# 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.

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 ![](https://lh3.googleusercontent.com/1hcKyIWDVT39Q71qOsZWmx_NyGPh7n3IIBiO_TxjZ0W9Reu20ouS50xgTxnCguizWjPQFCcQZ36dxR3DSJCEHdcUP8mOmLHEsLxnxoFLyEgQFp5Bd-z0MTYWb_aeWMQjcVj018Cq) **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 | | | --- # 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-004-claiming.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.