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hfw-005-claim-tracking.md

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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