HFW-001: Enroll Beneficiary

This transaction allows a POS system to enroll a patient/beneficiary into a Health Financing and Insurance System, to save patient/beneficiary level demographic data to a Client Registry (optional) and to save the beneficiary insurance identifier to a Client Registry (optional). Coverage eligibility can be verified beforehand.

Example Use Cases

• A field agent of the national insurance provider registers a household into a specific insurance scheme.

Workflow Maturity	Newly Defined Workflow is defined and ARB approved Initial implementations are underway
Referenced Standards	HL7 FHIR Financial Module: http://hl7.org/fhir/financial-module.html
Assumptions & Prerequisites	The registration process uses existing Patient Identity Management processes for registration and querying Unique insuree identifier is managed by FIS IOL implicitly verifies all messages for syntax The PoS system has a curated list of FIS that interact with that system
Actors	PoS - The point of service system that captures an enrollment request. IOL - Mediates the transactions between the PoS system and the infrastructure services to facilitate easier interoperability. CR - The source of truth for patient demographic and identifier detail. It is able to be queried using an identifier to find the enterprise identifier for a particular person. FIS - Financing and Insurance System that manages data on beneficiaries and their coverage.
Validations	The IOL should validate the FHIR resources being submitted.

Interaction Description

Source code

(link to permanent text in https://www.websequencediagrams.com/)

title HFW-001: Enroll beneficiary
participant PoS
participant IOL
participant FIS
participant CR

note over PoS, CR
Assumes that registration or querying of CR is done here

PoS->HIE: [1] Fetch / Register patient (CRWF-1,3,4)
end Note

PoS->IOL: [2] Submit enrollment request
IOL->FIS: [3] Forward enrollment request
FIS->FIS: [4] Verify enrollment eligibility

alt success
  FIS->FIS: [5] Process enrollment
  opt
	FIS->CR: [6] * Register HF identifier with CR (CRWF-2)
  end
  FIS->IOL: [7] Return positive enrollment response
  IOL->PoS: [8] Forward positive enrollment response
  PoS->PoS: [9] Add details to patient record
else validation error
  FIS->IOL: [10] Return negative enrollment response
  IOL->PoS: [11] Forward negative enrollment response
end

Technical Details

#	Interaction	Endpoint	Data	Transaction Options
1	Fetch / Register patient	CR		(CRWF-1,3,4)
2	Submit enrollment request	IOL
3	Forward enrollment request	FIS	FHIR Contract(Patient,Organization,InsurancePlan)	http://hl7.org/fhir/contract.html
4	Verify enrollment eligibility	internal
5	Process enrollment	internal
6	Register HF identifier with CR	CR		(CRWF-2)
7	Return positive enrollment response	IOL	FHIR Contract(Patient,Organization,InsurancePlan)	http://hl7.org/fhir/contract.html
8	Forward positive enrollment response	POS
9	Add details to patient record	internal
10	Return negative enrollment	IOL	FHIR Contract(Patient,Organization,InsurancePlan)	http://hl7.org/fhir/contract.html
11	Forward negative enrollment response	POS