Claim Management Indicators in DHIS2
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 |
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19 | Claim type (%) | Number of claims by each type (OPD, Emergency, IPD, Referral) | Total number/value of all types of claims |
| VisitType | claim.type |
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20 | Top 10 Diagnoses | Number of claims per diagnosis |
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| ICDID | claim.diagnosis |
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21 | Trend of Diagnoses-Groups, i.e. NCD | Number of Claims for Treatment of Diagnosis Group | several possible: Number of Claims for Diagn. A group in year before, an average of several years before |
| ICDID | claim.diagnosis |
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22 | List of number/value of the type of service per period per level |
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| ServiceID | claim.item.service |
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23 | List of Numbers/Value of most prescribed drugs per period | Numbers/Value of most prescribed drugs per period of time |
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24 | List of Numbers/Value of most prescribed drugs per period as % of total Number/Value of claims | List of Numbers/Value of most prescribed drugs per period of time | Total Number/Value of all claims |
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25 | List of Numbers/Value of most prescribed drugs per period as % of total Number/Value of claims which prescribed drugs | List of Numbers/Value of most prescribed drugs per period | Total Number/Value of all claims which prescribed drugs |
| HFLevel/LegalForm | type |
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26 | Number/Value of Claims reviewed/valuated |
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| Claim reviewer | HFLevel/LegalForm/Valuated | type |
| Facility Type, Gender |
27 | Number/Value of Claims reviewed/valuated (%) | Total Number/Value of claims reviewed/valuated | Total Number/Value of all claims submitted | Claim reviewer | HFLevel/LegalForm/Valuated | type |
| Facility Type, Gender, Age Group |
28 | Valuated Value of claims as a share of total value of submitted claims | Aggregated Value of claims after being revised (include rejected claims?) | aggregated Value of all submitted claims | Facility types |
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29 | Incurred administration expense ratio | Total value of incurred administration expenses | Total value of collected contributions and subsidies |
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30 | Incurred claims ratio | Total value of incurred claims | Total value of earned contributions and subsidies |
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31 | OOP ratio | Total sum of OOP spending | Total sum of health expenditure = OOP + claims |
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32 | Benefit coverage rate | Number of accepted claims | Total number of reported medical cases |
| Approved | claimResponse.totalBenefit |
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33 | Complaint ratio | Total number of complaints | Total number of covered individuals |
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34 | Promptness of claim approval | Period of time between submission and approval of a claim |
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| DateClaimed - DateProcessed | claim.created - claimResponse.created |
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35 | Health infrastructure | Number of health facilities/health personnel | Population |
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36 | Average cost per (inpatient) visit | Total Value of all (inpatient) claims | Total number of inpatients |
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37 | Number of cases for specific diseases |
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| ICDID | claim.diagnosis |
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38 (a) | Payment allocation by diseases and its severity/Inpatient admissions/Primary health care sensitive diagnosis/tracer conditions | Total payments in the defined time period | Total enrolled population in the defined time period |
| RemuneratedAmount | claimResponse.item.adjudication.amount |
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39 (b) | Ratio of highly complex to fewer complex patients. | Total number of highly complex patients seen in the defined area during the defined time period | Total number of low complexity patients seen in the defined area during the defined time period |
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40 | Net income(profit) ratio | Total Value of collected (premiums + subsidies) - paid claims | Total amount of collected premiums + subsidies |
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