PATIENT ADMINISTRTAION (PA) Workgroup Development Draft

7.0 Financial Resources

The table below details various common business activities which occur in the financial realm, and the focal resources which may be exchanged, along with supporting resources, to accomplish the business activities. Whether or not the resources specified are actually needed requires consideration of the business itself and the exchange methodology and transport being used.

For example, if a definitive 'Request' does not need to be documented and communicating parties are using REST then a GET may be used in place of a CREATE of the request resource. Alternately, if FHIR Operations are being used then the specified focal resource may not be required or may be employed as one of the Operation parameters.

Note: The SupportingDocumentation resource has been deprecated in favour of DocumentManifest for the excahnge of attachments and supporting materials, PDF, Images, XRays, etc.

Business ActivityRequest ResourceResponse Resource
Eligibility CheckEligibilityRequestEligibilityResponse
Enrollment UpdateEnrollmentRequestEnrollmentResponse
ClaimClaim (type={discipline}, use=complete)ClaimResponse
Pre-determinationClaim (type={discipline}, use=exploratory)ClaimResponse
Pre-AuthorizationClaim (type={discipline}, use=proposed)ClaimResponse
ReversalProcessRequest (action=cancel, nullify=false)ClaimResponse
NullifyProcessRequest (action=cancel, nullify=true)ClaimResponse
Re-adjudicationProcessRequest (action=reprocess)ClaimResponse
Status CheckProcessRequest (action=status)ProcessResponse
Pended Check (Polling)ProcessRequest (action=poll){Resource} or ProcessResponse
Payment NoticePaymentNoticeProcessResponse
Payment ReconciliationProcessRequest (action=poll, include=PaymentReconciliation)PaymentReconciliation
Send AttachmentsDocumentManifestProcessResponse
Request an Explanation of Benefits   ProcessRequest (action=poll, include=ExplanationOfBenefit)ExplanationOfBenefit

{disipline} means the type of claim: OralHealth, Vision, Pharmacy, Professional or Institutional.

{Resource} means any pended or undelivered resource subject to the selection details specified in the request.


Support
Administrative
NameAliasesDescription
ContractA formal agreement between parties regarding the conduct of business, exchange of information or other matters.
CoverageFinancial instrument which may be used to pay for or reimburse for health care products and services.
EligibilityRequestThis resource provides the insurance eligibility details from the insurer regarding a specified coverage and optionally some class of service.
EligibilityResponseThis resource provides eligibility and plan details from the processing of an Eligibility resource.
EnrollmentRequestThis resource provides the insurance Enrollment details to the insurer regarding a specified coverage.
EnrollmentResponseThis resource provides Enrollment and plan details from the processing of an Enrollment resource.
ProcessRequestThis resource provides the target, request and response, and action details for an action to be performed by the target on or about existing resources.
ProcessResponseThis resource provides processing status, errors and notes from the processing of a resource.
DocumentManifestA manifest that defines a set of documents.

Billing
Claims, processing and responses
NameAliasesDescription
ClaimA provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery.
ClaimResponseRemittance AdviceThis resource provides the adjudication details from the processing of a Claim resource.

Payment
Used to support service payment processing and reporting
NameAliasesDescription
PaymentNoticeThis resource provides the status of the payment for goods and services rendered, and the request and response resource references.
PaymentReconciliationThis resource provides payment details and claim references supporting a bulk payment.

Other
Patient reporting and other purposes
NameAliasesDescription
ExplanationOfBenefitEOBThis resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.

Additional Resources will be added in the future. A list of hypothesized resources can be found on the HL7 wiki. Feel free to add any you think are missing or engage with one of the HL7 Work Groups to submit a proposal to define a resource of particular interest.