HFW-005: Claim Tracking

Workflow Maturity
​

Newly Defined
Workflow is defined and ARB approved
Initial implementations are underway
Description
This workflow allows a PoS to request the current processing status of a claim in the FIS.
Example
A hospital has sent an electronic reimbursement claim to the insurance company. After a waiting period the hospital wants to verify if the claim was processed.
Status
OHIE LEVEL 0
Referenced Standards
HL7 FHIR Financial Module: http://hl7.org/fhir/financial-module.html​
Assumptions & Prerequisites
Unique claim identifier is managed by FIS
The PoS system has already sent a claim to the FIS and has received a unique identifier for the claim (-> HFW-004)
Actors
PoS - The point of service system that has formulated a claim and waits for a response from the FIS.
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-005: Claim Tracking
participant PoS
participant IOL
participant FIS
​
note over PoS, FIS
Assumes that claiming was done already (HFW-004: Claiming)
​
end note
​
PoS -> IOL: [1] Submit claim response query (Claim ID)
IOL -> FIS: [2] Forward query
FIS -> FIS: [3] Process query
​
alt accepted
	FIS -> IOL: [4] Return positive claim result
	IOL -> PoS: [5] Forward positive claim result
else rejected
	FIS -> IOL: [6] Return negative claim result
	IOL -> PoS: [7] Forward negative claim result
else queued
	FIS -> IOL: [8] Return queued status notification
	IOL -> PoS: [9] Forward queued status notification
else not found
	FIS -> IOL: [10] Return not found notification
	IOL -> PoS: [11] Forward not found notification
end
Technical Details
Ref
Interaction
Endpoint
Data
Transaction Spec
1
Submit claim response query (Claim ID)
IOL
FHIR ClaimResponse
​http://hl7.org/fhir/R4/claimresponse.html​
2
Forward query
FIS
​
​
3
Process query
internal
​
​
4
Return positive claim result
IOL
FHIR ClaimResponse
​http://hl7.org/fhir/R4/claimresponse.html​
5
Forward positive claim result
PoS
​
​
6
Return negative claim result
IOL
FHIR ClaimResponse
​http://hl7.org/fhir/R4/claimresponse.html​
7
Forward negative claim result
PoS
​
​
8
Return queued status notification
IOL
FHIR ClaimResponse
​http://hl7.org/fhir/R4/claimresponse.html​
9
Forward queued status notification
PoS
​
​
10
Return not found notification
IOL
HTTP 404
​https://www.w3.org/Protocols/rfc2616/rfc2616-sec10.html​
11
Forward not found notification
PoS
​
​

Ref	Interaction	Endpoint	Data	Transaction Spec
1	Submit claim response query (Claim ID)	IOL	FHIR ClaimResponse	http://hl7.org/fhir/R4/claimresponse.html
2	Forward query	FIS
3	Process query	internal
4	Return positive claim result	IOL	FHIR ClaimResponse	http://hl7.org/fhir/R4/claimresponse.html
5	Forward positive claim result	PoS
6	Return negative claim result	IOL	FHIR ClaimResponse	http://hl7.org/fhir/R4/claimresponse.html
7	Forward negative claim result	PoS
8	Return queued status notification	IOL	FHIR ClaimResponse	http://hl7.org/fhir/R4/claimresponse.html
9	Forward queued status notification	PoS
10	Return not found notification	IOL	HTTP 404	https://www.w3.org/Protocols/rfc2616/rfc2616-sec10.html
11	Forward not found notification	PoS

HFW-004: Claiming

How to Provide Feedback and Input

Last modified 1yr ago

Workflow Maturity	Newly Defined Workflow is defined and ARB approved Initial implementations are underway
Description	This workflow allows a PoS to request the current processing status of a claim in the FIS.
Example	A hospital has sent an electronic reimbursement claim to the insurance company. After a waiting period the hospital wants to verify if the claim was processed.
Status	OHIE LEVEL 0
Referenced Standards	HL7 FHIR Financial Module: http://hl7.org/fhir/financial-module.html
Assumptions & Prerequisites	Unique claim identifier is managed by FIS The PoS system has already sent a claim to the FIS and has received a unique identifier for the claim (-> HFW-004)
Actors	PoS - The point of service system that has formulated a claim and waits for a response from the FIS. 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.