List of content:

Description:

Currently, the OpenIMIS Claim is mapped only partially because the current version is focused on claim submission. In the current version are mapped fields required by uspUpdateClaimFromPhone database stored procedure (SP) which is used by python claim service to submitting the claim.

Only GET and POST HTTP methods are currently exposed because of the current version is focused on the claim submitting. The GET operation can be used to fetch information about all claim (or a specific one) and the POST operation can be used to submit the claim (response for the request is the OperationOutcome which notice about success or failure).

Notes / Assumptions:

• The current version of mapping will be focused on aspects of claiming.
• To fully mapped the claim probably need to be used two different FHIR resources. Claim - contains base information about the claim (request), ClaimResponse - contains information which is the outcome of processing claim (response).
• The claim code is used as the resource primary key because of the uspUpdateClaimFromPhone didn't return the value of id a new claim
  

FHIR resources:

Fields mapping:

Table legend:

Claim mapping:

Note:

• The claim items (tblClaimItems) and services (tblClaimServices) are represented as an FHIR "claim.item".
• Additional in the "insurance" field we can contain information about policies related to insuree (using Reference(Coverage)).

ClaimItem mapping:

see subpage: openIMIS tblClaimItems resource (FHIR Claim / ClaimResponse)

ClaimService mapping:

see subpage: openIMIS tblClaimServices resource (FHIR Claim / ClaimResponse)

Endpoint specification:

Example of endpoint URL:

http://127.0.0.1:8000/api_fhir/Claim/

Supported HTTP operation:

• CREATE - used to submitting the claim. The FHIR claim representation is converted to python ClaimSubmit (https://github.com/openimis/openimis-be-claim_py/blob/master/claim/services.py#L38) which is used by the python claim service. List of supported fields can be found in the table which shows the mapping between OpenIMIS and FHIR. Should be used the POST HTTP method and the body as JSON representation (example can be found below).

  Note:

  • The claim service is used to process the request (https://github.com/openimis/openimis-be-claim_py/blob/master/claim/services.py#L146).

  • The response is OperationOutcome which notice about success or failure (list of possible errors). Example of the outcome can be found below.
• READ - by default return list of all available resources. To fetch information about a specific object you should add the primary key to URL for instance:
  http://127.0.0.1:8000/api_fhir/Claim/{claimcode}
  , where "{claimcode}" is the value of the primary key (claim code in case of that resource). Should be used the GET HTTP method.
• UPDATE - the operation currently not supported
• DELETE - the operation currently not supported

Module configuration used by the endpoint: 

Example JSON representation of content:

FHIR Claim:

{
    "resourceType": "Claim",
    "billablePeriod": {
        "start": "2019-02-19"
    },
    "created": "2019-06-27",
    "diagnosis": [
        {
            "diagnosisCodeableConcept": {
                "coding": [
                    {
                        "code": "icdcod"
                    }
                ]
            },
            "sequence": 1,
            "type": [
                {
                    "text": "icd_0"
                }
            ]
        }
    ],
    "enterer": {
        "reference": "Practitioner/code"
    },
    "facility": {
        "reference": "Location/hfcode"
    },
    "identifier": [
        {
            "type": {
                "coding": [
                    {
                        "code": "ACSN",
                        "system": "https://hl7.org/fhir/valueset-identifier-type.html"
                    }
                ]
            },
            "use": "usual",
            "value": "8"
        },
        {
            "type": {
                "coding": [
                    {
                        "code": "MR",
                        "system": "https://hl7.org/fhir/valueset-identifier-type.html"
                    }
                ]
            },
            "use": "usual",
            "value": "clCode"
        }
    ],
    "item": [
        {
            "category": {
                "text": "item"
            },
            "quantity": {
                "value": 1
            },
            "sequence": 1,
            "service": {
                "text": "ICode"
            },
            "unitPrice": {
                "value": 20
            }
        },
        {
            "category": {
                "text": "service"
            },
            "quantity": {
                "value": 1
            },
            "sequence": 2,
            "service": {
                "text": "SCode"
            },
            "unitPrice": {
                "value": 20
            }
        }
    ],
    "patient": {
        "reference": "Patient/chfid"
    },
    "total": {
        "value": 0
    }
}

FHIR OperationOutcome - sucess:

{
    "resourceType": "OperationOutcome",
    "issue": [
        {
            "code": "informational",
            "details": {
                "text": "Claim submit created"
            },
            "severity": "information"
        }
    ]
}

FHIR OperationOutcome - failure:

{
    "resourceType": "OperationOutcome",
    "issue": [
        {
            "code": "exception",
            "details": {
                "text": "Duplicate Claim Code"
            },
            "severity": "error"
        }
    ]
}