Patient Access KPIs & Reporting

KPI Summary

KPI ID	KPI Name	Formula (Conceptual)	Target	Data Source	Frequency
KPI-PAC-001	Eligibility Verification Rate	`encounters with eligibility_verified_before_service / total_encounters × 100`	≥ 98%	`eligibility_checks`, `eligibility_responses`, `encounters`	Daily / Monthly
KPI-PAC-002	Prior Auth Approval Rate	`approved prior_authorizations / total prior_auth_requests × 100`	≥ 85%	`prior_authorizations`, `prior_auth_requests`	Weekly / Monthly
KPI-PAC-003	Prior Auth Turnaround Time	`AVG(approved_date - requested_date)`	≤ 3 business days	`prior_authorizations`, `prior_auth_requests`	Weekly / Monthly
KPI-PAC-004	Pre-Registration Completion Rate	`appointments with pre_registration_complete / total_scheduled_appointments × 100`	≥ 70%	`pre_registration_records`, `appointments`	Daily / Weekly
KPI-PAC-005	Cost Estimate Accuracy	`AVG(ABS(actual_patient_responsibility - estimated_patient_responsibility) / actual_patient_responsibility) × 100`	Within 20% variance	`cost_estimates`, billing `patient_invoices` (external)	Monthly
KPI-PAC-006	Authorization-Related Denial Rate	`claims denied for no_auth / total_claims × 100`	≤ 2%	`billing_claims`, `claim_responses`, `prior_authorizations`	Monthly
KPI-PAC-007	Referral Completion Rate	`referrals where patient_attended / total_referrals × 100`	≥ 75%	`referrals`, `appointments`, `encounters`	Monthly
KPI-PAC-008	Financial Clearance Rate	`encounters financially_cleared_before_service / total_encounters × 100`	≥ 90%	`eligibility_checks`, `prior_authorizations`, `pre_registration_records`, `encounters`	Daily / Monthly

Note: Some tables (e.g., billing_claims, patient_invoices) are owned by other RCM modules and referenced here conceptually; exact schemas are defined in their respective 03-data-specifications files.

KPI Definitions

KPI-PAC-001: Eligibility Verification Rate

Definition

Percentage of encounters for which insurance eligibility was successfully verified before the start of service. This measures front-end discipline in verifying coverage and is a key driver of reduced denials and patient complaints in UAE payer environments (DHA eClaimLink, DOH eClaims).

Calculation Formula

Assumptions:

encounters.encounter_id (from scheduling)
eligibility_checks.encounter_id (FK to encounters.encounter_id, nullable)
eligibility_checks.status IN ('success', 'failed', 'pending', …)
eligibility_checks.check_datetime
encounters.service_start_datetime

SQL

SELECT
    (COUNT(CASE
              WHEN ec.check_id IS NOT NULL
                   AND ec.status = 'success'
                   AND ec.check_datetime <= e.service_start_datetime
            THEN 1 END) * 100.0
     / NULLIF(COUNT(*), 0)) AS eligibility_verification_rate
FROM encounters e
LEFT JOIN eligibility_checks ec
       ON ec.encounter_id = e.encounter_id
      AND ec.check_datetime = (
            SELECT MAX(ec2.check_datetime)
            FROM eligibility_checks ec2
            WHERE ec2.encounter_id = e.encounter_id
      )
WHERE e.service_start_datetime >= :start_date
  AND e.service_start_datetime < :end_date;

Target / Benchmark

Metric	Target	Source / Rationale
Eligibility Verification Rate	≥ 98%	Internal RCM best practice; aligned with DOH/DHA focus on reducing technical denials

Data Source

encounters.encounter_id, encounters.service_start_datetime, encounters.facility_id, encounters.department_id, encounters.provider_id
eligibility_checks.check_id, eligibility_checks.encounter_id, eligibility_checks.payer_id, eligibility_checks.plan_id, eligibility_checks.check_datetime, eligibility_checks.status

Dimensions / Filters

Time: day, week, month, quarter, year
Facility: encounters.facility_id
Department / clinic: encounters.department_id
Provider: encounters.provider_id
Payer: eligibility_checks.payer_id
Visit type: outpatient / inpatient / day surgery (from encounter_details)

Visualization

Primary: Line chart (monthly trend) with 98% target line.
Drill-down: Bar chart by department and payer.
Detail: Table of encounters without successful eligibility before service.

Alert Thresholds

Warning: < 98% for any facility-month.
Critical: < 95% for any facility-month or < 90% for any department-month.
Notifications:
Registration Supervisor (facility-level warnings)
Patient Access Manager and RCM Director (critical)
Automated worklist of encounters without eligibility for same-day follow-up.

KPI-PAC-002: Prior Auth Approval Rate

Definition

Percentage of prior authorization requests that are approved by payers (DHA, DOH, and private payers). Indicates effectiveness of documentation and adherence to payer rules.

Calculation Formula

Assumptions:

prior_authorizations.auth_id
prior_authorizations.auth_status ('approved', 'denied', 'pending', 'cancelled', …)
prior_auth_requests.request_id, prior_auth_requests.auth_id (multiple submissions per auth possible)
We count unique auth_id as a “request episode”.

