2nd DSTU Draft For Comment
This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
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.
| Business Activity | Request Resource | Response Resource |
| Eligibility Check | EligibilityRequest | EligibilityResponse |
| Enrollment Update | EnrollmentRequest | EnrollmentResponse |
| Claim | {discipline}Claim (use=complete) | ClaimResponse |
| Pre-determination | {discipline}Claim (use=exploratory) | ClaimResponse |
| Pre-Authorization | {discipline}Claim (use=proposed) | ClaimResponse |
| Reversal | Reversal (nullify=false) | ClaimResponse |
| Nullify | Reversal (nullify=true) | ClaimResponse |
| Re-adjudication | Readjudication | ClaimResponse |
| Status Check | StatusRequest | StatusResponse |
| Pended Check (Polling) | PendedRequest | {Resource} or StatusResponse |
| Payment Notice | PaymentNotice | StatusResponse |
| Payment Reconciliation | PendedRequest (include=PaymentReconciliation) | PaymentReconciliation |
| Send Attachments | SupportingDocumentation | StatusResponse |
| Request an Explanation of Benefits | PendedRequest (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 | ||
| Name | Aliases | Description |
| Coverage | Financial instrument which may be used to pay for or reimburse for health care products and services. | |
| EligibilityRequest | This resource provides the insurance eligibility details from the insurer regarding a specified coverage and optionally some class of service. | |
| EligibilityResponse | This resource provides eligibility and plan details from the processing of an Eligibility resource. | |
| EnrollmentRequest | This resource provides the insurance Enrollment details to the insurer regarding a specified coverage. | |
| EnrollmentResponse | This resource provides Enrollment and plan details from the processing of an Enrollment resource. | |
| PendedRequest | This resource provides the request and response details for the resource for which the status is to be checked. | |
| Reversal | This resource provides the request and response details for the request for which all actions are to be reversed or terminated. | |
| StatusRequest | This resource provides the request and response details for the resource for which the processing status is to be checked. | |
| StatusResponse | This resource provides processing status, errors and notes from the processing of a resource. | |
| SupportingDocumentation | Attachments Supporting Information | This resource provides the supporting information for a process, for example clinical or financial information related to a claim or pre-authorization. |
| Billing | ||
| Claims, processing and responses | ||
| Name | Aliases | Description |
| ClaimResponse | Remittance Advice | This resource provides the adjudication details from the processing of a Claim resource. |
| InstitutionalClaim | A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery. | |
| OralHealthClaim | A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery. | |
| PharmacyClaim | A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery. | |
| ProfessionalClaim | A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery. | |
| Readjudicate | This resource provides the request and line items details for the claim which is to be re-adjudicated. | |
| VisionClaim | A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery. | |
| Payment | ||
| Used to support service payment processing and reporting | ||
| Name | Aliases | Description |
| PaymentNotice | This resource provides the status of the payment for goods and services rendered, and the request and response resource references. | |
| PaymentReconciliation | This resource provides payment details and claim references supporting a bulk payment. | |
| Other | ||
| Patient reporting and other purposes | ||
| Name | Aliases | Description |
| ExplanationOfBenefit | EOB | This 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.
© HL7.org 2011+. FHIR DSTU (v0.4.0-4167) generated on Mon, Feb 23, 2015 09:24+1100.
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