During the FHIR Connectathon #9 in Paris the focus will be on the creation and exchange of FHIR based eClaims. The testing scenarios shown below form the core of the "Financial" test track. There are three test scenarios:
- Submit a Claim via REST (Create), Retrieve a ClaimResponse (Get)
- Submit a Claim via WSI Web Services and Receive a ClaimResponse
- Retrieve deferred ClaimResponse via ProcessRequest
You may select one or more of these testing scenarios - whatever appeals to you most given your particular context. We encourage you to create generic tests, but the only tests which can be assured are those using sample resources based on the data provided here.
All Claim submission examples will be for Oral Health, Dental, claims submitted using the subset of service codes provided below. You are free to trial Pre-determinations and Pre-Authorizations, Claims with use=proposed or use=exploratory. Testing samples are also limited to a single insurance coverage.
Submit a Claim via REST, Retrieve a ClaimResponse
The FHIR Client will construct a Claim having either already submitted the supporting resources or with the supporting resources provided within the Claim as contained resources.
To obtain the ClaimResponse for the submitted Claim the client with perform a GET on ClaimResponse with search parameters which may be expected to select the intended response.
Submit a Claim via WSI Web Services and Receive a ClaimResponse
The FHIR Client will construct a Claim with the supporting information provided within the Claim as contained resources. The response to the Claim will be an OperationOutcome if the Claim cannot be understood or a ClaimResponse if it can.
If the priority=deferred then a ClaimResponse containing only errors or acknowledgement detail will be returned. The ClaimResponse containing adjudication details can be obtained later as the response to a ProcessRequest (action=poll) resource, for example:
Retrieve deferred ClaimResponse via ProcessRequest
Submission of a ProcessRequest (action=poll) resource which contains a reference to the previously submitted claim via WSI Web Services will result in the return of the ClaimResponse containing the adjudicated results of the previously submitted Claim.
<ProcessRequest xmlns="http://hl7.org/fhir"> <contained> <Claim> <id value="claim-1"/> <identifier> <system value="http://happyvalley.com/claim"/> <value value="1500"/> </identifier> </Claim> </contained> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div> </text> <action value="poll"/> <identifier> <system value="http://happyvalley.com/processrequest"/> <value value="111"/> </identifier> <created value="2015-04-16"/> <organization> <reference value="Organization/1"/> </organization> <request> <reference value="#claim-1"/> </request> <include>ClaimResponse</include> </ProcessRequest>
|Field||Patient #1 Claim||Patient #2 Claim|
|Claim Type||Oral Health||Oral Health|
|Name||John M. Smith (Usual)||Judy F. Robinson (Usual)|
|Exceptions||Full-time student (Code 1) at Rozdale University|
|Address||1234 Any Street
Menlo Park, California 90123
|1 Landingpad Lane
Loma Linda, California 90310
|Dentist||Dr. Darryl Dentist (# 904563)
Happy Valley Clinic (# 1535)
|Dr. Phil Amolar (# 678543)
Happy Valley Clinic (# 1535)
|Referral||Practitioner (# 720415)
Reason: Rampant decay (Code 7)
|Insurance||The Benefit Company (BINN# 654123)
Certificate: A7G345, Policy: 123YHT56 SubSection: 35 Dependent: 01 Relationship: Self
|Health Management Corp (BINN# 564378)
Certificate: RF98765 Policy: GALACTIC Dependent: 04 Relationship: Child Frank Robinson born 1953-05-14
|Service Code, Fee, Tooth Surface, Lab#1 Code, Lab#1 Fee, Lab#2 Code, Lab#2 Fee|
|Service #1||1102, $65.00||1101, $55.00|
|Service #2||21211, $105.00, 21, L||2102, $730.00|
|Service #3||27211, $900.00, 22, , 99111, $250.00||21211, $105, 21, L|
|Service #4||21212, $200.00, 42, DI|
|Service #5||11101, $135.00|
|1101||Exam, comp, primary||55.00|
|1102||Exam, comp, mixed||60.00|
|1103||Exam, comp, permanent||65.00|
|1201||Exam, comp, primary||45.00|
|2101||Radiograph, series (12)||530.00|
|2102||Radiograph, series (16)||730.00|
|11101||Polishing, 1 unit||35.00|
|11102||Polishing, 2 unit||70.00|
|11103||Polishing, 3 unit||105.00|
|11104||Polishing, 4 unit||135.00|
|21211||Amalgam, 1 surface||105.00|
|21212||Amalgam, 2 surface||200.00|
|99333||Lab, in office||200.00|
Copyright © Health Level Seven International ® ALL RIGHTS RESERVED. The reproduction of this material in any form is strictly forbidden without the written permission of the publisher.