SQL

SELECT
    (COUNT(CASE WHEN pa.auth_status = 'approved' THEN 1 END) * 100.0
     / NULLIF(COUNT(*), 0)) AS prior_auth_approval_rate
FROM prior_authorizations pa
WHERE pa.requested_date >= :start_date
  AND pa.requested_date < :end_date;

Optionally, to restrict denominator to completed decisions:

SQL

AND pa.auth_status IN ('approved', 'denied')

Target / Benchmark

Metric	Target	Source / Rationale
Prior Auth Approval Rate	≥ 85%	Internal RCM benchmark; aligns with UAE payer expectations for well-documented auths

Data Source

prior_authorizations.auth_id, patient_id, encounter_id, payer_id, auth_status, requested_date, approved_date, denied_date, service_codes, icd10_codes
prior_auth_requests.request_id, auth_id, submission_datetime, submission_channel, payer_response, response_datetime

Dimensions / Filters

Time: by requested_date or approved_date
Facility / department (via encounters)
Requesting provider: prior_authorizations.requesting_provider_id
Payer: prior_authorizations.payer_id
Service category (derived from service_codes / authorization service master)
Submission channel: prior_auth_requests.submission_channel (eClaimLink, DOH eClaims, portal, fax)

Visualization

Primary: Bar chart by payer (approval rate).
Trend: Line chart (monthly approval rate).
Drill-down: Stacked bar (approved vs denied vs pending) by service category.

Alert Thresholds

Warning: Approval rate < 80% for any payer-month.
Critical: Approval rate < 70% overall or for a top-5 payer.
Notifications:
Authorization Specialist team lead (payer-specific warnings)
Patient Access Manager and Medical Director (critical, for clinical documentation review).

KPI-PAC-003: Prior Auth Turnaround Time

Definition

Average time from initial prior authorization request submission to final approval. Measures operational efficiency and payer responsiveness; critical for scheduling elective procedures.

Calculation Formula

Assumptions:

Use prior_authorizations.requested_date and approved_date.
Only include records with auth_status = 'approved' and both timestamps populated.

SQL

SELECT
    AVG(TIMESTAMPDIFF(HOUR, pa.requested_date, pa.approved_date)) AS avg_auth_tat_hours
FROM prior_authorizations pa
WHERE pa.auth_status = 'approved'
  AND pa.requested_date >= :start_date
  AND pa.requested_date < :end_date;

To express in business days (8-hour days):

SQL

SELECT
    AVG(TIMESTAMPDIFF(HOUR, pa.requested_date, pa.approved_date) / 8.0) AS avg_auth_tat_business_days
FROM prior_authorizations pa
WHERE pa.auth_status = 'approved'
  AND pa.requested_date >= :start_date
  AND pa.requested_date < :end_date;

Target / Benchmark

Metric	Target	Source / Rationale
Avg Prior Auth TAT	≤ 3 business days	Internal SLA; aligned with UAE payer service expectations

Data Source

prior_authorizations.auth_id, payer_id, auth_status, requested_date, approved_date
Optional: prior_auth_requests.submission_datetime, response_datetime for more granular TAT stages.

Dimensions / Filters

Time: by requested_date
Facility / department (via encounters)
Payer
Service category (e.g., imaging, surgery, physiotherapy)
Submission channel

Visualization

Primary: Line chart of average TAT (business days) by month, with 3-day target line.
Secondary: Box-and-whisker plot by payer.
Detail: Table of outliers (e.g., TAT > 7 business days).

Alert Thresholds

Warning: Average TAT > 3 business days for any payer-month.
Critical: Average TAT > 5 business days overall or > 7 days for high-volume services.
Notifications:
Authorization Supervisor (warnings)
Patient Access Manager and Contracting team (critical, for payer escalation).

KPI-PAC-004: Pre-Registration Completion Rate

Definition

Percentage of scheduled appointments for which pre-registration (demographics, insurance, consents) is completed before the day of service. Supports smoother check-in and better financial clearance.

Calculation Formula

Assumptions:

pre_registration_records.prereg_id, appointment_id, status, completed_datetime
pre_registration_records.status values: 'completed', 'in_progress', 'not_started', 'cancelled'
appointments.appointment_id, appointments.scheduled_start_datetime

SQL

SELECT
    (COUNT(CASE
              WHEN pr.status = 'completed'
                   AND pr.completed_datetime < a.scheduled_start_datetime
            THEN 1 END) * 100.0
     / NULLIF(COUNT(*), 0)) AS pre_registration_completion_rate
FROM appointments a
LEFT JOIN pre_registration_records pr
       ON pr.appointment_id = a.appointment_id
WHERE a.scheduled_start_datetime >= :start_date
  AND a.scheduled_start_datetime < :end_date
  AND a.status NOT IN ('cancelled', 'no_show');

Target / Benchmark

Metric	Target	Source / Rationale
Pre-Registration Completion Rate	≥ 70%	Internal operational target for UAE outpatient workflows

Data Source

appointments.appointment_id, scheduled_start_datetime, status, facility_id, department_id, provider_id, visit_type
pre_registration_records.prereg_id, appointment_id, completed_datetime, status, demographics_complete, insurance_verified, auth_verified, consent_obtained

Dimensions / Filters

Time: by appointment date
Facility / department
Provider
Visit type (e.g., new patient, follow-up, procedure)
Channel: portal vs phone vs onsite (if tracked via pre_registration_records.request_source)

Visualization

Primary: Line chart (weekly trend) with target line.
Drill-down: Bar chart by department and visit type.
Detail: Worklist-style table of upcoming appointments with incomplete pre-registration.

