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
19	Claim type (%)	Number of claims by each type (OPD, Emergency, IPD, Referral)	Total number/value of all types of claims		VisitType	claim.type
20	Top 10 Diagnoses	Number of claims per diagnosis			ICDID	claim.diagnosis
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
22	List of number/value of the type of service per period per level				ServiceID	claim.item.service
23	List of Numbers/Value of most prescribed drugs per period	Numbers/Value of most prescribed drugs per period of time
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
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
26	Number/Value of Claims reviewed/valuated			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
29	Incurred administration expense ratio	Total value of incurred administration expenses	Total value of collected contributions and subsidies
30	Incurred claims ratio	Total value of incurred claims	Total value of earned contributions and subsidies
31	OOP ratio	Total sum of OOP spending	Total sum of health expenditure = OOP + claims
32	Benefit coverage rate	Number of accepted claims	Total number of reported medical cases		Approved	claimResponse.totalBenefit
33	Complaint ratio	Total number of complaints	Total number of covered individuals
34	Promptness of claim approval	Period of time between submission and approval of a claim			DateClaimed - DateProcessed	claim.created - claimResponse.created
35	Health infrastructure	Number of health facilities/health personnel	Population
36	Average cost per (inpatient) visit	Total Value of all (inpatient) claims	Total number of inpatients
37	Number of cases for specific diseases				ICDID	claim.diagnosis
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
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
40	Net income(profit) ratio	Total Value of collected (premiums + subsidies) - paid claims	Total amount of collected premiums + subsidies

openIMIS

Claim Management Indicators in DHIS2

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