other should only archive by setting the DateValidTo)	Policy holder	30/09/20	31/10/20
PolicyHolder contribution plan bundle	webapp	UC11	1	Search	PolicyHolder List > "Select" PolicyHolder > contribution plan tab > use the search box > search, the default list will show only the active contribution plan	Policy holder	30/09/20	31/10/20
PolicyHolder contribution plan bundle	webapp	UC11	2	Add	PolicyHolder List > "Select" PolicyHolder > contribution plan tab > 'add' contribution plan bundles > fill the details on the Policy holder insuree page > save	Policy holder	30/09/20	31/10/20
PolicyHolder contribution plan bundle	webapp	UC11	3	Replace (new version)	Select PolicyHolder > contribution plan tab > "Select" a contribution plan bundles >> update the contribution plan > create a new version > add ValidityTo	Policy holder	30/09/20	31/10/20
PolicyHolder contribution plan bundle	webapp	UC11	4	Delete	PolicyHolder List > "Select" PolicyHolder > contribution plan tab > "Select" a contribution plan bundles > Delete	Policy holder	30/09/20	31/10/20
PolicyHolder contribution plan bundle	backend	UC11	5	Replacing / removing propagation to policyholder insure contribution plan bundle		Policy holder	30/09/20	31/10/20
Contract	webapp	UC3	1	Add bulk "contract"	Policy holder List > select policyholder(s) > Contract list > generate bulk contract > enter the date on which the contract must be created if not already covered by previous contract.	Contract	31/01/21	31/04/21
Contract	webapp	UC3	2	Add "contract"	Policy holder List > Select a Policy Holder > Contract list> Generate contract > enter the date on which the contract must be created if not already covered by previous contract.> confirmation with the contract dates	Contract	31/01/21	31/04/21
Contract	webapp	UC3	3	Update contract details	Policy holder List > Select a Policy Holder > Contract list > Select contract > updates one/ several lines > save	Contract	31/01/21	31/04/21
Contract	webapp	UC3	4	Submit/sign "contract"	Policy holder List > Select a Policy Holder > Contract list > Select contract(s) > Submit/sign contract	Contract	31/01/21	31/04/21
Contract	webapp	UC3	5	Review "Contract"	Policy holder List > Select a Policy Holder > Contract list > Select contract(s) > contract Reviewed (only for submitted contract)	Contract	31/01/21	31/04/21
Contract	webapp	UC3	6	Ask updates "Contract"	Policy holder List > Select a Policy Holder > Contract list > Select contract(s) > ask update (only for submitted contract)	Contract	31/01/21	31/04/21
Contract	webapp	UC3	7	Amend "contract"	Policy holder List > Select a Policy Holder > Contract list > Select contract >Generate Amendment > confirmation with Amendment number > add details (if it is about a new employee, they should be added before on the employee list)	Contract	31/01/21	31/04/21
Contract	backend	UC3	8	send payment notification by email		Contract	31/01/21	31/04/21
Contract	backend	UC3	9	send update required (from ask update) notification by email		Contract	31/01/21	31/04/21
Payment	webapp	UC4	1	Add payment	Policy holder List > Select a Policy Holder > contract list > create payment > enter value > save > confirmation giving the contract status	Contract	31/01/21	31/04/21
Payment	webapp	UC4	2	update payment	Policy holder List > Select a Policy Holder > payment list > Select payment > update value > save > confirmation giving the contract status	Contract	31/01/21	31/04/21
Payment	webapp	UC4	3	delete payment	Policy holder List > Select a Policy Holder > payment list > Select payment > delete payment > confirmation giving the contract status	Contract	31/01/21	31/04/21
Payment	webapp	UC4	5	add credit note from contract or amendment	Policy holder List > Select a Policy Holder > payment list > add credit note (negative payment)	Contract	31/01/21	31/04/21
Payment	backend	UC4	6	assign a credit note to contract	On contract approval, if there is a credit note not assigned to a contract, it will be assigned to the newly approved contract.	Contract	31/01/21	31/04/21
Payment	backend	UC5	1	When a full payment is received for a contract, the policy of the policyholder insuree part of the contact will be renewed if needed		Contract	31/01/21	31/04/21
Payment	backend	UC5	2	When a full payment is received for a contract, the insureepolicy of the policyholder insuree part of the contact will be activated		Contract	31/01/21	31/04/21
Policy holder users	portal	UC13	6	add users	UserList > add user	portal	31/01/21	31/04/21
Policy holder users	portal	UC13	7	update user	UserList > (Search user) >Select User > change details > Save	portal	31/01/21	31/04/21
Policy holder users	portal	UC13	8	block user	UserList > (Search user) >Select User > change details > Delete	portal	31/01/21	31/04/21
Policy holder insuree	portal	UC12	1	Search	My Insuree tab > use the search box > search, the default list will show only the active policy holder insuree	portal	31/01/21	31/04/21
Policy holder insuree	portal	UC12	2	Add	My Insuree tab > 'add' insure > fill the details on the Policy holder insuree page > save	portal	31/01/21	31/04/21
Policy holder insuree	portal	UC12	3	Update (error)	My Insuree tab > update the details on the Policy holder page > save	portal	31/01/21	31/04/21
Policy holder insuree	portal	UC12	4	Replace (new version)	My Insuree tab > update the details on the Policy holder page > create new version > add ValidityTo	portal	31/01/21	31/04/21
Policy holder insuree	portal	UC12	5	Delete	My insuree tab > "Select" an insuree> Delete (this role should be only available to admin, other should only archive by setting the DateValidTo)	portal	31/01/21	31/04/21
Contract	portal	UC14	1	search contract	My Contract list >fill search criteria > search	portal	31/01/21	31/04/21
Contract	portal	UC14	2	Update details	My Contract list > Select contract > update one/several line > save	portal	31/01/21	31/04/21
Contract	portal	UC14	3	Submit/sign "contract"	My Contract list > Select contract(s) > Submit/Sign contract	portal	31/01/21	31/04/21
profile	webapp	UC13	1	search profile	Profile list > enter search criteria > search	profile	30/09/20	31/10/20
profile	webapp	UC13	2	add profile	Profile list > add > select the authorities and define name > save	profile	30/09/20	31/10/20
profile	webapp	UC13	3	update profile	Profile list > Select Profile > update the authorities and name > save	profile	30/09/20	31/10/20
profile	webapp	UC13	4	replace profile	Profile list > Select Profile > update the authorities and name > replace > define replacement date	profile	30/09/20	31/10/20
profile	webapp	UC13	5	remove profile	Profile list > Select Profile > remove > select replacement profile > conf	profile	30/09/20	31/10/20
profile	backend	UC13	7	propagation of replacing / removing to user		profile	30/09/20	31/10/20
profile	webapp	UC13	8	duplicate profile	Profile list > Select Profile >duplicate > give the new name > conf	profile	30/09/20	31/10/20

openIMIS

Formal Sector Modules