Alert Thresholds

Warning: Rate < 70% for any department-week.
Critical: Rate < 60% overall or < 50% for high-revenue service lines (e.g., surgery).
Notifications:
Registration Supervisor (department-level warnings)
Patient Access Manager (critical).

KPI-PAC-005: Cost Estimate Accuracy

Definition

Average percentage variance between estimated and actual patient responsibility for services, for encounters where both an estimate and final bill exist. Measures quality of cost estimation and transparency to patients.

Calculation Formula

Assumptions:

cost_estimates.estimate_id, encounter_id, estimated_patient_responsibility
Billing module table patient_invoices (or equivalent) with encounter_id, actual_patient_responsibility
Exclude cases where actual_patient_responsibility = 0 to avoid division by zero.

SQL

SELECT
    AVG(
        ABS(pi.actual_patient_responsibility - ce.estimated_patient_responsibility)
        / NULLIF(pi.actual_patient_responsibility, 0)
    ) * 100.0 AS avg_cost_estimate_variance_pct
FROM cost_estimates ce
JOIN patient_invoices pi
     ON pi.encounter_id = ce.encounter_id
WHERE ce.estimate_datetime >= :start_date
  AND ce.estimate_datetime < :end_date
  AND ce.acknowledged_by_patient = TRUE;

Target / Benchmark

Metric	Target	Source / Rationale
Avg variance	Within 20%	Internal RCM target; supports UAE patient transparency goals
High variance outliers	< 10% of cases > 30%	Internal quality objective

Data Source

cost_estimates.estimate_id, encounter_id, payer_id, estimated_patient_responsibility, estimate_datetime, acknowledged_by_patient
Billing: patient_invoices.encounter_id, actual_patient_responsibility, invoice_date

Dimensions / Filters

Time: by estimate date or invoice date
Facility / department
Payer / plan
Service category (from planned_cpt_codes)
Self-pay vs insured

Visualization

Primary: Line chart of average variance (%) by month.
Secondary: Histogram of variance distribution.
Detail: Table of high-variance cases (>30%) for review.

Alert Thresholds

Warning: Average variance > 20% in any month.
Critical: Average variance > 30% or > 10% of cases with variance > 50%.
Notifications:
Financial Counseling Manager and Patient Access Manager.
Finance Director for persistent critical deviations.

Definition

Percentage of claims denied due to missing, invalid, or expired prior authorization. This is a key technical denial metric and directly linked to Patient Access performance.

Calculation Formula

Assumptions:

billing_claims.claim_id, encounter_id, payer_id
claim_responses.claim_id, denial_reason_code
Denial reason 'no_auth' (or mapped codes from DHA eClaimLink / DOH eClaims).

SQL

SELECT
    (COUNT(CASE
              WHEN cr.denial_reason_code = 'no_auth'
            THEN 1 END) * 100.0
     / NULLIF(COUNT(*), 0)) AS auth_related_denial_rate
FROM billing_claims bc
JOIN claim_responses cr
     ON cr.claim_id = bc.claim_id
WHERE bc.submission_date >= :start_date
  AND bc.submission_date < :end_date;

Optionally restrict denominator to denied claims only or all submitted claims depending on organizational definition. Above uses all claims with a response.

Target / Benchmark

Metric	Target	Source / Rationale
Authorization-Related Denial Rate	≤ 2%	Internal RCM best practice; aligned with UAE payer expectations

Data Source

billing_claims.claim_id, encounter_id, payer_id, submission_date
claim_responses.claim_id, denial_reason_code, response_date
prior_authorizations.encounter_id, auth_status, valid_from, valid_to

Dimensions / Filters

Time: by claim submission date
Facility / department (via encounters)
Payer
Service category
Presence of prior auth (join to prior_authorizations)

Visualization

Primary: Line chart (monthly denial rate) with 2% target line.
Secondary: Bar chart by payer and department.
Detail: Table of denied claims with missing/invalid auth details.

Alert Thresholds

Warning: > 2% for any payer-month.
Critical: > 5% overall or for a top-3 payer.
Notifications:
Patient Access Manager, Billing Manager.
Contracting / Policy & Contract Management team for payer-specific issues.

KPI-PAC-007: Referral Completion Rate

Definition

Percentage of referrals that result in at least one attended appointment. Measures effectiveness of referral coordination and patient follow-through.

