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
2
Forward query
FIS
3
Process query
internal
4
Return positive claim result
IOL
FHIR ClaimResponse
5
Forward positive claim result
PoS
6
Return negative claim result
IOL
FHIR ClaimResponse
7
Forward negative claim result
PoS
8
Return queued status notification
IOL
FHIR ClaimResponse
9
Forward queued status notification
PoS
10
Return not found notification
IOL
HTTP 404
11
Forward not found notification
PoS