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HFW-003: Check Coverage Eligibility

This workflow can be used to check if a patient is enrolled in coverage and optionally examining whether specific services can be applied.

Example use cases:

  • If a mother presents at a hospital, this workflow can be used to determine if she is enrolled in the MCH postnatal care scheme of the MoH.
  • A patient is diagnosed with cancer and needs chemotherapy. The hospital inquires about coverage for chemotherapy.
Workflow Maturity


Newly Defined

  • Workflow is defined and ARB approved
  • Initial implementations are underway
Standards
Assumptions & Prerequisites None
Actors
  • PoS - The point of service system that captures a patient clinical encounter, it is responsible for sending this encounter on to the HIE.
  • IOL - Mediates the transactions between the PoS system and the infrastructure services to facilitate easier interoperability.
  • CR - The source of truth for patient demographic and identifier detail. It is able to be queried using an identifier to find the enterprise identifier for a particular person.
  • FIS - Financing and Insurance System that manages data on beneficiaries and their coverage.
Validations The PoS or IOL should validate the FHIR resources being submitted.

Interaction Description

Source Code

(link to permanent text in https://www.websequencediagrams.com/)

title HFW-003: Check Coverage Eligibility
participant PoS
participant IOL
participant FIS



opt Get code lists for Medical Procedures & Items
	PoS -> IOL: [1] Submit Medical Procedures & Items Query
	IOL -> FIS: [2] Forward query
	FIS -> FIS: [3] Process query
	FIS -> IOL: [4] Return  Medical Procedures & Items
	IOL -> PoS: [5] Forward Medical Procedures & Items
end opt
 

PoS -> IOL: [6] Submit Coverage Eligibility Query
IOL -> FIS: [7] Forward Query
FIS -> FIS: [8] Process Insuree Query
FIS -> FIS: [9] Process Policy Query
FIS -> IOL: [10] Return Coverage Eligibility Result
IOL -> PoS: [11] Forward Coverage Eligibility Result

Technical Details

Ref Interaction Endpoint Data Transaction Spec
1 Submit Medical Procedures & Items Query IOL
2 Forward Query FIS FHIR ActivityDefinition, FHIR Medication

http://hl7.org/fhir/R4/activitydefinition.html
http://hl7.org/fhir/R4/medication.html

3 Process query internal
4 Return Medical Procedures & Items IOL FHIR ActivityDefinition, FHIR Medication

http://hl7.org/fhir/R4/activitydefinition.html
http://hl7.org/fhir/R4/medication.html

5 Forward Medical Procedures & Items POS
6 Submit Coverage Eligibility Query IOL
7 Forward Query FIS FHIR CoverageEligibilityRequest http://hl7.org/fhir/R4/coverageeligibilityrequest.html
8 Process Insuree Query internal
9 Process Policy Query internal
10 Return Coverage Eligibility Result IOL FHIR CoverageEligibilityResponse http://hl7.org/fhir/R4/coverageeligibilityresponse.html
11 Forward Coverage Eligibility Result POS