201601 Financial Management

Financial Management

Proposed Track Lead

Coordinator: Paul Knapp Skype: paulknapp

Roles

FHIR Client - Eligibility Submitter

Enable the creation and submission of the Eligibility resource and the receiving or obtaining of an EligibilityResponse.

FHIR Server - Eligibility Processor

Support the receiving and processing of the Eligibility resource and creation of the EligibilityResponse resource.

FHIR Client - Claims Submitter

Enable the creation and submission of the Claim resource and the receiving or obtaining of a ClaimResponse. This may be as a Pre-Authorization, Pre-Determination or a completed Claim for actual adjudication.

FHIR Server - Claims Processor

Support the receiving and processing of the Claim resource as a: Pre-Authorization; Predetermination; or, actual Claim; and creation of the ClaimResponse resource.

FHIR Client - Claims Attachment Submitter

Enable the creation and submission of the DocumentManifest resource and the receiving or obtaining of a ProcessResponse. This may be as supporting information for a Pre-Authorization, Pre-Determination or a completed Claim for actual adjudication.

FHIR Server - Claims Attachment Processor

Support the receiving and processing of the DocumentManifest resource as supporting information for a Pre-Authorization, Predetermination or actual Claim; and creation of the ProcessResponse resource.

FHIR Client - ProcessRequest Submitter

Enable the creation and submission of the ProcessRequest resource and the receiving or obtaining of a ProcessResponse. This may be to: request a Claim Reversal, request a deferred response, or a PaymentReconciliation or to obtain the processing status.

FHIR Server - ProcessRequest Processor

Support the receiving and processing of the ProcessRequest resource and creation of the ProcessResponse resource.

FHIR Server - PaymentReconciliation Processor

Support the receiving and processing of the ProcessRequest resource and creation of the PaymentReconciliation resource.

FHIR Server - Explanation of Benefit Processor

Support the receiving and processing of the ProcessRequest resource and creation of the ExplanationOfBenefit resource.

Scenarios

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 execute these scenarios with varying test data, but the only test executions which can be assured are those using resources based on the data provided here.

Submit a Claim via REST, Retrieve a ClaimResponse

Action: 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.

Precondition: None

Success Criteria: Claim processed correctly by the FHIR Server (inspect via browser or available UI)

Bonus point: N/A

Submit a Claim via WSI Web Services and Receive a ClaimResponse

Action: 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%7C1500

Precondition: None

Success Criteria: Claim processed correctly by the FHIR Server (inspect via browser or available UI)

Bonus point: N/A

Retrieve deferred ClaimResponse via ProcessRequest

Action: 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.

Precondition: None

Success Criteria: ClaimResponse returned correctly by the FHIR Server (inspect via browser or available UI)

Bonus point: N/A