Business Requirements: e-Prescription Support for Claiming and Pre-Authorization Configuration

Version: Business-focused – ePrescription primary for ensuring MD-issued drugs & external care; Pre-auth as optional by-product
Focus: Pure business concepts, rules, and flows only. Reuses core openIMIS entities (Claim, Review, Item/Service) with targeted extensions. Introduces new business concepts: ePrescription and Prescription Consumption.
Goal: ePrescription ensures that drugs and external services (labs, etc.) are issued by a qualified MD. This provides traceability and control with low claim admin workload (single review point per episode + automatic quantity rejection). Pre-authorization is an optional additional control layer applied only when the Item/Service flag is set.

1. Business Objectives

The primary goal of introducing ePrescription is to ensure that drugs and external services (such as laboratory tests performed outside the health facility, medications dispensed at pharmacies, etc.) are issued by a qualified Medical Doctor (MD). This creates a formal, traceable authorization from the prescriber while giving flexibility for care delivered outside the facility.

Pre-authorization adds a convenient optional workflow that can be applied on top when needed for specific high-control items.

Key design principles to keep claim administration workload low:

• Only the claim that generates the ePrescription may require review.

• Subsequent claims (using the ePrescription) are not automatically reviewed unless:

  • Price deviations on subsequent claims may trigger review or rejection.

  • Any quantity above the prescribed quantity is automatically rejected.

This reuses existing openIMIS Claim and Review concepts, adds light flags to Item/Service, and introduces ePrescription and Prescription Consumption as new business concepts.

Specific objectives:

• Enable ePrescription as the mechanism to guarantee MD-issued authorization for drugs and external care.

• Enforce strict quantity control: no claim can exceed the quantity prescribed in the ePrescription.

• Support efficient processing of subsequent claims (refills, external fulfillments) when they respect the agreed price and quantity from the ePrescription.

• Allow pre-authorization as an optional additional control layer (activated per Item/Service) without making it mandatory for every ePrescription.

• Never block actual provision or consumption of the prescribed item/service.

• Limit review workload to at most one claim per ePrescription episode.

2. Key Business Concepts

Existing openIMIS Concepts (with targeted extensions)

Item / Service (from Medical management)

• Core entity representing billable drugs, procedures, consultations, etc.

• New attributes (business flags):

  • Requires Pre-Authorization: Yes/No (optional secondary flag). When set to Yes on top of the ePrescription flag, the Original Claim that generates the ePrescription will go through review. Pre-auth is a convenient add-on, not required for every ePrescription.

  • Requires Prescription: Yes/No. When set to Yes, a service provider is not allowed to provide the item/service without a prescription and therefore cannot claim it without a linked prescription.

Service Provider (renamed from Health Facility or an new sibling model of Health Facility)

• The entity delivering care or dispensing items (previously referred to as health facility).

• New attribute:

  • Enforce Prescription: Yes/No. Determines whether this service provider can provide items/services that require a prescription without an actual prescription being present.

Claim and Claim Details

• The central entity for requesting reimbursement or coverage.

• New linkage:

  • A Claim can be explicitly linked to one or more ePrescriptions.

  • Original Claim: Links the ePrescription(s) in the prescriptions reference list.

  • Subsequent Claim: Links the ePrescription both in the sourcePrescriptions list and associates the matching prescription line/detail with the corresponding claim items and claim services.

  • When an ePrescription is created for an item that also has Requires Pre-Authorization = Yes, the system designates the Original Claim for review. For items without the pre-auth flag, ePrescription still provides MD issuance control and quantity enforcement without mandatory review.

Review / Adjudication

• The existing claim review and approval workflow.

• Applies as mandatory to the Original Claim that has at least one Prescription and Requires Pre-Authorization = Yes for the Service/Item part of that prescription. Other claims linked to prescriptions follow the formal review flow.

• Subsequent Claims (claims linked to a prescription as sourcePrescriptions) will be automatically reviewed if:

  • The Original Claim is reviewed (a new status “on-hold” will be assigned to the Subsequent Claim until the Original Claim is reviewed or processed).

  • The Claim contains only prescribed items and services that are part of Original Claims’ prescription. or the service provider is allowed to claim the addtionnal items and services without prescriptions

  • The Claimed quantity is lower or equal to the prescribed quantity (if higher, the quantity is adapted and the claim is flagged for review).

  • The prescribed service/item code matches the claim item/service code (otherwise the claim is flagged for review).

New Business Concepts

ePrescription

• A formal business record authorizing the provision of a specific Item/Service to a specific patient (or beneficiary).

• Represents the prescriber’s intent and instructions (what, how much, how often, duration, etc.).

• Attached to one Original Claim and to Subsequent Claim Items or Services for traceability and claiming purposes.

• Can exist independently of claim approval status.

Prescription Consumption (also called Dispense or Fulfillment)

• The actual event where the prescribed item is physically provided or administered to the patient.

• Records what was really given (may differ slightly from the original ePrescription in quantity or product).

