openIMIS beyond health features needs

This page is only an idea of implementation from @Patrick Delcroix , not validated nor reviewed by the community

overall-beyond-health-openIMIS Business structure.drawio (2).png

 

Uncovered Use case

Basic user stories not covered by openIMIS today:

1- A woman is 8 months pregnant and is allowed to not work anymore until the 3 month the child , she claim wage compensation for the 4 coming months, the compensation should match with 80 % of the mean income of the previous 6 months

2- An insuree is eligible for a cash payment and claims it

3- A worker is getting retired and claims his retirements funds to be paid monthly, but not all of his working history is in openIMIS

4- A insuree have a work related accident, he claim is wage compensation but before approving it a committee must review the case so the board ca take the decision

5- A insuree got treated in an hospital(resp. lab analysis) without agreement with the scheme operators, he claim the reimbursement of the paid fees

6- A familly with 3 children below 16 is eligible for familly benefit so she enter the right form to collect the information required to handle her case

7- Before any real assessment of the claim, the admin department ensure that all the required prood are present in the claims, each region has an admin department and there is different team for each team of claim

8- A controlling body is auditing claims and wants to used imis to follow the cases

9- Following a disaster the insurance is bankrupt but it call its reinsurance for helps, the reinsurance will provide funding because the scheme dully paid all its past contributions

10- Once the claims are validated, the payment is sent to financial services so the claimee will get the financing claimed

11- A insuree got the approval of a review board he has now access to care/episode of care (voucher or pressurization)

12- Scheme administrator want to define bundle of items/services for claims

Features requires:

On the modeling parts:

  • FHIR Questionnaire could be attached based on the type of claims

 

 

 

 

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