OpenHIE Finance and Insurance Service (FIS)

Finance and Insurance Service stores, categorizes, and facilitates the administration of centralised claims and finance related data to care provision to patients within the HIE. The service receives claims/financial data from Point of Service applications (including financing applications acting as a point of service interface outside of other PoS systems) and curates the management of them.

See also Non-Functional Requirements.

Major Process Group: Beneficiary Management

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Business Processes
Recommended

FISF-01

BP required;

FISF-02

BP recommended

FISF-03

BP required;

FISF-04

BP recommended

FISF-05

BP required;

Major Process Group: Provider Management

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Business Processes
Recommended

FISF-06

BP required;

WF recommended

FISF-07

Recommended

Major Process Group: Premium Management

#
Business Processes
Recommended

FISF-08

BP Required; WF required

Major Process Group: Claims Management

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Business Processes
Recommended

FISF-09

BP required;

FISF-10

BP required;

FISF-11

BP recommended

FISF-12

BP recommended

Major Process Group: Accounting

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Business Processes
Recommended

FISF-13

FISF-14

BP Required;

WF recommended

FISF-15

BP Required;

WF recommended

Major Process Group: Care Management

#
Business Processes
Recommended

FISF-16

BP optional

FISF-17

BP optional

FISF-18

BP optional

FISF-19

BP optional

Major Process Group: Utilization Management

#
Business Processes
Recommended

FISF-20

BP recommended

FISF-21

BP recommended

Major Process Group: Provider Quality Management

#
Business Processes
Recommended

FISF-22

BP recommended (align with FR)

Major Process Group: Financial / Audit Management

#
Business Processes
Recommended

FISF-23

BP recommended,

WF recommended

FISF-24

BP recommended

FISF-25

BP recommended

FISF-26

BP recommended

Major Process Group: Medical Loss

#
Business Processes
Recommended

FISF-27

  • Correct and balance any inequities or variances across regional boundaries and across service provision types

BP recommended

Major Process Group: Audit and Fraud

#
Business Processes
Recommended

FISF-28

BP recommended

WF recommended

FISF-29

BP recommended

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