Claim Management Indicators in DHIS2

S No

Indicator

Numerator

Denominator

Disaggregation

openIMIS Concept

FHIR Mapping

openIMIS Concept

FHIR Mapping

 

 

 

 

 

Numerator

Denominator

1

Value of all claims entered in openIMIS

Value of all claims

 

 

ClaimStatus

claimResponse.processNotexx

 

 

2

Individuals/HHs with claims

 

 

 

ClaimCode

claim.Identifier

 

 

3

Average value claimed per member/HH with claims

Value of all claims

Number of members with claims

 

RemuneratedAmount

claimResponse.item.adjudication.amount

 

 

4

Incurred claims per capita

Value of all claims

Total number of enrolled persons

 

RemuneratedAmount

claimResponse.item.adjudication.amount

 

 

5

Average claim value

Value of all claims

 

 

RemuneratedAmount

claimResponse.item.adjudication.amount

 

 

6

HHs hitting ceiling

HHs whose claims add up to 50000 NPR

 

 

ExceedCeilingAmount

claimResponse.item.adjudication.amount

 

 

7

HHs hitting ceiling through families (%)

HHs hitting ceiling up to 50000 NPR during the time period

Families with claims during the time period

 

ExceedCeilingAmount

claimResponse.item.adjudication.amount

 

 

8

Rejected claims

Number of rejected claims

 

Facility type

ClaimStatus

claimResponse.processNote

 

 

9

Submitted claims

Number of submitted claims

 

Facility type

 

 

 

 

10

Pending claims

Number of pending claims

 

Facility type

ClaimStatus

claimResponse.processNotexx

 

 

11

Pending claims (%)

Number of pending claims

Number of submitted claims

Facility type

ClaimStatus

claimResponse.processNotexx

 

 

12

Reimbursed claims

Number of reimbursed claims

 

Facility type

RemuneratedAmount

claimResponse.item.adjudication.amount

 

 

13

Reimbursed claims (%)

Number of reimbursed claims

Number of submitted claims

Facility type

ClaimStatus

claimResponse.processNotexx

 

 

14

Rejection rate of claims (automated/by claims review)

Total Number of rejected claims during the time period

Total number of claims during the time period

Facility type, Type of Claim, emergency, OPD, IPD, Referral

ClaimStatus

claimResponse.processNote

 

 

15

Total Revenue in Health Insurance Fund

Premium plus subsidy from public fund/MoF plus other private sources (e.g. donations)

NA

Enrollment data, MOF/HIB,

 

 

 

 

16

HHs revenue contribution (%)

Total premium collected from HHs

Total revenue in Health Insurance fund

 

 

 

 

 

17

Government subsidy contribution (%)

Total premium received from MoF

Total revenue in Health Insurance fund

 

 

 

 

 

18

Total claims by types

Total claims by the type (OPD, Emergency, IPD, Referral)

 

 

VisitType

claim.type