Enhancing the Communication cycle for more Structured Queries

[abhimail]

Definition

In the context of the Health Claims ecosystem, a query refers to a request for missing, illegible, or additional information necessary to complete the claim adjudication process. This communication is initiated by Claim Processors (Insurers and other health benefit providers) to the Claim originators (Health Service Providers). The HCX protocol provides a structured Communication cycle, comprising a CommunicationRequest and Communication (as response), to facilitate such queries.

Challenges

While the HCX Protocol does provide a means to send queries and receive responses, the current approach lacks standardized terminologies for the purpose or reason behind each query. As a result, query issuers are free to express their queries in free-form text or documents, leaving the specificity for the reason or purpose of the query to the sender. This lack of standardized terminology may make it difficult for the receiver to decipher the actual information being requested. Therefore, there is a pressing need to establish standardized terminologies for the types of information or documents sought in queries, ensuring clarity and efficiency in communication between Claim Processors and Claim originators.

Scope

The focus of this workstream is to document the usual types of queries within the claim processing workflow, and propose enhancements to the HCX protocol to handle these common query types in a structured manner while maintaining flexibility to accommodate changing needs or claim-specific requirements.

The scope includes queries typically sent during IPD and OPD claims. Both cashless and reimbursement modes of claim submissions are within the scope, ensuring that the proposed enhancements cater to various claim processing scenarios.

Usual Types of Queries

In the claim processing workflow, queries typically fall into distinct categories based on the type of documents or information sought. Common types of queries include:

1. Documents: These queries involve requesting specific documents to be submitted along with the claim. Examples include:
   1. Investigation reports
   2. Discharge summaries
   3. Patient’s medical history
   4. Related/previous claims
   5. Settlement reports
   6. FIR reports for certain claims, etc.
2. Information: These queries seek additional information, clarifications or explanations regarding certain aspects of the claim. Examples include:
   7. Explanation for irrelevant or seeming unnecessary investigations or bill items
   8. Necessity for hospitalization when it is not apparent from the DS or investigation reports
   9. Correlation between investigations and diagnosis/procedures
   10. Date of diagnosis
   11. PED information
   12. Explanation for extended length of stay
   13. Billed amount is greater than tariff amount
   14. Unusual usage of some consumables, etc.

The categories and list of usual types of queries presented here have been compiled through interviews with various stakeholders and extensive discussions within the workstream.

Proposed Protocol Enhancements

After discussing with the community, it became evident that the list of requirements mentioned earlier might need to include more types of artifacts, especially different kinds of documents. Based on this feedback and a thorough review of the current CommunicationRequest and Communication profiles, the following enhancements are proposed:

1. Borrow the Codes from the existing LOINC code system based valueset - https://build.fhir.org/valueset-doc-typecodes.html as values for document codes.
2. Incorporate these codes into the existing valueset at https://ig.hcxprotocol.io/v0.9/ValueSet-communication-reason-codes.html . The protocol already uses this value set to specify reasons for communication requests and responses (e.g., indicating consent or account information needed).
3. Apply this value set to the reasonCode fields in CommunicationRequest (https://ig.hcxprotocol.io/v0.9/StructureDefinition-CommunicationRequest-definitions.html#CommunicationRequest.reasonCode ) and Communication (https://ig.hcxprotocol.io/v0.9/StructureDefinition-Communication-definitions.html#Communication.reasonCode ).

This approach ensures flexibility by accommodating a wide range of document types outlined in https://build.fhir.org/valueset-doc-typecodes.html.

Technical Changes Required in the HCX Protocol

Apart from the value set enhancements suggested above, no additional protocol changes are expected.