Connectathon9 Financial

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