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
  1. 1.
    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).
  2. 2.
    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.
  3. 3.
    Claiming: a PoS system (e.g. Hospital) sends a request for reimbursement of costs incurred for a certain treatment to the FIS
Example
  1. 1.
    An expensive treatment is needed and the Hospital wants to estimate the inputs they can apply.
  2. 2.
    A costly surgery is needed and has to be pre-approved by the insurance before it can be done.
  3. 3.
    A patient was treated in the hospital and the hospital requests reimbursement of the incurred costs.
Status
OHIE LEVEL 1 - Emerging Collection
Referenced Standards
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
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
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Interaction Description
Technical Details