Idea: Claims pre-authorisation

Content

Summary

Some schemes require that a health facility requests a pre-authorization of a treatment from the insurer before they administer it to the client in order to have the assurance that the costs will be covered. For eg. expensive treatments like certain type of heart surgeries might require a pre-authorization request to be approved by the insurer (including indication of amount to be blocked from the patients ceiling) before the hospital undertakes the surgery. Request is derived from Service Desk issue reported by users in Egypt captured in OSD - 42

Overview

Process Group

JLN Group - Claims Management

Function

JLN Process - Pre-authorization

Source

https://openimis.atlassian.net/browse/OSD-42

https://openimis.atlassian.net/browse/OSD-50

Impact on costs

(man hours, man days)

 

Impact on schedule

 

Category of change

Minor
Major
Principal

Related

Prioritisation

Score

05

Current Relevance

03

Future Relevance

06

Global Good

06

Local Funding

 

Discussion

At the moment, this is out of scope of openIMIS as normally benefit packages are pre defined etc. Might become relevant again when looking at formal sector.

 

Requirement

1.1           Goals/Scope

 

1.2           Background

JLN Process description:JLN Process - Pre-authorization

Draft specification of pre-determination data workflow as special case of a claims workflow:

 

1.3           Assumptions

 

1.4           User stories

 

1.5 Implementation Cases

 

Technical Specification

2.1     Impact on the general architecture

2.2    Impact on the database structure

 

 

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