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Difference between revisions of "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:
 
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 Claim Response (Get)
+
#Submit a Claim via REST (Create), Retrieve a ClaimResponse (Get)
 
#Submit a Claim via WSI Web Services and Receive a ClaimResponse
 
#Submit a Claim via WSI Web Services and Receive a ClaimResponse
−
#Retrieve deferred ClaimResponse via PendedRequest
+
#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 the sample resources provided here.
+
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.
  
−
==Overview==
+
==Scenarios==
  
−
===Submit a Claim via REST, Retrieve a Claim Response===
+
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. 
−
One of the main use-cases for mapping will be to populate a FHIR Resource Repository using data derived from a HL7 version 2 message feeds. The FHIR Specification details some of the [http://hl7-fhir.github.io/comparison-v2.html differences between HL7v2 and FHIR], and contains a partial mapping of resources to HL7 version 2 (e.g. [http://hl7.org/fhir/2015May/observation-mappings.html observation resource]). This test track will focus on the most commonly used HL7v2 trigger events, i.e. ADT and ORU.
+
 
−
+
===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===
 
===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.
  
−
===Retrieve deferred ClaimResponse via PendedRequest===
+
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:
−
Hl7v2.5 ADT messages: process a sequence comprised of A31, A01, A02, A08, A03 trigger events. The sequence A31-A01-A02 will contain 2 allergies, A08 drops one allergy (A08 and A03 only contain 2 allergies).  
+
*<nowiki>[base]/ClaimResponse?request.identifier=http://happyvalley.com/claim|1500</nowiki>
  
−
#Test for ''Transformation Agent / FHIR Client'':
+
===Retrieve deferred ClaimResponse via ProcessRequest===
−
#*(easy option, assumes that the FHIR Server supports Messaging) - process/read this sequence of HL7v2.5 messages, transform each of them to a FHIR Message, send FHIR messages to FHIR Server.
+
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.
−
#**Determine what the most appropriate 'focal resource(s)' should be that should be referenced in messageHeader.data
+
<nowiki>
−
#*(difficult option, assumes that the FHIR server only supports REST) - process/read this sequence of HL7v2.5 messages, transform each of them into a series of FHIR resources, query/update/delete resources on the FHIR Server.
+
<ProcessRequest xmlns="http://hl7.org/fhir">
−
#**The ''Transformation agent'' will have to detect that one allergy has been dropped from the message -compared to the previous message about the same patient and encounter-, and that an allergy has to be deleted.
+
  <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></nowiki>
  
 
==Sample Data==
 
==Sample Data==
Line 27: Line 57:
  
 
{|border="1" cellpadding="2" cellspacing="0"
 
{|border="1" cellpadding="2" cellspacing="0"
−
| width="30%" colspan="1" aligh="left" style="background:#f0f0f0;"|'''Field'''
+
| width="30%" colspan="1" align="left" style="background:#f0f0f0;"|'''Field'''
 
| width="35%" colspan="1" align="left" style="background:#f0f0f0;"|'''Patient #1 Claim'''
 
| width="35%" colspan="1" align="left" style="background:#f0f0f0;"|'''Patient #1 Claim'''
 
| width="35%" colspan="1" align="left" style="background:#f0f0f0;"|'''Patient #2 Claim'''
 
| width="35%" colspan="1" align="left" style="background:#f0f0f0;"|'''Patient #2 Claim'''
Line 107: Line 137:
 
||
 
||
 
||11101, $135.00
 
||11101, $135.00
 +
|}
 +
 +
===Services===
 +
 +
{|border="1" cellpadding="2" cellspacing="0"
 +
| width="30%" colspan="1" align="left" style="background:#f0f0f0;"|'''Code'''
 +
| width="35%" colspan="1" align="left" style="background:#f0f0f0;"|'''Description'''
 +
| width="10%" colspan="1" align="right" style="background:#f0f0f0;"|'''Fee'''
 +
|-
 +
||1101
 +
||Exam, comp, primary
 +
|width="10%" align="right" |55.00
 +
|-
 +
||1102
 +
||Exam, comp, mixed
 +
|width="10%" align="right" |60.00
 +
|-
 +
||1103
 +
||Exam, comp, permanent
 +
|width="10%" align="right" |65.00
 +
|-
 +
||1201
 +
||Exam, comp, primary
 +
|width="10%" align="right" |45.00
 +
|-
 +
||1205
 +
||Exam, emergency
 +
|width="10%" align="right" |75.00
 +
|-
 +
||2101
 +
||Radiograph, series (12)
 +
|width="10%" align="right" |530.00
 +
|-
 +
||2102
 +
||Radiograph, series (16)
 +
|width="10%" align="right" |730.00
 +
|-
 +
||2141
 +
||Radiograph, bytewing
 +
|width="10%" align="right" |530.00
 +
|-
 +
||2601
 +
||Radiograph, panoramic
 +
|width="10%" align="right"|420.00
 +
|-
 +
||11101
 +
||Polishing, 1 unit
 +
|width="10%" align="right"|35.00
 +
|-
 +
||11102
 +
||Polishing, 2 unit
 +
|width="10%" align="right"|70.00
 +
|-
 +
||11103
 +
||Polishing, 3 unit
 +
|width="10%" align="right"|105.00
 +
|-
 +
||11104
 +
||Polishing, 4 unit
 +
|width="10%" align="right"|135.00
 +
|-
 +
||21211
 +
||Amalgam, 1 surface
 +
|width="10%" align="right"|105.00
 +
|-
 +
||21212
 +
||Amalgam, 2 surface
 +
|width="10%" align="right"|200.00
 +
|-
 +
||27211
 +
||Crown, PFM
 +
|width="10%" align="right"|900.00
 +
|-
 +
||99111
 +
||Lab, commercial
 +
|width="10%" align="right"|250.00
 +
|-
 +
||99333
 +
||Lab, in office
 +
|width="10%" align="right"|200.00
 +
|-
 +
||99555
 +
||Lab, Expense
 +
|width="10%" align="right"|0.00
 
|}
 
|}

Latest revision as of 07:06, 22 April 2015

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
Retrieved from "https://wiki.hl7.org/w/index.php?title=Connectathon9_Financial&oldid=99270"