Bridge HMS Suite · health
Insurance & Claims
$0.25 per user/moScheme rules, pre-authorisation, claim batching and revenue-cycle follow-up.
Works with
Billing & Cashiering
Billing & Cashiering01
Pre-Authorization
Dedicated hms.insurance.preauth model with auto-numbered reference (PA/YEAR/nnnnnn sequence) for every insurer authorization request.
Service-Type ClassificationTags each request as consultation, lab, imaging, surgery, admission, chemotherapy, dialysis, maternity or other.
Clinical Justification CaptureMandatory free-text medical-necessity justification enforced before a pre-auth can be submitted.
ICD-10 & Procedure CodingAttach multiple ICD-10 diagnoses and insurance procedure codes to substantiate the request.
Supporting Document AttachmentsUpload any number of supporting files to the pre-auth via a many2many binary widget.
Estimated Amount & CurrencyRecords an estimated cost with per-company currency and constrains it to be non-negative.
02
Claims Lifecycle
hms.insurance.claim model with auto-numbered claim number (CLAIM/YEAR/nnnnnn) unique per company.
Auto-Creation from BillingOverrides hms.bill.action_invoice to auto-create a draft claim whenever an invoiced bill carries a policy and insurance amount.
Automatic Charge PullPulls every non-canceled charge with an insurance share onto the claim and derives service date-from/to from them.
11-State Claim LifecycleDraft, submitted, in-review, approved, partially approved, rejected, paid, partially paid, appealed, closed and canceled with enforced transitions.
Filing-Deadline EnforcementBlocks submission of claims past the scheme's filing-deadline window and prompts recording a past-filing rejection instead.
Full & Partial ApprovalApprove in full or record a partial approval that must be strictly between zero and the claimed amount.
03
Appeals
hms.insurance.appeal model with auto-numbered reference (APP/YEAR/nnnnnn) cascade-linked to the source claim.
Appeal from RejectionLaunches an appeal wizard directly from rejected or partially-approved claims, pre-filling claim and date.
8-State Appeal WorkflowDraft, submitted, under review, upheld, overturned, partially overturned, final rejection and withdrawn states.
New-Documentation AttachmentsAttach fresh supporting documents specific to the appeal submission.
Decision Drives Claim StateUpheld reverts the claim to rejected, overturned re-approves it, partial overturn sets partially approved with a revised amount, final rejection closes it.
Revised Approved AmountCaptures the insurer's revised approved figure and writes it back to the claim on overturn.
04
Batches & Submission Channels
hms.insurance.claim.batch model grouping claims per scheme/facility/period with a BATCH/year/month/seq number.
Six Submission ChannelsPaper form, e-mail PDF, NHIF API, SHA/SHIF API, corporate API and payer portal transport options.
Auto-Attach to BatchOn submission, claims auto-attach to (or create) a draft monthly batch when the scheme has auto-submit-batched enabled.
Batch PDF GenerationRenders a batch cover PDF via QWeb report and stores it as an attachment on the batch.
E-mail PDF SubmissionEmails the batch PDF to the scheme's claims-inbox address with an auto-composed cover letter.
Batch Totals RollupStored computed claim count and total claimed/approved/paid aggregated across batch claims.
05
Payment Reconciliation
hms.insurance.reconciliation model (REC/YEAR/nnnnnn) capturing an insurer payment statement per scheme and date.
Statement Line ItemsLine model holding each payment reference, statement amount and matched claim/amount.
Auto-Match EngineMatches unlinked statement lines to open claims by payment reference and scheme, capping the matched amount at approved/claimed.
Matched vs Unmatched TotalsStored computed matched total and remaining unmatched balance against the statement's total paid.
Post to ClaimsPosting a fully-matched statement writes matched amounts to claims, sets payment-advice ref and marks each paid.
Post-GuardBlocks posting until every statement line is matched to a claim, and prevents canceling posted reconciliations.
06
Insurer API Integration
Transport-safe hms.sha.api.client abstract model with configurable base URL, client-id and secret per scheme for sandbox/UAT/production.
Pre-Auth API SubmissionPosts pre-auth payloads (member, service type, ICD-10, procedures, justification) and stores the returned insurer reference.
Claim & Batch API SubmissionSubmits individual claims and whole batches over REST and captures the insurer's reference number.
Retry & Timeout HandlingHTTP calls retry once on transport errors with a 30-second timeout and surface unrecoverable failures as user errors.
Offline Simulation ModeWhen the requests library is absent, returns deterministic stub responses so offline staging and tests still succeed.
Claim Status Pollingquery_claim_status and sync_open_claims refresh open claims from the insurer, auto-approving or rejecting based on returned status.
07
Configuration & Catalogs
Extends insurance schemes with claim channel, API base URL, client-id/secret, API key and claims-inbox e-mail.
Filing & TAT ParametersPer-scheme filing-deadline days, average payment turnaround days and historical approval-rate percentage.
Pre-Auth ThresholdConfigurable monetary threshold above which pre-authorization becomes mandatory for a scheme.
Preferred Coding SystemPer-scheme choice of ICD-10 WHO, NHIF catalog, CPT, SNOMED-CT or SHA/SHIF catalog.
Scheme Claim CountersComputed claim and paid-claim counts per scheme with an Open Claims button.
Procedure Code Cataloghms.insurance.procedure.code master with code, description, category, coding system, indicative price and long description.
08
Cross-Module Integration
Adds claim list, claim count and a pending-claim flag to hospital bills with a smart button to view claims.
Patient Claim DashboardAdds patient-level counts of submitted, paid and pending claims plus total claimed and insurer-paid amounts with view buttons.
Visit Pre-Auth RequirementComputes preauth_required on visits from scheme rules and inpatient type, with pre-auth count and view button.
Visit & Bill Claim NavigationContext-aware actions open claims/pre-auths pre-filled with the visit's or bill's patient, policy and facility.
Integrated apps
Insurance & Claims shares one database with the rest of BridgeERP — these are the apps it already talks to, with nothing to buy in between.
Builds on
Insurance & Claims needs these to run — they come with it in the same plan.
And the wider platform
Any BridgeERP app can join the same database.
AccountingFull double-entry accounting, bank reconciliation, assets, budgets and statutory reports.
ExpensesEmployee expense claims with receipt capture and reimbursement.
InvoicingCustomer invoices, vendor bills, payments and tax handling.
SignSend documents for legally binding electronic signature.
SubscriptionsRecurring contracts, automatic renewals and MRR reporting.
EmployeesEmployee records, contracts, attendance, skills, appraisals and referrals.More Bridge HMS Suite apps
HMS CorePatient master index, facility setup, clinicians, encounters and role security.
ReceptionRegistration, queueing, triage desk and visit slips.
AppointmentsClinician diaries, online booking and reminders.
Consultation / OPDOutpatient consultation, SOAP notes, orders, prescriptions and visit summaries.
Electronic Health RecordLongitudinal record, problem lists, allergies, care plans and clinical decision support.
LaboratoryTest catalogue, sample tracking, analysers, result validation and reporting.From front desk to discharge, on one system
One patient record across reception, clinics, wards, theatre, lab, pharmacy and the cash office — with billing and insurance claims built in.