Insurance & Claims¶
Manage payers (government schemes like HIB, corporate, TPAs), enrol patient policies, and process claims with co‑pay splits, appeals, and partial settlement.
Schemes & policies¶
- Schemes (
/medical/insurance/schemes) — define payers by type (Government / Corporate / TPA) with coverage limits, coverage %, and co‑pay %. - Policies (
/medical/insurance/policies) — enrol a patient on a scheme with member number, enrolment date, and validity. An eligibility check confirms an active policy before credit billing.
Screenshot: Insurance policies — TODO
Claims¶
Medical → Insurance → Claims (/medical/insurance/claims) — the claim lifecycle:
- Draft → Submit (gated on eligibility; consumes the policy credit).
- Approve (with remarks) or Reject (with reason).
- Resubmit / appeal — a rejected claim can be appealed: it re‑checks eligibility, re‑consumes the credit, returns to Submitted, and records the appeal note + count.
- Record payment — payers often pay in instalments, so payment accrues: a claim stays Partially Paid until the cumulative amount reaches the credit total, then becomes Paid. Each instalment posts its own reimbursement to finance.
The co‑pay split comes from the policy, and the diagnosis is coded to ICD (AI‑assisted). A pre‑submission denial‑risk check is available — advisory only.
Only draft claims can be edited. Once a claim is submitted (or beyond), opening it shows a read‑only detail view with the full lifecycle trail (submission, decision, denial reason, appeals, payments); attempting to open the edit form redirects there. Lifecycle actions stay on the claims list.
Nepal payers
Government schemes (e.g. the Health Insurance Board, HIB) are first‑class payer types. Claims carry ICD‑coded diagnoses so they line up with payer requirements.
AI is advisory
The denial‑risk prediction and ICD suggestions guide the user; a person makes the call. All AI actions are recorded — see Medical AI & Coding.