# 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:
- Treatment plan submitted to Insurer to reserve funds: Claim {use=preauthorization} ()
|
| 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/](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 | | |