Calculation Formula

Assumptions:

referrals.referral_id, patient_id, status ('active', 'completed', 'expired', 'cancelled'), valid_from, valid_to
appointments.appointment_id, patient_id, referral_id (FK, if available), status ('attended', 'no_show', 'cancelled')
If referral_id not stored on appointment, join by patient and specialist provider within validity window.

SQL

SELECT
    (COUNT(DISTINCT CASE
                       WHEN EXISTS (
                           SELECT 1
                           FROM appointments a
                           WHERE a.referral_id = r.referral_id
                             AND a.status = 'attended'
                       )
                    THEN r.referral_id END) * 100.0
     / NULLIF(COUNT(DISTINCT r.referral_id), 0)) AS referral_completion_rate
FROM referrals r
WHERE r.valid_from >= :start_date
  AND r.valid_from < :end_date;

Target / Benchmark

Metric	Target	Source / Rationale
Referral Completion Rate	≥ 75%	Internal care coordination benchmark

Data Source

referrals.referral_id, patient_id, referring_provider_id, specialist_provider_id, payer_id, service_type, authorized_visits, used_visits, valid_from, valid_to, status
appointments.appointment_id, patient_id, referral_id, specialist_provider_id, scheduled_start_datetime, status

Dimensions / Filters

Time: by referral creation or validity start
Referring provider / clinic
Specialist provider / department
Payer
Service type (e.g., cardiology, orthopedics)

Visualization

Primary: Bar chart by specialty (completion rate).
Trend: Line chart by month.
Detail: Table of referrals without attended visits, for follow-up.

Alert Thresholds

Warning: Completion rate < 75% for any specialty-quarter.
Critical: Completion rate < 60% overall or for high-priority specialties.
Notifications:
Referral Management team, Patient Access Manager.
Quality / Care Coordination leads for persistent issues.

KPI-PAC-008: Financial Clearance Rate

Definition

Percentage of encounters that are fully financially cleared (eligibility verified, required prior auth/referral obtained, and financial arrangements in place if needed) before service start. This is the primary composite KPI for Patient Access.

Calculation Formula

Assumptions:

encounters.encounter_id, service_start_datetime
Derived flag encounters.financially_cleared_before_service or computed via joins:
Successful eligibility check before service.
No required prior auth/referral missing.
For self-pay/high OOP, financial counseling completed (optional).

If a boolean field exists:

SQL

SELECT
    (COUNT(CASE
              WHEN e.financially_cleared_before_service = TRUE
            THEN 1 END) * 100.0
     / NULLIF(COUNT(*), 0)) AS financial_clearance_rate
FROM encounters e
WHERE e.service_start_datetime >= :start_date
  AND e.service_start_datetime < :end_date;

If computed on the fly (simplified):

SQL

SELECT
    (COUNT(CASE
              WHEN ec.check_id IS NOT NULL
                   AND ec.status = 'success'
                   AND ec.check_datetime <= e.service_start_datetime
                   AND (pa_required = 0 OR (pa_required = 1 AND pa_ok = 1))
            THEN 1 END) * 100.0
     / NULLIF(COUNT(*), 0)) AS financial_clearance_rate
FROM encounters e
LEFT JOIN eligibility_checks ec
       ON ec.encounter_id = e.encounter_id
      AND ec.check_datetime = (
            SELECT MAX(ec2.check_datetime)
            FROM eligibility_checks ec2
            WHERE ec2.encounter_id = e.encounter_id
      )
-- pa_required / pa_ok derived via join to coverage rules and prior_authorizations
WHERE e.service_start_datetime >= :start_date
  AND e.service_start_datetime < :end_date;

(Implementation should materialize a financially_cleared_before_service flag during pre-registration/check-in to avoid complex runtime logic.)

Target / Benchmark

Metric	Target	Source / Rationale
Financial Clearance Rate	≥ 90%	Internal RCM target; supports low denial rates and patient satisfaction

Data Source

encounters.encounter_id, service_start_datetime, facility_id, department_id, provider_id, financially_cleared_before_service (if implemented)
eligibility_checks, prior_authorizations, referrals, pre_registration_records, financial_counseling_records (for underlying logic)

Dimensions / Filters

Time: by service date
Facility / department
Provider
Payer / plan
Visit type (elective vs emergency)

Visualization

Primary: Gauge chart (current month) with 90% target.
Trend: Line chart by month.
Drill-down: Bar chart by department and payer.

Alert Thresholds

Warning: < 90% for any facility-month.
Critical: < 85% overall or < 80% for elective procedures.
Notifications:
Patient Access Manager, RCM Director.
Department heads for underperforming areas.

