Claim Management Indicators in DHIS2
- Saurav Bhattarai
S No | Indicator | Numerator | Denominator | Disaggregation | openIMIS Concept | FHIR Mapping | openIMIS Concept | FHIR Mapping |
|---|---|---|---|---|---|---|---|---|
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| Numerator | Denominator | ||
1 | Value of all claims entered in openIMIS | Value of all claims |
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| ClaimStatus | claimResponse.processNotexx |
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2 | Individuals/HHs with claims |
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| ClaimCode | claim.Identifier |
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3 | Average value claimed per member/HH with claims | Value of all claims | Number of members with claims |
| RemuneratedAmount | claimResponse.item.adjudication.amount |
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4 | Incurred claims per capita | Value of all claims | Total number of enrolled persons |
| RemuneratedAmount | claimResponse.item.adjudication.amount |
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5 | Average claim value | Value of all claims |
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| RemuneratedAmount | claimResponse.item.adjudication.amount |
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6 | HHs hitting ceiling | HHs whose claims add up to 50000 NPR |
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| ExceedCeilingAmount | claimResponse.item.adjudication.amount |
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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 |
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8 | Rejected claims | Number of rejected claims |
| Facility type | ClaimStatus | claimResponse.processNote |
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9 | Submitted claims | Number of submitted claims |
| Facility type |
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10 | Pending claims | Number of pending claims |
| Facility type | ClaimStatus | claimResponse.processNotexx |
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11 | Pending claims (%) | Number of pending claims | Number of submitted claims | Facility type | ClaimStatus | claimResponse.processNotexx |
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12 | Reimbursed claims | Number of reimbursed claims |
| Facility type | RemuneratedAmount | claimResponse.item.adjudication.amount |
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13 | Reimbursed claims (%) | Number of reimbursed claims | Number of submitted claims | Facility type | ClaimStatus | claimResponse.processNotexx |
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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 |
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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, |
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16 | HHs revenue contribution (%) | Total premium collected from HHs | Total revenue in Health Insurance fund |
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17 | Government subsidy contribution (%) | Total premium received from MoF | Total revenue in Health Insurance fund |
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18 | Total claims by types | Total claims by the type (OPD, Emergency, IPD, Referral) |
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| VisitType | claim.type | ||