Connectathon9 Financial

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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:

  1. Submit a Claim via REST (Create), Retrieve a ClaimResponse (Get)
  2. Submit a Claim via WSI Web Services and Receive a ClaimResponse
  3. 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.

Scenarios

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:

  • [base]/ClaimResponse?request.identifier=http://happyvalley.com/claim|1500

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>

Sample Data

Claims

Field Patient #1 Claim Patient #2 Claim
Claim Number 1500 1501
Processing Priority Normal Normal
Claim Type Oral Health Oral Health
Name John M. Smith (Usual) Judy F. Robinson (Usual)
Gender M F
Birthdate 1973-04-14 1993-06-24
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

Services

Code Description Fee
1101 Exam, comp, primary 55.00
1102 Exam, comp, mixed 60.00
1103 Exam, comp, permanent 65.00
1201 Exam, comp, primary 45.00
1205 Exam, emergency 75.00
2101 Radiograph, series (12) 530.00
2102 Radiograph, series (16) 730.00
2141 Radiograph, bytewing 530.00
2601 Radiograph, panoramic 420.00
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
27211 Crown, PFM 900.00
99111 Lab, commercial 250.00
99333 Lab, in office 200.00
99555 Lab, Expense 0.00

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