EHIS & CBHI Health Insurance Claims Processing

1. Overview & Business Value#

This comprehensive operational guide details the architecture, business workflows, configuration parameters, and execution steps for EHIS & CBHI Health Insurance Claims Processing within SmartERP.

Manage Ethiopian Health Insurance Service (EHIS) eligibility, Community-Based Health Insurance (CBHI) tariffs, and electronic claims batching.

{screenshot:ehis-cbhi-health-insurance-claims-overview-dashboard}

2. Prerequisites & Security Access Groups#

• Required Modules: smarterp_healthcare, smarterp_clinical_core, smarterp_pharmacy
• Security Groups:
  • Healthcare Receptionist (Technical ID: smarterp_healthcare.group_medical_receptionist)
  • Physician / Attending Doctor (Technical ID: smarterp_healthcare.group_medical_doctor)
  • Pharmacy Dispenser (Technical ID: smarterp_healthcare.group_medical_pharmacist)
• Master Data Dependencies: Patient master registry (Medical Record Number - MRN), EFDA drug formulary, Ethiopian Ministry of Health (MoH) HMIS disease codes, and EHIS insurance tariffs.

3. Step-by-Step Configuration & Execution#

Step 1: Navigating to the Module Interface#

1. Log into your SmartERP instance at https://smarterp.et/odoo.
2. Open the main App Switcher (grid icon in the top-left corner).
3. Select the Healthcare app icon.
4. From the top navigation bar, open Healthcare → Clinical Dashboard → OPD Triage / Inpatient ADT / EMR / Pharmacy Dispensing.

{screenshot:ehis-cbhi-health-insurance-claims-app-switcher-navigation}

Step 2: Creating and Parameterizing Records#

1. Click the New button in the top-left control panel.
2. Complete the mandatory fields in the record form:
   • Medical Record Number (MRN) (Mandatory): Unique national health identifier or generated hospital record code
   • Patient Demographics (Mandatory): Full legal name, gender, date of birth, and Kebele residential location
   • Encounter Type (Mandatory): Outpatient (OPD), Inpatient (IPD), Emergency, or Triage consultation
   • Attending Physician (Mandatory): Licensed healthcare practitioner responsible for clinical encounter
3. Configure optional operational parameters and localized tags as required:
   • Insurance Provider & Policy (Optional): EHIS CBHI/SHI policy or corporate credit contract
   • Triage Vital Signs (Optional): Blood pressure, pulse rate, respiratory rate, temperature, and SpO2
   • ICD-11 / HMIS Diagnosis Code (Optional): Standardized diagnosis category for statutory health reporting
4. Click the Save icon in the control bar to commit the record.

{screenshot:ehis-cbhi-health-insurance-claims-record-creation-form}

Step 3: Validating and Processing Transactions#

• State Transitions: Execute operational state progression (Reception / Triage → Consultation → Lab / Radiology → Prescription → Billing / Discharge).
• Ledger & System Impact: Patient billing registers medical service revenue, debits patient or insurance accounts receivable, and debits pharmaceutical inventory upon prescription dispensing.
• Audit Verification: Automated recording of author ID, timestamp, and immutable revision history.

{screenshot:ehis-cbhi-health-insurance-claims-transaction-processing-state}

EHIS & CBHI Regulatory Framework#

The Ethiopian Health Insurance Service (EHIS) administers social health risk pooling across urban and rural communities. Healthcare facilities contract with Woreda CBHI schemes to deliver outpatient and inpatient medical care reimbursed against standardized national tariffs.

The claims lifecycle proceeds through defined verification and settlement gates:

[health-ehis-cbhi-claim-flow]

Member Verification at Reception#

1. When a CBHI beneficiary arrives, open Healthcare > Registration > Insurance Check.
2. Enter the CBHI Member Identification Number and scan the beneficiary Kebele passbook.
3. Validate scheme parameters:
   • Woreda of registration (e.g., Gulele Woreda 04 CBHI Scheme).
   • Renewal validity stamp (confirm membership is current for the fiscal year).
   • Beneficiary relationship (Principal Member, Spouse, Dependent Child).
4. The system flags the visit encounter as EHIS-CBHI Billing.

Tariff Mapping & Standardized Coding#

SmartERP automatically links all ordered services and medications to the official EHIS reimbursement tariff schedule:

• Consultation rates fixed by hospital tier (Primary, General, Referral).
• Lab tests and imaging billed according to national ceiling tariffs.
• Generic pharmaceuticals priced according to the EPSS standard supply price list plus allowed institutional handling markups.
• Any non-covered elective service is isolated onto an out-of-pocket patient co-pay invoice.

Generating Electronic Claim Batches#

At month-end:

1. Navigate to Healthcare > Insurance > Claim Batches and click New Batch.
2. Select Payer: Ethiopian Health Insurance Service - Addis Ababa Branch.
3. Set period: First Day to Last Day of Month.
4. Click Aggregate Unbilled Claims:
   • The system compiles all eligible encounters, clinical diagnosis codes, itemized service lines, and signed electronic doctor order proofs.
5. Run the Automated Claims Auditor:
   • Validates missing diagnosis codes, invalid CBHI numbers, or unlinked service items.
6. Click Generate EHIS Claim Submission File.
7. Export the standardized electronic XML / Excel schedule for submission to the Woreda Health Office.

Claims Reconciliation and Remittance#

Upon receiving the bank remittance advice from EHIS:

1. Open the submitted Claim Batch.
2. Enter the received bank payment reference and amount.
3. Reconcile accepted items and flag disallowed deductions (e.g., documentation queries).
4. Disallowed amounts can be disputed via formal resubmission within 30 days.

4. Advanced Configuration Points#

• Automated Actions & Scheduled Tasks (Crons):
  • Healthcare: Generate daily MoH HMIS aggregate tally (smarterp_healthcare.ir_cron_hmis_sync): Runs daily at 23:00 to prepare DHIS2 health data summaries
  • Pharmacy: Flag expiring EFDA medicine batches (smarterp_healthcare.ir_cron_fefo_expiry): Runs daily at 06:00 to alert dispensers of lots expiring within 60 days
• Custom Print Templates & Reports:
  • Official Patient Encounter Summary & Medical Certificate
  • Electronic Prescription Order Form (Model 19 Compliant)
  • Ethiopian Health Insurance Service (EHIS) Claim Dossier
  • Daily MoH Outpatient / Inpatient Morbidity Tally Sheet
• Multi-Company Rules: Record-level security isolation under Company 1 (Ashewa Technology Solutions S.C.), preventing cross-company ledger leakage across parent and subsidiary legal entities.

5. Comprehensive Troubleshooting Matrix#