Standard Reports

Report ID	Report Name	Purpose	Audience	Frequency	Format
RPT-PAC-001	Patient Access KPI Dashboard	Real-time view of key KPIs (eligibility, auth, pre-reg, clearance)	Patient Access Manager, RCM Leadership	Real-time / Daily	Interactive dashboard (HTML)
RPT-PAC-002	Eligibility Verification Exception Report	List encounters without successful eligibility before service for follow-up	Registration Supervisors, Billing	Daily	HTML + CSV/Excel export
RPT-PAC-003	Prior Authorization Performance by Payer	Monitor auth approval rates and TAT by payer and service line	Authorization Team, Contracting	Weekly / Monthly	PDF + Excel
RPT-PAC-004	Pre-Registration Worklist & Completion	Track upcoming appointments with pre-registration status and completion rates	Registration Clerks, Supervisors	Daily	Interactive + Excel
RPT-PAC-005	Cost Estimate Accuracy Analysis	Compare estimates vs actuals, identify high-variance cases	Financial Counselors, Finance	Monthly	PDF + Excel
RPT-PAC-006	Authorization-Related Denials Summary	Analyze denials due to missing/invalid auth by payer, department, and provider	Billing, Patient Access Manager	Monthly	PDF + Excel
RPT-PAC-007	Referral Utilization & Completion	Monitor referral completion and utilization of authorized visits	Referral Coordinators, Clinical Leads	Monthly	HTML + Excel
RPT-PAC-008	Financial Clearance Compliance by Department	Track financial clearance rate and drivers (eligibility, auth, counseling) per department	Patient Access Manager, Department Heads	Monthly	Dashboard + PDF snapshot
RPT-PAC-009	UAE Payer Connectivity & Error Log	Monitor eClaimLink/DOH eClaims connectivity, error codes, and retry outcomes	IT / RCM Integration Team	Weekly / On-demand	HTML + CSV
RPT-PAC-010	PDPL Access & Audit Log (Patient Access)	Provide audit trail of access to financial/insurance data for PDPL compliance	DPO, Compliance Officer	On-demand / Quarterly	PDF + CSV

Dashboard Wireframe

The following HTML mockup represents the Patient Access Analytics dashboard (aligned with screen SCR-PAC-008).

Show HTML code

HTML

<!DOCTYPE html>
<html lang="en">
<head>
  <meta charset="UTF-8">
  <title>Patient Access Analytics Dashboard</title>
</head>
<body style="font-family: Arial, sans-serif; margin: 0; padding: 0; background:#f5f5f5;">
  <header style="background:#004c97; color:#fff; padding:12px 20px;">
    <h1 style="margin:0; font-size:20px;">Patient Access Analytics</h1>
    <div style="margin-top:6px; font-size:12px;">
      <span>Facility:</span>
      <select style="margin-right:10px;">
        <option>All Facilities</option>
        <option>Dubai General Hospital</option>
        <option>Abu Dhabi Medical Center</option>
      </select>
      <span>Period:</span>
      <select style="margin-right:10px;">
        <option>This Month</option>
        <option>Last Month</option>
        <option>Last 3 Months</option>
        <option>Custom...</option>
      </select>
      <span>Payer:</span>
      <select>
        <option>All Payers</option>
        <option>Daman</option>
        <option>THIQA</option>
        <option>Oman Insurance</option>
      </select>
    </div>
  </header>

  <main style="padding:15px;">
    <!-- KPI cards row -->
    <section style="display:flex; gap:10px; margin-bottom:15px;">
      <div style="flex:1; background:#fff; padding:10px; border-radius:4px; border-top:3px solid #2e7d32;">
        <div style="font-size:12px; color:#666;">Eligibility Verification Rate</div>
        <div style="font-size:24px; font-weight:bold;">98.6%</div>
        <div style="font-size:11px; color:#2e7d32;">Target ≥ 98%</div>
      </div>
      <div style="flex:1; background:#fff; padding:10px; border-radius:4px; border-top:3px solid #1976d2;">
        <div style="font-size:12px; color:#666;">Financial Clearance Rate</div>
        <div style="font-size:24px; font-weight:bold;">91.3%</div>
        <div style="font-size:11px; color:#1976d2;">Target ≥ 90%</div>
      </div>
      <div style="flex:1; background:#fff; padding:10px; border-radius:4px; border-top:3px solid #f9a825;">
        <div style="font-size:12px; color:#666;">Prior Auth Approval Rate</div>
        <div style="font-size:24px; font-weight:bold;">83.9%</div>
        <div style="font-size:11px; color:#f57f17;">Target ≥ 85%</div>
      </div>
      <div style="flex:1; background:#fff; padding:10px; border-radius:4px; border-top:3px solid #c62828;">
        <div style="font-size:12px; color:#666;">Auth-Related Denial Rate</div>
        <div style="font-size:24px; font-weight:bold;">2.7%</div>
        <div style="font-size:11px; color:#c62828;">Target ≤ 2%</div>
      </div>
    </section>

    <!-- Charts row -->
    <section style="display:flex; gap:10px; margin-bottom:15px;">
      <div style="flex:2; background:#fff; padding:10px; border-radius:4px; min-height:220px;">
        <h2 style="margin:0 0 5px 0; font-size:14px;">Financial Clearance & Eligibility Trend</h2>
        <div style="font-size:11px; color:#666; margin-bottom:5px;">Monthly trend for last 12 months</div>
        <div style="border:1px dashed #ccc; height:170px; text-align:center; padding-top:70px; color:#999; font-size:12px;">
          Line chart placeholder (Financial Clearance %, Eligibility %, Targets)
        </div>
      </div>
      <div style="flex:1; background:#fff; padding:10px; border-radius:4px; min-height:220px;">
        <h2 style="margin:0 0 5px 0; font-size:14px;">Pre-Registration Completion by Department</h2>
        <div style="border:1px dashed #ccc; height:190px; text-align:center; padding-top:80px; color:#999; font-size:12px;">
          Bar chart placeholder (Departments vs Pre-Reg %)
        </div>
      </div>
    </section>

