Claim processing up to batch run

Submit claims

Once the claim is “final“ from the HF point of view, the claim admin can submit the claim

at the claim submission automatic admin check are done one the claim

• Check if the insuree exist

• check insuree coverage

• check claimcode uniqueness

• check Item and service exist

• check that the Item and service are on the pricelist of the HF

• check Item and service limits (mask, frequency, ….)

Beyond health missing requirements:

• calculation of cash payment

review claims

Once the claim is submitted the scheme clerc can scutinize the claim

• check the claim based on supporting evidence (invoice, medical procedure results, coherence trreatment/items and services)

Beyond health missing requirements:

• Assigning claim to reviewer groups based on claim characterisitic (type fo claim, values … )

• Definition of different kind of review: admin, medical, audits

Process claims

Batch run

original design : <TO be uploaded>

Principle: the openIMIS batch run is used to calculate the the remunerated amount based for the item and services that have a relative pricing; it will also update the claim remunerated amount for that period

Task performed

• Calculation the relative indexes : (Per Product and period)

  • For all product on chosen location (should also take product on sub locations),

    • all contribution will be added up

    • all valuated amount for the “relative priced“ Items and services of that product will be added up

• update of the remunerated amount (Per Product and period)

  • for all “relative priced“ Items and services for the product for which the claim was processed in the period

• update all claims remunerated amount for that Product

  • add up the remunerated amount for 'R' claim items and services and remunerated amount (or valuated amount) for the non “r” claim items and service

Note: the claims of R1 but having a product from R2 should be taken into account when R2 batch run is launched