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
Newly Defined
  • Workflow is defined and ARB approved
  • Initial implementations are underway
Standards
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.

Interaction Description

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

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
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Interaction Description
Technical Details