    <!-- Second charts row -->
    <section style="display:flex; gap:10px; margin-bottom:15px;">
      <div style="flex:1; background:#fff; padding:10px; border-radius:4px; min-height:220px;">
        <h2 style="margin:0 0 5px 0; font-size:14px;">Prior Auth TAT by Payer</h2>
        <div style="border:1px dashed #ccc; height:190px; text-align:center; padding-top:80px; color:#999; font-size:12px;">
          Box/column chart placeholder (Business days by payer)
        </div>
      </div>
      <div style="flex:1; background:#fff; padding:10px; border-radius:4px; min-height:220px;">
        <h2 style="margin:0 0 5px 0; font-size:14px;">Cost Estimate Accuracy Distribution</h2>
        <div style="border:1px dashed #ccc; height:190px; text-align:center; padding-top:80px; color:#999; font-size:12px;">
          Histogram placeholder (Variance buckets)
        </div>
      </div>
      <div style="flex:1; background:#fff; padding:10px; border-radius:4px; min-height:220px;">
        <h2 style="margin:0 0 5px 0; font-size:14px;">Referral Completion by Specialty</h2>
        <div style="border:1px dashed #ccc; height:190px; text-align:center; padding-top:80px; color:#999; font-size:12px;">
          Bar chart placeholder (Specialty vs Completion %)
        </div>
      </div>
    </section>

    <!-- Exceptions table -->
    <section style="background:#fff; padding:10px; border-radius:4px;">
      <div style="display:flex; justify-content:space-between; align-items:center;">
        <h2 style="margin:0; font-size:14px;">Exceptions Requiring Attention</h2>
        <button style="font-size:11px; padding:4px 8px;">Export CSV</button>
      </div>
      <table style="width:100%; border-collapse:collapse; margin-top:8px; font-size:11px;">
        <thead>
          <tr style="background:#eee;">
            <th style="border:1px solid #ddd; padding:4px;">Encounter ID</th>
            <th style="border:1px solid #ddd; padding:4px;">Patient</th>
            <th style="border:1px solid #ddd; padding:4px;">Service Date</th>
            <th style="border:1px solid #ddd; padding:4px;">Payer</th>
            <th style="border:1px solid #ddd; padding:4px;">Issue</th>
            <th style="border:1px solid #ddd; padding:4px;">Department</th>
            <th style="border:1px solid #ddd; padding:4px;">Owner</th>
          </tr>
        </thead>
        <tbody>
          <tr>
            <td style="border:1px solid #ddd; padding:4px;">ENC-2026-00123</td>
            <td style="border:1px solid #ddd; padding:4px;">Ahmed Al-Maktoum</td>
            <td style="border:1px solid #ddd; padding:4px;">07-Feb-2026</td>
            <td style="border:1px solid #ddd; padding:4px;">Daman</td>
            <td style="border:1px solid #ddd; padding:4px;">No eligibility check</td>
            <td style="border:1px solid #ddd; padding:4px;">Orthopedics</td>
            <td style="border:1px solid #ddd; padding:4px;">Registration</td>
          </tr>
          <tr>
            <td style="border:1px solid #ddd; padding:4px;">ENC-2026-00456</td>
            <td style="border:1px solid #ddd; padding:4px;">Fatima Al-Nahyan</td>
            <td style="border:1px solid #ddd; padding:4px;">06-Feb-2026</td>
            <td style="border:1px solid #ddd; padding:4px;">THIQA</td>
            <td style="border:1px solid #ddd; padding:4px;">Auth expired</td>
            <td style="border:1px solid #ddd; padding:4px;">Imaging</td>
            <td style="border:1px solid #ddd; padding:4px;">Auth Team</td>
          </tr>
        </tbody>
      </table>
    </section>
  </main>
</body>
</html>

Regulatory Reports

This section focuses on UAE-specific regulatory and compliance reporting related to Patient Access.

MOH (Ministry of Health and Prevention)

While MOH does not typically require module-specific Patient Access reports, the HIS must support:

Insurance & Coverage Statistics for Federal Facilities
Aggregated counts of insured vs self-pay encounters.
Breakdown by payer type (government vs private).
Fields: encounters.facility_id, eligibility_checks.payer_id, eligibility_responses.is_eligible.
Service Access & Equity Monitoring
Ability to report on financial counseling and charity care utilization:
- financial_counseling_records.counseling_type, patient_decision
- Link to billing discounts / charity write-offs (from billing module).

These reports should be exportable in CSV/Excel for MOH ad-hoc requests.

