> For the complete documentation index, see [llms.txt](https://guides.ohie.org/arch-spec/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://guides.ohie.org/arch-spec/dev-1/introduction/openhie-finance-and-insurance-services-workflows/hfw-003-check-coverage-eligibility.md).

# HFW-003: Check Coverage Eligibility

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.

| Workflow Maturity           | <p></p><p><img src="https://lh6.googleusercontent.com/Kxkqfa92YGW3mIOmWio0Twi4YLMA92z6mL1MuFzkx4AWS5CX5zbzWid5z4p2W-e6O66llKpaU0r6lzwyXfhbIiWmkVEuPDy6stX5x5L8uC2DkEXs6qUFX-7xxXTlb9hbkg" alt=""><br>Newly Defined </p><ul><li>Workflow is defined and ARB approved</li><li>Initial implementations are underway</li></ul>                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 |
| --------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| Standards                   | <ul><li>HL7 FHIR Financial Module: <a href="http://hl7.org/fhir/financial-module.html"><http://hl7.org/fhir/financial-module.html></a></li></ul>                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           |
| Assumptions & Prerequisites | None                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |
| Actors                      | <ul><li><a href="https://guides.ohie.org/arch-spec/openhie-component-specifications-1/point-of-care-systems">PoS</a> - The point of service system that captures a patient clinical encounter, it is responsible for sending this encounter on to the HIE. </li><li><a href="https://guides.ohie.org/arch-spec/openhie-component-specifications-1/openhie-interoperability-layer-iol">IOL</a> - Mediates the transactions between the PoS system and the infrastructure services to facilitate easier interoperability.</li><li><a href="https://guides.ohie.org/arch-spec/openhie-component-specifications-1/client-registry">CR</a> - 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. </li><li><a href="https://guides.ohie.org/arch-spec/openhie-component-specifications-1/openhie-finance-and-insurance-service">FIS</a> - Financing and Insurance System that manages data on beneficiaries and their coverage.</li></ul> |
| Validations                 | The PoS or IOL should validate the FHIR resources being submitted.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |

### Interaction Description

![](https://lh6.googleusercontent.com/nGHZHLc5wa6NUe9utNSFkDWHIl2zaAq88pA-E1anht-t5lIiiZt-aF_uOfuyYktkd4N2BvAs6Hkcv_tHVA50L_0HtSFIfwL8Y09bbodxBCrqdov66xPX_s4DREqOsGVI8Wbhb9-0)

#### Source Code

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

```
title HFW-003: Check Coverage Eligibility
participant PoS
participant IOL
participant FIS



opt Get code lists for Medical Procedures & Items
	PoS -> IOL: [1] Submit Medical Procedures & Items Query
	IOL -> FIS: [2] Forward query
	FIS -> FIS: [3] Process query
	FIS -> IOL: [4] Return  Medical Procedures & Items
	IOL -> PoS: [5] Forward Medical Procedures & Items
end opt
 

PoS -> IOL: [6] Submit Coverage Eligibility Query
IOL -> FIS: [7] Forward Query
FIS -> FIS: [8] Process Insuree Query
FIS -> FIS: [9] Process Policy Query
FIS -> IOL: [10] Return Coverage Eligibility Result
IOL -> PoS: [11] Forward Coverage Eligibility Result

```

### Technical Details

<table><thead><tr><th width="150">Ref</th><th width="197">Interaction</th><th width="150">Endpoint</th><th width="176">Data</th><th>Transaction Spec</th></tr></thead><tbody><tr><td>1</td><td>Submit Medical Procedures &#x26; Items Query</td><td>IOL</td><td></td><td></td></tr><tr><td>2</td><td>Forward Query</td><td>FIS</td><td>FHIR ActivityDefinition, FHIR Medication</td><td><a href="http://hl7.org/fhir/R4/activitydefinition.html
http://hl7.org/fhir/R4/medication.html ">http://hl7.org/fhir/R4/activitydefinition.html<br>http://hl7.org/fhir/R4/medication.html </a></td></tr><tr><td>3</td><td>Process query</td><td>internal</td><td></td><td></td></tr><tr><td>4</td><td>Return  Medical Procedures &#x26; Items</td><td>IOL</td><td>FHIR ActivityDefinition, FHIR Medication</td><td><a href="http://hl7.org/fhir/R4/activitydefinition.html
http://hl7.org/fhir/R4/medication.html ">http://hl7.org/fhir/R4/activitydefinition.html<br>http://hl7.org/fhir/R4/medication.html </a></td></tr><tr><td>5</td><td>Forward Medical Procedures &#x26; Items</td><td>POS</td><td></td><td></td></tr><tr><td>6</td><td>Submit Coverage Eligibility Query</td><td>IOL</td><td></td><td></td></tr><tr><td>7</td><td>Forward Query</td><td>FIS</td><td>FHIR CoverageEligibilityRequest</td><td><a href="http://hl7.org/fhir/R4/coverageeligibilityrequest.html">http://hl7.org/fhir/R4/coverageeligibilityrequest.html</a></td></tr><tr><td>8</td><td>Process Insuree Query</td><td>internal</td><td></td><td></td></tr><tr><td>9</td><td>Process Policy Query</td><td>internal</td><td></td><td></td></tr><tr><td>10</td><td>Return Coverage Eligibility Result</td><td>IOL</td><td>FHIR CoverageEligibilityResponse</td><td><a href="http://hl7.org/fhir/R4/coverageeligibilityresponse.html ">http://hl7.org/fhir/R4/coverageeligibilityresponse.html </a></td></tr><tr><td>11</td><td>Forward Coverage Eligibility Result</td><td>POS</td><td></td><td></td></tr></tbody></table>