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.
The detail view carries a Payer panel: print the claim form, download the claim file (FHIR R4 for HIB, JSON for SSF), and transmit to the payer — so you no longer have to go back to the list to send a claim you are already looking at.
Government funds¶
Three government payers are seeded for every tenant:
| Scheme | Type | Settlement |
|---|---|---|
| HIB — Health Insurance Board | GOVT_HIB |
FHIR R4 claim, API once provisioned |
| SSF — Social Security Fund | GOVT_SSF |
JSON claim, API once provisioned |
| BNK — Bipanna Nagarik Kosh | GOVT_BNK |
Offline only — printed claim form |
Bipanna Nagarik Kosh is the DoHS treatment fund for economically vulnerable citizens. Entitlement is certificate‑based, not contribution‑based: enrol the patient with the government eligibility certificate or referral number as the member number, the certificate's validity as the policy window, and the sanctioned ceiling as the credit limit. DoHS publishes no claim API, so the fund stays un‑wired — Print claim form, submit it with the supporting bill and certificate, then record the reimbursement against the claim reference when it arrives. Everything else (eligibility gate, co‑pay split, credit consumption, partial settlement, GL posting) behaves exactly as it does for HIB and SSF.
HIB and SSF wire formats are not yet verified
Both integrations are built mock‑first. Neither payer has published an integration document we have been able to verify against, so the claim field sets, URL conventions, and auth are inferred. Leave API enabled off until the payer's own spec has been reconciled against the code.
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.