# 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 |

HL7 FHIR Financial Module:

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 ![](https://lh6.googleusercontent.com/nGHZHLc5wa6NUe9utNSFkDWHIl2zaAq88pA-E1anht-t5lIiiZt-aF_uOfuyYktkd4N2BvAs6Hkcv_tHVA50L_0HtSFIfwL8Y09bbodxBCrqdov66xPX_s4DREqOsGVI8Wbhb9-0) #### Source Code (link to permanent text in [https://www.websequencediagrams.com/](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 | | | --- # Agent Instructions: Querying This Documentation If you need additional information that is not directly available in this page, you can query the documentation dynamically by asking a question. Perform an HTTP GET request on the current page URL with the `ask` query parameter: ``` GET https://guides.ohie.org/arch-spec/introduction/openhie-finance-and-insurance-services-workflows/hfw-003-check-coverage-eligibility.md?ask= ``` The question should be specific, self-contained, and written in natural language. The response will contain a direct answer to the question and relevant excerpts and sources from the documentation. Use this mechanism when the answer is not explicitly present in the current page, you need clarification or additional context, or you want to retrieve related documentation sections.