HFW-003: Check Coverage Eligibility
Last updated
Last updated
This workflow can be used to check if a patient is enrolled in coverage and optionally examining whether specific services can be applied.
Example use cases:
If a mother presents at a hospital, this workflow can be used to determine if she is enrolled in the MCH postnatal care scheme of the MoH.
A patient is diagnosed with cancer and needs chemotherapy. The hospital inquires about coverage for chemotherapy.
(link to permanent text in https://www.websequencediagrams.com/)
Ref | Interaction | Endpoint | Data | Transaction Spec |
---|---|---|---|---|
1
Submit Medical Procedures & Items Query
IOL
2
Forward Query
FIS
FHIR ActivityDefinition, FHIR Medication
3
Process query
internal
4
Return Medical Procedures & Items
IOL
FHIR ActivityDefinition, FHIR Medication
5
Forward Medical Procedures & Items
POS
6
Submit Coverage Eligibility Query
IOL
7
Forward Query
FIS
FHIR CoverageEligibilityRequest
8
Process Insuree Query
internal
9
Process Policy Query
internal
10
Return Coverage Eligibility Result
IOL
FHIR CoverageEligibilityResponse
11
Forward Coverage Eligibility Result
POS
Workflow Maturity
Workflow is defined and ARB approved
Initial implementations are underway
Standards
HL7 FHIR Financial Module: http://hl7.org/fhir/financial-module.html
Assumptions & Prerequisites
None
Actors
PoS - The point of service system that captures a patient clinical encounter, it is responsible for sending this encounter on to the HIE.
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 PoS or IOL should validate the FHIR resources being submitted.
Newly Defined