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- central reviewing mechanism/filter claims/ payment advice
- payment
3. Group Exercise - break OpenIMIS into multiple building blocks/ connections with the systems that you have
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moral hazard with checking eligibility prior to the
- EMR
- what is the logic flow around submitting a claim
- identify patient (CR call)
- query for insurance number
- need for a beneficiary registry
- IMIS
- HIE
- client registry/terminology service/ MFR/ HWR
- Process
- multiple questions that inform the eligibility verification
- enrollment (can be in health facility)
- when does eligibility occur
- check eligibillity- multiple eligibility check
- eligibility and verification check
- multi share mediation claims workflow
- rules engine for benefits/coverage
- submit query for benefits package/ coverage request
- using appropriate terminology standard codes
- either preloaded in the EMR or query a terminology service for this
- asynchornous claims submission-submit claims
- prior authorization
- feed back loop for recoding and denial
- EMR
- services provided
- submission and subsequent response to the submission
- FHIR/HL7 messaging submission standard
- account, coverage, elibility request and response, enrollment , payment, explanation of benefit resource
- content standard- EDI X12 in the US
Workflows identified:
Level 1 (initial)
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