• Linked back to the original ePrescription.

• Serves as the key trigger or supporting evidence for final claim processing and payment.

• Can occur at any time — it is not gated by the review status of the related Original Claim.

3. Business Rules

Primary Rule: ePrescription for MD-Issued Control (Always Active)

For any Item/Service with Generates ePrescription = Yes:

1. Creating an ePrescription creates a formal record that the drug or external service was issued by a qualified MD.

2. The ePrescription establishes the prescribed quantity and (when priced) the reference price for the episode.

3. Strict quantity control applies to all claims linked to this ePrescription:

   • Any claim line with quantity greater than the prescribed quantity is automatically rejected.

4. Subsequent claims (refills, external lab tests, pharmacy dispenses, etc.) linked to the same ePrescription are processed efficiently when they respect the prescribed quantity and agreed price.

5. Prescription Consumption (actual provision of the drug or external service) can occur at any time and is never blocked.

Optional Rule: Pre-Authorization Layer (Activated Only When Flag is Set)

When an Item/Service also has Requires Pre-Authorization = Yes (in addition to Generates ePrescription = Yes):

1. Creating the ePrescription automatically creates or designates an Initial Claim.

2. Only this Initial Claim enters the standard Review process. This remains the single review point per ePrescription episode.

3. Review outcome provides formal pre-authorization / coverage confirmation as a convenient by-product.

4. Subsequent claims still follow the same efficient rules (price deviation may trigger review/reject; over-quantity is auto-rejected).

5. The provider/patient may optionally check the Initial Claim status for coverage assurance, but this is not required for consumption to proceed.

Workload Control Principle (Core Design Goal)

• ePrescription itself provides the main control (MD issuance + quantity enforcement) without requiring review on every claim.

• This supports flexible external care (drugs, labs outside the facility) while preventing unnecessary growth in claim administration workload.

Statuses and Transitions (Business View)

ePrescription Statuses : see FHIR composition statuses

Initial Claim Statuses (reuses existing Claim statuses):

• Entered → Under Review → Approved / Rejected

Prescription Consumption Statuses:

• Recorded

• Verified (optional)

• Linked to Claim

4. High-Level Business Flow

Open

5. Example Business Scenarios

Scenario 1: External Laboratory Test – ePrescription Ensures MD Issuance

• A lab test panel has Requires ePrescription = Yes.

• During consultation the MD creates an ePrescription for the external lab test → this formally records that the test was ordered by a qualified doctor.

• MD send the consultation claim (original claim) with the link to the prescription, need to have the associated diagnostic

• Patient has the test performed at an external laboratory the same day (Prescription Consumption recorded).

• No review dedicated is required (will trust the Original claim review) unless the scheme also set Requires Pre-Authorization = Yes on this item.

• The ePrescription guarantees MD authorization and sets the maximum quantity (usually 1 for a lab panel).

Scenario 2: Chronic Medication with Multiple Refills – Workload Control + MD Control

• Expensive chronic medication has Generates ePrescription = Yes.

• MD issues a 6-month ePrescription → establishes prescribed total quantity and reference price.

• First dispense happens immediately at the pharmacy.

• Subsequent monthly refill claims:

  • Respect prescribed quantity and agreed price → processed efficiently with no review.

  • Attempt higher price → may be routed for review or rejected.

  • Attempt quantity above what remains prescribed → automatically rejected.

• Pre-authorization review on the Initial Claim is optional (only if the secondary flag is also set) and happens only once.

Scenario 3: Optional Pre-Auth for High-Cost Item (By-Product)

• Same chronic medication, but the scheme has also set Requires Pre-Authorization = Yes.

• MD creates ePrescription → Initial Claim is created and goes through review once.

• After approval, subsequent refills follow the fast-track rules above.

• The pre-auth step provides extra coverage assurance but does not block any consumption and does not repeat for every refill.

6. Benefits (Business Perspective)

• Ensures MD-issued control for drugs and external care: ePrescription guarantees that prescribed drugs and services performed outside the facility (labs, pharmacy, etc.) are formally issued by a qualified Medical Doctor.

• Low claim administration workload by design: Review occurs at most once per ePrescription episode and only when the optional pre-auth flag is active. Most subsequent claims are fast-tracked.

• Strong automatic controls: Any quantity above the prescribed amount is rejected outright. Price deviations on subsequent claims can trigger review or rejection.

• Flexibility without losing control: Enables external fulfillment while maintaining traceability and MD authorization.

• Patient care is never delayed: Prescription Consumption proceeds independently of any optional review.

• Configurable: Schemes can activate the optional pre-auth layer on specific high-control items without making it mandatory for all ePrescriptions.

8. Summary of Required Business Changes

Open Questions

• how to manage implemetation without eclaims regarding :

  • data entry: we could have a checkbox in HF claim "prescribed" that would generate the eprescription

  • how to get the prescriptor: new field on claim service/item

  • how to display eprescription on review screen: possible an other set of service/item below the claim