Health Financing, FHIR and OpenHIE 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

1 2 3 4 5 6 7 8 9 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

1 2 3 4 5 6 7 8 9 10 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

1 2 3 4 5 6 7 8 9 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

1 2 3 4 5 6 7 8 9 title Check beneficiary balance/treatment options PoS->PoS: [1] Fetch claims data PoS->IOL: [2] Submit FHIR Claim {use=exploratory} resource IOL->IOL: [3] Validate FHIR resource IOL->openIMIS: [4] Query patient balance/treatment options openIMIS->IOL: [5] Return treatment options/reimbursement details IOL->PoS: [6] Return FHIR ClaimResponse resource PoS->PoS: [7] Process response



Preauthorization of claim

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 title Preauthorization of claim PoS->PoS: [1] Fetch claims data PoS->IOL: [2] Submit FHIR Claim {use=proposed} resource IOL->IOL: [3] Validate FHIR resource IOL->openIMIS: [4] Submit claim to reserve funds alt Acknowledgement of preauthorization openIMIS->IOL: [5] Return acknowledgement of preauthorization IOL->PoS: [6] Return FHIR ClaimResponse resource PoS->PoS: [7] Process response else Additional information requested openIMIS->IOL: [5] Request for additional information IOL->PoS: [6] Return FHIR CommunicationRequest resource PoS->PoS: [7] Process response and fetch claims data PoS->IOL: [8] Submit FHIR Communication resource IOL->IOL: [9] Validate FHIR resource IOL->openIMIS: [10] Submit supporting information openIMIS->IOL: [11] Return adjudicated response IOL->PoS: [12] Return FHIR ClaimResponse resource PoS->PoS: [13] Process response end

Track status of claim

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 title Track status of claim PoS->PoS: [1] Fetch claims data alt Check claim status PoS->IOL: [2] Submit FHIR ProcessRequest {action=status} resource else Poll on claim status loop text PoS->IOL: [2] Submit FHIR ProcessRequest {action=poll} resource end end IOL->IOL: [3] Validate FHIR resource IOL->openIMIS: [4] Submit claim status check openIMIS->IOL: [6] Return claim status IOL->PoS: [7] Return FHIR ProcessResponse resource PoS->PoS: [8] Process response

Submit claim

1 2 3 4 5 6 7 8 9 10 title Submit claim PoS->PoS: [1] Fetch patient visit data PoS->IOL: [2] Submit FHIR Claim {use=complete} resource IOL->IOL: [3] Validate FHIR resource IOL->openIMIS: [4] Submit patient claim openIMIS->openIMIS: [5] Process claim openIMIS->IOL: [6] Return claim outcomes IOL->PoS: [7] Return FHIR ClaimResponse resource PoS->PoS: [8] Process response

Indicator Reporting

openIMIS Indicator Reporting

1 2 3 4 5 6 7 8 title openIMIS Indicator Reporting openIMIS->openIMIS: [1] Generate indicators to meet reporting needs openIMIS->IOL: [2] Submit report IOL->IOL: [3] Validate report / indicators IOL->IOL: [4] Transform report (e.g. FHIR Measure Report to ADX) IOL->HMIS: [5] Submit to HMIS HMIS->HMIS: [6] Evaluate and persist report / indicators

openIMIS Patient Level Indicator Reporting

1 2 3 4 5 6 7 8 9 10 11 12 13 title openIMIS Patient Level Indicator Reporting openIMIS->openIMIS: [1] Generate FHIR resources to meet reporting needs openIMIS->IOL: [2] Submit FHIR resources IOL->IOL: [3] Validate FHIR resources IOL->FHIR Server: [4] Persist FHIR resources CQL Engine->CQL Engine: [5] Trigger / external request for report CQL Engine->FHIR Server: [6] Evaluate FHIR Measure(s) / Measure Report(s) CQL Engine->IOL: [7] Submit to DHIS2 IOL->IOL: [8] Validate FHIR Measure(s) / Measure Report(s) IOL->IOL: [9] Transform report (e.g. FHIR Measure Report to ADX) IOL->HMIS: [10] Submit to HMIS HMIS->HMIS: [11] Evaluate and persist report / indicators

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

  • ...