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 Claim Response (Get)
2. Submit a Claim via WSI Web Services and Receive a ClaimResponse
3. Retrieve deferred ClaimResponse via PendedRequest

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 exploratory. Testing Samples are also limited to a single insurance coverage.

Submit a Claim via REST, Retrieve a Claim Response

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.

Retrieve deferred ClaimResponse via PendedRequest

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).

1. Test for Transformation Agent / FHIR Client:
   • (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.
     • Determine what the most appropriate 'focal resource(s)' should be that should be referenced in messageHeader.data
   • (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.
     • 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.

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