OpenIMIS-SOSYS Integration Use Cases

Use case Name	Claim Application
Description	This module is used to store the claim information into OpenIMIS Database.
Actor	Hospital
Pre-Condition	The user, which can perform this Entry, must be authenticated and authorized.
Post-Condition	Claim information added successfully to the System.
Business Rule	System must have a user with authority to enter this data. Check the contributor information into OpenIMIS before application submit, if not exits into it then fetch contributor information from SOSYS Database via API and save into OpneIMIS. Check contributor policy into SOSYS Database via API
Attributes	SSFID Contributor Name Claim Id Claim Date Claim Amount Employer Id Employer Name Hospital code Bank Id Bank Branch Id Bank Account Number Bank Account Name And so on
Validation	All Required field must be entered.

Use case Name	Employer Portal => Employer Recommended
Description	This module is used to recommend or verify the claim Application.
Actor	Employer
Pre-Condition	The user, which can perform this Entry, must be authenticated and authorized.
Post-Condition	Claim information verify successfully to the System.
Business Rule	System must have a user with authority to enter this data. Check the claim information. Approve or reject claim application.
Attributes	SSFID Contributor Name Claim Id Claim Date Claim Amount Employer Id Employer Name Hospital code Bank Id Bank Branch Id Bank Account Number Bank Account Name And so on
Validation	All Required field must be entered.

Use case Name	Claim Settlement Application
Description	This module is used to store the claim settlement information into OpenIMIS Database.
Actor	SSF Officer
Pre-Condition	The user, which can perform this Entry, must be authenticated and authorized.
Post-Condition	Claim settlement information added successfully to the System.
Business Rule	System must have a user with authority to enter this data. Check contributor policy and active into SOSYS Database via API Check dossier completed or not if not complete then exit and send message to applicant. If dossier completed then go to nature of accident that are:- Damage to health Work Accident Accident Occupational Disease If not Damage to heath then reject the application If damage to health then go to work Accident If work Accident then go to recognize work Accident If not work Accident then go to Accident If Accident then go to recognize Accident If not Accident then go to Occupational Disease If Occupational Disease then go to recognize the OD Otherwise link to Health Insurance After recognize Nature of Accident, check Insurance case possible or not If not Insurance case possible then link to Health Insurance If insurance case possible then go to Scrutinize case components If case component not complete then link to Health Insurance If case component complete then go to Insurance case recognize If Insurance case not recognize then link to Health Insurance If Insurance case recognize then go to Payment application
Attributes	SSFID Contributor Name Claim Id Claim Date Claim Amount Employer Id Employer Name Hospital code Bank Id Bank Branch Id Bank Account Number Bank Account Name And so on
Validation	All Required field must be entered.

Use case Name	Contributor Portal => Claim Application
Description	This module is used to store the claim information into OpenIMIS Database via Api.
Actor	Contributor
Pre-Condition	The user, which can perform this Entry, must be authenticated and authorized.
Post-Condition	Claim information added successfully into OpenIMIS System.
Business Rule	System must have a user with authority to enter this data. Check the contributor information into OpenIMIS before application submit, if not exits into it then fetch contributor information from SOSYS Database via API and save into OpneIMIS. Check contributor policy into SOSYS Database
Attributes	SSFID Contributor Name Claim Id Claim Date Claim Amount Employer Id Employer Name Hospital code Bank Id Bank Branch Id Bank Account Number Bank Account Name And so on
Validation	All Required field must be entered.

Use case Name	Contributor Portal => View Claim Status
Description	This module is used to display the claim status.
Actor	Contributor
Pre-Condition	The user, which can perform this Entry, must be authenticated and authorized.
Post-Condition	Claim information displayed successfully via reports
Business Rule	System must have a user with authority to enter this data. Show the claim history. Search Criteria
Attributes	SSFID Contributor Name Claim Id Claim Date Claim Amount Employer Id Employer Name Hospital code Hospital Name And so on

Use case Name	Dependent Portal => Claim Application
Description	This module is used to store the claim information into OpenIMIS Database via Api.
Actor	Dependent
Pre-Condition	The user, which can perform this Entry, must be authenticated and authorized.
Post-Condition	Claim information added successfully into OpenIMIS System.
Business Rule	System must have a user with authority to enter this data. Check the contributor information into OpenIMIS before application submit, if not exits into it then fetch contributor information from SOSYS Database via API and save into OpneIMIS. Check contributor policy into SOSYS Database
Attributes	SSFID Contributor Name Claim Id Claim Date Claim Amount Employer Id Employer Name Hospital code Bank Id Bank Branch Id Bank Account Number Bank Account Name And so on
Validation	All Required field must be entered.

Use case Name	Dependent Portal => View Claim Status
Description	This module is used to display the claim status.
Actor	Dependent
Pre-Condition	The user, which can perform this Entry, must be authenticated and authorized.
Post-Condition	Claim information displayed successfully via reports
Business Rule	System must have a user with authority to enter this data. Show the claim history. Search Criteria
Attributes	SSFID Contributor Name Claim Id Claim Date Claim Amount Employer Id Employer Name Hospital code Hospital Name And so on

Use case Name	Officer Portal => Claim Application
Description	This module is used to store the claim information into OpenIMIS Database via Api.
Actor	SSF Officer
Pre-Condition	The user, which can perform this Entry, must be authenticated and authorized.
Post-Condition	Claim information added successfully into OpenIMIS System.
Business Rule	System must have a user with authority to enter this data. Check the contributor information into OpenIMIS before application submit, if not exits into it then fetch contributor information from SOSYS Database via API and save into OpneIMIS. Check contributor policy into SOSYS Database
Attributes	SSFID Contributor Name Claim Id Claim Date Claim Amount Employer Id Employer Name Hospital code Bank Id Bank Branch Id Bank Account Number Bank Account Name And so on
Validation	All Required field must be entered.
Use case Name	Officer Portal => View Claim Status
Description	This module is used to display the claim status.
Actor	SSF Officer
Pre-Condition	The user, which can perform this Entry, must be authenticated and authorized.
Post-Condition	Claim information displayed successfully via reports
Business Rule	System must have a user with authority to enter this data. Show the claim history. Search Criteria
Attributes	SSFID Contributor Name Claim Id Claim Date Claim Amount Employer Id Employer Name Hospital code Hospital Name And so on

openIMIS

OpenIMIS-SOSYS Integration Use Cases

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