HFW-004: Claiming

Workflow Maturity	Newly Defined Workflow is defined and ARB approved Initial implementations are underway
Description	In the claiming process offers three functions Pre-determination: A PoS system (e.g. Hospital) requests an estimation of the expected reimbursement for a beneficiary’s specific treatment from the FIS (e.g Insurance). Pre-authorization: A PoS system (e.g. Hospital) requests an approval for a specific treatment from the FIS (e.g Insurance). At the FIS a manual intervention is needed to authorize the requested treatment. The insurer might need to reserve funds in the budget. Claiming: a PoS system (e.g. Hospital) sends a request for reimbursement of costs incurred for a certain treatment to the FIS
Example	An expensive treatment is needed and the Hospital wants to estimate the inputs they can apply. A costly surgery is needed and has to be pre-approved by the insurance before it can be done. A patient was treated in the hospital and the hospital requests reimbursement of the incurred costs.
Status	OHIE LEVEL 1 - Emerging Collection
Referenced Standards	HL7 FHIR Financial Module: http://hl7.org/fhir/financial-module.html Treatment plan submitted to Insurer to reserve funds: Claim {use=preauthorization} (http://hl7.org/fhir/financial-module.html#order)
Assumptions & Prerequisites	The PoS system has a curated list of insurance providers that interact with that system All relevant patient data is available in the PoS.
Actors	PoS - The point of service system that captures a patient clinical encounter and sends the formatted claim to the HIE. IOL - Mediates the transactions between the PoS system and the infrastructure services to facilitate easier interoperability. FIS - Financing and Insurance System that manages the claims processing and scrutinisation. EXT - an (OpenHIE) external payment layer
Validations	The PoS or IOL should validate the FHIR resources being submitted.

Interaction Description

Source code

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

title HFW-004: Claiming
participant PoS
participant IOL
participant FIS
participant EXT


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 -> PoS: [6] Build claim
PoS -> IOL: [7] Submit claim (use)
IOL -> FIS: [8] Forward query
FIS -> FIS: [9] Process claim

alt accepted
	opt Payout
    	note over IOL, EXT: [10] Process payment
	end opt
	FIS -> IOL: [11] Return positive claim result
	IOL -> PoS: [12] Forward positive claim result
else rejected
	FIS -> IOL: [13] Return negative claim result
	IOL -> PoS: [14] Forward negative claim result
else queued
	FIS -> IOL: [15] Return queued status notification
	IOL -> PoS: [16] Forward queued status notification
end

Technical Details

Ref	Interaction	Endpoint	Data	Transaction Spec
1	Submit medical procedures & items query	IOL	FHIR ActivityDefinition, FHIR Medication	http://hl7.org/fhir/R4/activitydefinition.html http://hl7.org/fhir/R4/medication.html
2	Forward query	FIS
3	Process query	internal
4	Return medical procedures & items	IOL	FHIR ActivityDefinition, FHIR Medication	http://hl7.org/fhir/R4/activitydefinition.html http://hl7.org/fhir/R4/medication.html
5	Forward medical procedures & items	PoS
6	Build claim	internal
7	Submit claim (use)	IOL	FHIR Claim (use=[preauthorizsation, predetermination , claim])	http://hl7.org/fhir/R4/claim.html
8	Forward query	FIS
9	Process claim	internal
10	Process payment	EXT
11	Return positive claim result	IOL	FHIR ClaimResponse	http://hl7.org/fhir/R4/claimresponse.html
12	Forward positive claim result	PoS
13	Return negative claim result	IOL	FHIR ClaimResponse (use=[preauthorizsation, predetermination , claim])	http://hl7.org/fhir/R4/claimresponse.html
14	Forward negative claim result	PoS
15	Return queued status notification	IOL	FHIR ClaimResponse (use=[preauthorizsation, predetermination , claim])	http://hl7.org/fhir/R4/claimresponse.html
16	Forward queued status notification	PoS