HFW-004: Claiming
Last updated
Last updated
Source code
(link to permanent text in https://www.websequencediagrams.com/)
Ref | Interaction | Endpoint | Data | Transaction Spec |
---|---|---|---|---|
1
Submit medical procedures & items query
IOL
FHIR ActivityDefinition, FHIR Medication
2
Forward query
FIS
3
Process query
internal
4
Return medical procedures & items
IOL
FHIR ActivityDefinition, FHIR Medication
5
Forward medical procedures & items
PoS
6
Build claim
internal
7
Submit claim (use)
IOL
FHIR Claim (use=[preauthorizsation, predetermination , claim])
8
Forward query
FIS
9
Process claim
internal
10
Process payment
EXT
11
Return positive claim result
IOL
FHIR ClaimResponse
12
Forward positive claim result
PoS
13
Return negative claim result
IOL
FHIR ClaimResponse (use=[preauthorizsation, predetermination , claim])
14
Forward negative claim result
PoS
15
Return queued status notification
IOL
FHIR ClaimResponse (use=[preauthorizsation, predetermination , claim])
16
Forward queued status notification
PoS
Workflow Maturity
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.
Newly Defined