DOH (Abu Dhabi) – Malaffi / DOH eClaims Context

DOH eClaims Technical Denial Monitoring
Support extraction of authorization-related denial metrics by payer and service line for DOH eClaims submissions.
Fields: billing_claims.submission_channel = 'DOH_eClaims', claim_responses.denial_reason_code, prior_authorizations.auth_number.
Access & Utilization Statistics for DOH
Ability to provide:
- Pre-authorization rates for high-cost imaging and procedures.
- Referral patterns between providers in Abu Dhabi.
Aggregated by facility_id, department_id, payer_id.

DHA (Dubai) – NABIDH / eClaimLink Context

DHA eClaimLink Eligibility & Auth Performance
Reports on:
- Volume of eligibility checks via eClaimLink (eligibility_checks.request_source = 'DHA_eClaimLink').
- Error codes and response times from payers.
Used internally to ensure compliance with DHA eClaimLink standards and SLAs.
NABIDH Data Completeness Support
While NABIDH focuses on clinical data, Patient Access must ensure:
- Accurate patient identifiers and payer information are captured and available for NABIDH submissions.
Provide internal reports on missing Emirates ID, missing payer, or invalid coverage for Dubai facilities.

UAE PDPL (Federal Decree-Law No. 45/2021) – Data Protection

Patient Access handles sensitive personal and financial data; the HIS must support:

Access Audit Report (Patient Access Module) - Who accessed or modified:
- Insurance details
- Cost estimates
- Financial counseling records
- Fields (from shared audit log):
- audit_log.user_id, audit_log.action, audit_log.timestamp, audit_log.module = 'patient-access', audit_log.patient_id.
- Used for PDPL data subject access requests and internal audits.
Consent & Purpose-of-Use Reporting - Ability to show:
- When consent for sharing data with payers was obtained (pre_registration_records.consent_obtained, timestamp).
- Which payers received eligibility/auth data (via integration logs).
Data Minimization & Retention - Reports to support retention policy reviews:
- Age of eligibility_checks, eligibility_responses, cost_estimates, financial_counseling_records.
- Used to plan anonymization or deletion in line with PDPL and facility policy.

NABIDH / Malaffi Compliance Metrics

Although Patient Access is not the primary source of clinical data, it underpins identity and encounter integrity for HIEs:

Identity & Coverage Consistency Report
Percentage of encounters with:
- Valid Emirates ID format.
- Primary payer recorded.
Supports NABIDH/Malaffi data quality programs.
Encounter Registration Timeliness
Time from appointment start to encounter creation and financial clearance.
Ensures encounters are ready for timely HIE submission.

All regulatory-related reports must:

Support export in CSV and PDF.
Allow filtering by facility and emirate (e.g., Dubai vs Abu Dhabi).
Be restricted to users with appropriate compliance/PDPL permissions.

Ad-Hoc Reporting

Available Data Fields (Key Domains)

Ad-hoc reporting tools should expose, at minimum, the following fields (subject to role-based access and PDPL controls):

Eligibility & Coverage

eligibility_checks.check_id
eligibility_checks.patient_id
eligibility_checks.encounter_id
eligibility_checks.payer_id
eligibility_checks.plan_id
eligibility_checks.member_id
eligibility_checks.check_datetime
eligibility_checks.check_type (real-time, batch, pre-reg, DOS)
eligibility_checks.request_source (DHA eClaimLink, DOH eClaims, direct API, manual)
eligibility_checks.status (success, failed, pending)
eligibility_responses.response_id
eligibility_responses.check_id
eligibility_responses.is_eligible
eligibility_responses.effective_date
eligibility_responses.termination_date
eligibility_responses.copay_amount
eligibility_responses.copay_percentage
eligibility_responses.deductible_total
eligibility_responses.deductible_met
eligibility_responses.coinsurance
eligibility_responses.annual_max
eligibility_responses.annual_max_remaining
eligibility_responses.payer_response_code

Prior Authorizations

prior_authorizations.auth_id
prior_authorizations.patient_id
prior_authorizations.encounter_id
prior_authorizations.payer_id
prior_authorizations.auth_number
prior_authorizations.service_codes
prior_authorizations.icd10_codes
prior_authorizations.auth_status
prior_authorizations.requested_date
prior_authorizations.approved_date
prior_authorizations.denied_date
prior_authorizations.valid_from
prior_authorizations.valid_to
prior_authorizations.approved_units
prior_authorizations.used_units
prior_authorizations.requesting_provider_id
prior_auth_requests.request_id
prior_auth_requests.submission_datetime
prior_auth_requests.submission_channel
prior_auth_requests.payer_response
prior_auth_requests.response_datetime
prior_auth_requests.peer_review_scheduled

Referrals

referrals.referral_id
referrals.patient_id
referrals.referring_provider_id
referrals.specialist_provider_id
referrals.payer_id
referrals.referral_number
referrals.service_type
referrals.authorized_visits
referrals.used_visits
referrals.valid_from
referrals.valid_to
referrals.status
referrals.icd10_code

