Health Financing, FHIR and OpenHIE Workflows

Owned by Daniel Futerman
Last updated: Nov 12, 2019
4 min read

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

  • ...

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