openIMIS Backend Claim reference module

This repository holds the files of the openIMIS Backend Claim reference module. It is dedicated to be deployed as a module of openimis-be_py.

Code climate (develop branch)

ORM mapping:

• tblClaimAdmin > ClaimAdmin
• tblFeedback > Feedback
• tblClaim > Claim
• tblClaimItems > ClaimItem
• tblClaimServices > ClaimService
• claim_ClaimAttachment > ClaimAttachment

Listened Django Signals

• signal_mutation_module_validate["claim"]: handles ClaimMutation

Services

• DEPRECATED ClaimSubmitService.submit, mapped to uspUpdateClaimFromPhone Stored Proc (used by api_fhir reference implementation: needs replacement, with signals)
• ClaimReportService, loading the necessary data for the Claim printing

Reports (template can be overloaded via report.ReportDefinition)

• claim_claims (Claim printing)

GraphQL Queries

• claims
• claim_admins
• claim_admins_str
• claim_officers
• claim_attachments

GraphQL Mutations - each mutation emits default signals and return standard error lists (cfr. openimis-be-core_py)

• create_claim
• update_claim
• submit_claims
• select_claims_for_feedback
• deliver_claim_feedback
• bypass_claims_feedback
• skip_claims_feedback
• select_claims_for_review
• deliver_claims_review
• bypass_claims_review
• skip_claims_review
• save_claims_review
• process_claims
• delete_claims
• add_claim_attachment
• update_attachment
• delete_claim_attachment

Additional Endpoints

• print: generating Claim PDF

Reports

• claim_claim: Claim summary

Configuration options (can be changed via core.ModuleConfiguration)

• default_validations_disabled: bypass (defaul) claim validations in Submit and Process mutations (default: False)

• gql_query_claims_perms: required rights to call claims GraphQL Query (default: ["111001"])

• gql_query_claim_admins_perms: required rights to call claim_admins GraphQL Query (default: [])

• gql_query_claim_officers_perms: required rights to call claim_officers GraphQL Query (default: [])

• gql_mutation_create_claims_perms: required rights to call create_claim GraphQL Mutation (default: ["111002"])

• gql_mutation_update_claims_perms: required rights to call update_claim GraphQL Mutation (default: ["111010"])

• gql_mutation_submit_claims_perms: required rights to call submit_claim GraphQL Mutation (default: ["111007"])

• gql_mutation_select_claim_feedback_perms: required rights to call select_claim_feedback GraphQL Mutation (default: ["111010"])

• gql_mutation_bypass_claim_feedback_perms: required rights to call bypass_claim_feedback GraphQL Mutation (default: ["111010"])

• gql_mutation_skip_claim_feedback_perms: required rights to call skip_claim_feedback GraphQL Mutation (default: ["111010"])

• gql_mutation_deliver_claim_feedback_perms: required rights to call deliver_claim_feedback GraphQL Mutation (default: ["111009"])

• gql_mutation_select_claim_review_perms: required rights to call select_claim_review GraphQL Mutation (default: ["111010"])

• gql_mutation_bypass_claim_review_perms: required rights to call bypass_claim_review GraphQL Mutation (default: ["111010"])

• gql_mutation_skip_claim_review_perms: required rights to call skip_claim_review GraphQL Mutation (default: ["111010"])

• gql_mutation_deliver_claim_review_perms: required rights to call deliver_claim_review GraphQL Mutation (default: ["111010"])

• gql_mutation_process_claims_perms: required rights to call process_claims GraphQL Mutation (default: ["111011"])

• gql_mutation_delete_claims_perms: required rights to call delete_claims GraphQL Mutation (default: ["111004"])

• claim_print_perms: required rights to call print endpoint (default: ["111006"])

• claim_attachments_root_path: using os standard file system, root path for the claim attachments (default: None ... documents B64 in database)

  WARNINGS:

  • attachments in input are NOT streamed (posted in a GraphQL query and fully read when serving), gateway must be configure to limit request payload size
  • attachments in output are served from the python (django) os process, generating load (memory consumption) on the application server, customisation of the view to output a redirect to a static file server is recommended
  • in an attempt to prevent encoding problems, files are written as binaries on the filesystem, please ensure the mounted file system supports python binary access (wb flag)

• native_code_for_services: Defines whether the system must check the service & sub-services prices or not.

  • If the packagetype of the service is flat fee bundle, the system checks if claim_detail.price_adjusted or claim_detail.price_asked is higher than the price of the service. If it's the case, the final price of the claim becomes the price of the service.
  • On the other hand, if the service type is Fee-for-service bundle then the system checks all the sub-services of the claim to find out if the qty_provided of the sub-service is indeed equal to the qty_displayed of the claimserviceservice or if the qty_provided of the sub-item is indeed equal to the qty_displayed of the claimserviceitem. If all are not equal then the final price of the claim will be 0.
  • Also, if this parameter is False, then during the review, the quantities of the sub-services and sub-items will be recalculated, as well as the price_adjusted of the claim.

openIMIS Modules Dependencies

• core.models.VersionedModel
• core.models.InteractiveUser
• claim_batch.models.BatchRun
• insuree.models.Insuree
• location.models.HealthFacility
• medical.models.Diagnosis
• medical.models.Item
• medical.models.Service
• policy.models.Policy
• product.models.Product
• report.services.ReportService

price per stage

remunerated* is not a real claim status CHECKED and reviewed is not a different status that CHECKED

claim Stage	elm latest qty	elm latest price	claim value
SAVED	qty_provided	price_asked	x
CHECKED	qty_provided	price_adjusted	claimed
CHECKED and reviewed	qty_approved	price_approved	approved
PROCESSED	qty_approved	price_valuated	approved
VALUATED	qty_approved	price_valuated	valuated
remunerated*	x	remunerated_amount	remunerated

process steps

SAVED --Submit--> CHECKED --process--> PROCESSED --batch run--> VALUATED --payment--> remunerated*