Cost Estimates & Financial Counseling

cost_estimates.estimate_id
cost_estimates.patient_id
cost_estimates.encounter_id
cost_estimates.payer_id
cost_estimates.planned_cpt_codes
cost_estimates.estimated_charges
cost_estimates.estimated_payer_payment
cost_estimates.estimated_patient_responsibility
cost_estimates.deductible_applied
cost_estimates.copay_applied
cost_estimates.coinsurance_applied
cost_estimates.estimate_datetime
cost_estimates.acknowledged_by_patient
cost_estimates.valid_until
financial_counseling_records.record_id
financial_counseling_records.patient_id
financial_counseling_records.counselor_id
financial_counseling_records.session_datetime
financial_counseling_records.counseling_type
financial_counseling_records.patient_situation
financial_counseling_records.options_presented
financial_counseling_records.patient_decision
financial_counseling_records.payment_plan_id
financial_counseling_records.charity_application_id

Pre-Registration

pre_registration_records.prereg_id
pre_registration_records.patient_id
pre_registration_records.appointment_id
pre_registration_records.invitation_sent_datetime
pre_registration_records.completed_datetime
pre_registration_records.demographics_complete
pre_registration_records.insurance_verified
pre_registration_records.auth_verified
pre_registration_records.consent_obtained
pre_registration_records.status

Shared Dimensions (via FKs)

Facility, department, provider, payer, plan, encounter type, appointment type, etc., via joins to shared master tables.

Export Formats

Ad-hoc and standard reports must support:

CSV: For data analysis and integration with external tools.
Excel (XLSX): For finance and management users (pivot tables, charts).
PDF: For official reporting, sign-off, and archival (especially for regulatory and PDPL audit reports).
On-screen HTML: Interactive filtering, sorting, and drill-down.

All exports must:

Respect role-based access and PDPL minimization (e.g., ability to mask patient identifiers for non-clinical users).
Log export events in an audit log (user, timestamp, report, filter criteria).

Scheduled Report Delivery

The reporting engine should allow:

Scheduling Options
Daily, weekly, monthly, quarterly.
Specific day/time (with timezone awareness for UAE).
Delivery Channels
Secure email with link to report (no PHI in email body; PDPL-compliant).
Internal portal notifications.
Secure shared folder (e.g., SFTP) for finance/compliance.
Access Control
Only users with appropriate roles (e.g., view_analytics, rcm_reporting) can subscribe.
Subscription lists auditable for PDPL compliance.

Typical schedules:

Daily:
RPT-PAC-002 Eligibility Exceptions.
RPT-PAC-004 Pre-Registration Worklist.
Weekly:
RPT-PAC-003 Prior Auth Performance.
RPT-PAC-009 Payer Connectivity & Error Log.
Monthly:
RPT-PAC-001 KPI Dashboard snapshot (PDF).
RPT-PAC-005 Cost Estimate Accuracy.
RPT-PAC-006 Auth-Related Denials.
RPT-PAC-007 Referral Completion.
RPT-PAC-010 PDPL Access & Audit Log (for DPO).

All scheduled jobs must be monitored, with failure alerts sent to IT/BI support and Patient Access Manager.

Patient Access KPIs & Reporting

KPI Summary

KPI Definitions

KPI-PAC-001: Eligibility Verification Rate

Calculation Formula

Target / Benchmark

Data Source

Dimensions / Filters

Visualization

Alert Thresholds

KPI-PAC-002: Prior Auth Approval Rate

Calculation Formula

Target / Benchmark

Data Source

Dimensions / Filters

Visualization

Alert Thresholds

KPI-PAC-003: Prior Auth Turnaround Time

Calculation Formula

Target / Benchmark

Data Source

Dimensions / Filters

Visualization

Alert Thresholds

KPI-PAC-004: Pre-Registration Completion Rate

Calculation Formula

Target / Benchmark

Data Source

Dimensions / Filters

Visualization

Alert Thresholds

KPI-PAC-005: Cost Estimate Accuracy

Calculation Formula

Target / Benchmark

Data Source

Dimensions / Filters

Visualization

Alert Thresholds

KPI-PAC-006: Authorization-Related Denial Rate

Calculation Formula

Target / Benchmark

Data Source

Dimensions / Filters

Visualization

Alert Thresholds

KPI-PAC-007: Referral Completion Rate

Calculation Formula

Target / Benchmark

Data Source

Dimensions / Filters

Visualization

Alert Thresholds

KPI-PAC-008: Financial Clearance Rate

Calculation Formula

Target / Benchmark

Data Source

Dimensions / Filters

Visualization

Alert Thresholds

Standard Reports

Dashboard Wireframe

Regulatory Reports

MOH (Ministry of Health and Prevention)

DOH (Abu Dhabi) – Malaffi / DOH eClaims Context

DHA (Dubai) – NABIDH / eClaimLink Context

UAE PDPL (Federal Decree-Law No. 45/2021) – Data Protection

NABIDH / Malaffi Compliance Metrics

Ad-Hoc Reporting

Available Data Fields (Key Domains)

Export Formats

Scheduled Report Delivery