HFW-003: Check Coverage Eligibility

This workflow can be used to check if a patient is enrolled in coverage and optionally examining whether specific services can be applied.

Example use cases:

• If a mother presents at a hospital, this workflow can be used to determine if she is enrolled in the MCH postnatal care scheme of the MoH.

• A patient is diagnosed with cancer and needs chemotherapy. The hospital inquires about coverage for chemotherapy.

Workflow Maturity	Newly Defined Workflow is defined and ARB approved Initial implementations are underway
Standards	HL7 FHIR Financial Module: http://hl7.org/fhir/financial-module.html
Assumptions & Prerequisites	None
Actors	PoS - The point of service system that captures a patient clinical encounter, it is responsible for sending this encounter on to the HIE. IOL - Mediates the transactions between the PoS system and the infrastructure services to facilitate easier interoperability. CR - The source of truth for patient demographic and identifier detail. It is able to be queried using an identifier to find the enterprise identifier for a particular person. FIS - Financing and Insurance System that manages data on beneficiaries and their coverage.
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-003: Check Coverage Eligibility
participant PoS
participant IOL
participant FIS



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 -> IOL: [6] Submit Coverage Eligibility Query
IOL -> FIS: [7] Forward Query
FIS -> FIS: [8] Process Insuree Query
FIS -> FIS: [9] Process Policy Query
FIS -> IOL: [10] Return Coverage Eligibility Result
IOL -> PoS: [11] Forward Coverage Eligibility Result

Technical Details

Ref	Interaction	Endpoint	Data	Transaction Spec
1	Submit Medical Procedures & Items Query	IOL
2	Forward Query	FIS	FHIR ActivityDefinition, FHIR Medication	http://hl7.org/fhir/R4/activitydefinition.html http://hl7.org/fhir/R4/medication.html
3	Process query	internal
4	Return Medical Procedures & Items	IOL	FHIR ActivityDefinition, FHIR Medication	http://hl7.org/fhir/R4/activitydefinition.html http://hl7.org/fhir/R4/medication.html
5	Forward Medical Procedures & Items	POS
6	Submit Coverage Eligibility Query	IOL
7	Forward Query	FIS	FHIR CoverageEligibilityRequest	http://hl7.org/fhir/R4/coverageeligibilityrequest.html
8	Process Insuree Query	internal
9	Process Policy Query	internal
10	Return Coverage Eligibility Result	IOL	FHIR CoverageEligibilityResponse	http://hl7.org/fhir/R4/coverageeligibilityresponse.html
11	Forward Coverage Eligibility Result	POS