Claim - History

Ticket

https://openimis.atlassian.net/browse/OMT-314

Legacy stored procedure

uspSSRSGetClaimHistory

 

Comments about the report

This report handles claims and products. Every report that handles claims with a specific product will not produce 100% reliable data. Due to architectural choices, claims are only linked to a specific product if they have already been submitted and if they have not been automatically rejected.

For a given product, it is currently impossible to know:

  • the number of entered claims (as in “not yet submitted”)

  • the number of automatically rejected claims (as opposed to manually rejected by a claim administrator)

Any “rejected” or “total” numbers of claims - if a specific product is given - will never include these two cases.

While this is usually not an issue with large numbers, it can make some totals seem wrong.

In this report, if a specific product is asked, it would be impossible to fetch all claims with that product as the ENTERED claims are not linked yet to the product and the SUBMITTED claims that were automatically rejected were not linked either.

Unfortunately, the legacy report is very chaotic, because too much information is displayed and the layout was changing depending on the scope, which made the report really hard to read.

To improve this, the scope has not been taken care of in this version. This report is using only the full scope of the previous report. If other scopes are necessary, separate reports should be created.

As mentioned during the Community Meetings, there is a general issue with the way various amounts are stored in Claim, ClaimItem and ClaimService. Sometimes, the amounts in the details (ClaimItem, ClaimService) of a claim don't add up to figures at the Claim level (e.g. all the amounts except “Claimed” in the screenshot example above). The figures used for calculating the total values are based only on the Claim-level figures.

 

How it works

 

A query fetches all claims with the requested criteria (insuree, product, region, district…).

Then, the content of each claim is analyzed:

  • Any amount at the claim level is added to the totals, except for the remunerated amount, as this information is never updated at the claim level (only at the ClaimItem and ClaimService levels).

  • The “Price approved” amount at the ClaimItem and ClaimService levels is based on the price and quantity approved, if any, otherwise on the price and quantity initially asked.

 

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