1 FHIR Financial Module
- 1.1 FHIR Resources
- 1.2 FHIR Interactions
- 1.3 Common Use Cases
2 Workflows
- 2.1 Beneficiary Enrollment
  - 2.1.1 Check enrollment status
  - 2.1.2 Enrol beneficiary
- 2.2 Claim Submission
  - 2.2.1 Check beneficiary validity
  - 2.2.2 Check beneficiary balance/treatment options
  - 2.2.3 Preauthorization of claim
  - 2.2.4 Track status of claim
  - 2.2.5 Submit claim
- 2.3 Indicator Reporting
  - 2.3.1 openIMIS Indicator Reporting
  - 2.3.2 openIMIS Patient Level Indicator Reporting
- 2.4 Other HIE Workflows

FHIR Financial Module

Adapted from http://hl7.org/fhir/financial-module.html (or http://hl7.org/fhir/STU3/financial-module.html for FHIR STU3).

The Financial module covers the resources and services provided by FHIR to support the costing, financial transactions and billing which occur within a healthcare provider as well as the eligibility, enrollment, authorizations, claims and payments which occur between healthcare providers and insurers and the reporting and notification between insurers and subscribers and patients.

FHIR Resources

FHIR Interactions

Common Use Cases

Workflows

The initial set of draft workflows are FHIR-based workflows leveraging the FHIR Financial moduel workflows and ongoing work in the OpenHIE UHC community on Integrating openIMIS into the OpenHIE Landscape.

Beneficiary Enrollment

Check enrollment status

title Check enrollment status

PoS->PoS: [1] Register patient
PoS->IOL: [2] FHIR Coverage resource search
IOL->IOL: [3] Validate FHIR resource
IOL->openIMIS: [4] Search for beneficiary
openIMIS->IOL: [5] Return beneficiary details
IOL->PoS: [6] Return FHIR Coverage resource
PoS->PoS: [7] Add details to patient record

Enrol beneficiary

title Enrol beneficiary

PoS->PoS: [1] Fetch / Register patient
PoS->IOL: [2] Submit FHIR EnrollmentRequest resource
IOL->IOL: [3] Validate FHIR resource
IOL->openIMIS: [4] Submit enrollment details
openIMIS->openIMIS: [5] Process enrollment
openIMIS->IOL: [6] Return enrollment response
IOL->PoS: [7] Return FHIR EnrollmentResponse resource
PoS->PoS: [8] Add details to patient record

Claim Submission

Check beneficiary validity

title Check beneficiary validity

PoS->PoS: [1] Fetch claims data 
PoS->IOL: [2] Submit FHIR EligibilityRequest resource
IOL->IOL: [3] Validate FHIR resource
IOL->openIMIS: [4] Query patient eligibility
openIMIS->IOL: [5] Return patient eligibility details
IOL->PoS: [6] Return FHIR EligibilityResponse resource
PoS->PoS: [7] Process response

Check beneficiary balance/treatment options

Preauthorization of claim

Track status of claim

Submit claim

Indicator Reporting

openIMIS Indicator Reporting

openIMIS Patient Level Indicator Reporting

Other HIE Workflows

'Patient leaves treatment setting' workflows
- Explanation of benefit and payment reconciliation
Client Registry (CR) interactions
- Beneficiary enrolment
- Beneficiary verification
Terminology Services (TS) and Product Registry (PR)
- Terminology and product code sync
...

openIMIS

Health Financing, FHIR and OpenHIE Workflows