R4 Ballot #2 (Mixed Normative/Trial use)
FinancialThis page is part of the FHIR Specification (v3.5.0: R4 Ballot #2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4 R3
| Work Group Financial Management | Ballot Status: Informative |
The Financial module covers the resources and services provided by FHIR to support the costing, financial transactions and billing which occur within a healthcare provider as well as the eligibility, enrollment, authorizations, claims and payments which occur between healthcare providers and insurers and the reporting and notification between insurers and subscribers and patients.
See also the Administration and WorkFlow modules.
Administrative
| Name | Aliases | Description |
| Account | Cost center | A financial tool for tracking value accrued for a particular purpose. In the healthcare field, used to track charges for a patient, cost centers, etc. |
| Coverage | Financial instrument which may be used to reimburse or pay for health care products and services. | |
| CoverageEligibilityRequest | The CoverageEligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an CoverageEligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy. | |
| CoverageEligibilityResponse | This resource provides eligibility and plan details from the processing of an CoverageEligibilityRequest 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. |
Claims, processing and responses
| Name | Aliases | Description |
| Claim | 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. | |
| ClaimResponse | Remittance Advice | This resource provides the adjudication details from the processing of a Claim resource. |
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. |
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.
Financial information in general and in particular when related to or including health information, such as claims data, are typically considered Protected Health Information and as such must be afforded the same protection and safeguards as would be afforded to purely clinical identified health data.
The Security and Privacy measures associated with FHIR, such as the use of Security labels and tags in the resource.meta, are encouraged in addition to the use of whatever measures for authorization and encryption are supported by the chosen exchange model, e.g. FHIR REST, Web Services, Direct, MLLP, SMTP and others.
For more general considerations, see the Security and Privacy module.
Financial information in general and in particular when related to or including health information, such as claims data, are typically considered Protected Health Information and as such must be afforded the same protection and safeguards as would be afforded to purely clinical identified health data.
| Term | Alias | Resource Type | Description |
| Adjudication | Claim, Preauthorization or Predetermination Processing | ClaimResponse | The processing by an insurer of a claim, preauthorization or predetermination to determine under the insurance plan what if any benefits are or would be payable. |
| Assignment of Benefit | Assignment | n/a | When a Beneficiary directs that any benefit they receive from the adjudication of a claim may be paid to the service provider who issued the claim. |
| Attachment | Communication | A collection of information objects sent to a party to support their understanding or processing of another resource such as a claim. | |
| Beneficiary | Patient | Patient | The party who's health care expenses may be covered by a policy issued by an Insurer. |
| Benefit Amount | Benefit | n/a | The amount payable under an insurance policy for a given expense incurred by a patient. |
| Claim | Claim | Claim | A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any. |
| Coordination of Benefit | COB | n/a | The the rules, usually regionally defined, which govern the order of application of multiple Insurance coverages or SelfPay to a given suite of health care expenses. |
| Dependent | Patient, RelatedPerson | A person who receives their coverage via a policy which is own or subscribed to by another. Typically these include spouses, partners and minor children but may also include students, parents and disabled persons. | |
| Insurer | Payer, Payor | Organization | A public or private insurer which will adjudicate Claims for health care goods and services to determine if the there is any benefit payable, amount due, under the policy which covers the patient. |
| Network | n/a | An insurer defined grouping of Providers for which the Beneficiary's plan preferentially covers the costs of treatment, eg. closed, rental, etc. | |
| Payer | Payor, Insurer | Organization | A public or private insurer. |
| Payor | Payer, Insurer | Organization | A public or private insurer. |
| Policy | Contract | A contract between an Insurer and an individual or other entity such as an employer to reimburse covered parties (Beneficiaries) for some or all of a prescribed suite of health-related goods and services. | |
| Policy Holder | Policy owner | Patient, RelatedPerson, Organization | The party which owns the policy. It may be the employer for work-related policies or the individual for purchased or public policies. |
| Preauthorization | Prior Authorization, Pre-Auth | Claim | A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted. |
| Predetermination | Pre-Determination, PreD | Claim | A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided. |
| Solicited Attachment | Communication | An attachment sent to provide supporting information in response to having received a request for additional information. | |
| Subscriber | Patient, RelatedPerson | The person who signs-up for the coverage. May be an employee or person with dependents. | |
| Unsolicited Attachment | Communication | An attachment sent to provide supporting information without first having received a request for additional information. |
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 the resources specified are actually needed requires consideration of the business itself and the exchange methodology and transport being used.
For example: If a content model is not required to obtain the appropriate status element then a SEARCH (GET) may be used, however if a content model is required to support the request for information then the content model will need to be CREATEd (POST). Alternately, if FHIR Operations are being used then the specified focal resource may be employed as one of the Operation parameters or might not be required.
| Business Activity | Request Resource | Response Resource |
| Eligibility Check | CoverageEligibilityRequest | CoverageEligibilityResponse |
| Enrollment Update | EnrollmentRequest | EnrollmentResponse |
| Claim | Claim (type={discipline}, use=claim) | ClaimResponse |
| Predetermination | Claim (type={discipline}, use=predetermination) | ClaimResponse |
| Preauthorization | Claim (type={discipline}, use=preauthorization) | ClaimResponse |
| Reversal | ProcessRequest (action=cancel, nullify=false) | ClaimResponse |
| Nullify | ProcessRequest (action=cancel, nullify=true) | ClaimResponse |
| Re-adjudication | ProcessRequest (action=reprocess) | ClaimResponse |
| Status Check | ProcessRequest (action=status) | ProcessResponse |
| Pended Check (Polling) | ProcessRequest (action=poll) | {Resource} or ProcessResponse |
| Payment Notice | PaymentNotice | ProcessResponse |
| Payment Reconciliation | ProcessRequest (action=poll, include=PaymentReconciliation) | PaymentReconciliation |
| Send Attachments | Communication | ProcessResponse |
| Request Attachments | ProcessRequest (action=poll, include=CommunicationRequest) | CommunicationRequest |
| Request an Explanation of Benefits | ProcessRequest (action=poll, include=ExplanationOfBenefit) | ExplanationOfBenefit |
{discipline} 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.
The table below details the relative order of events and use of financial resources for patient care during the care cycle. Not all steps or information exchanges may occur, and supporting information may be required more frequently than has been depicted below.
| Business Activity | Focal Resource |
| Patient visits Provider | |
| Provider checks for valid insurance coverage | CoverageEligibilityRequest |
| Insurer responds with coverage status and optional plan details | CoverageEligibilityResponse |
| Provider examines Patient and reviews treatment options | |
| Provider submits Predetermination(s) for treatment options to determine potential reimbursement | Claim {use=predetermination} |
| Insurer responds with potential reimbursement | ClaimResponse |
| Provider and Patient determine treatment plan | |
| Treatment plan submitted to Insurer to reserve funds | Claim {use=preauthorization} |
| Insurer acknowledges receipt of preauthorization | ClaimResponse |
| Insurer requests additional information | CommunicationRequest |
| Provider submits supporting information | Communication |
| Insurer provides adjudicated response to pre-authorization | ClaimResponse |
| Provider checks on status of pre-authorization processing | ProcessRequest {action=status} |
| Insurer responds indicating adjudication is ready | ProcessResponse |
| Provider retrieves pre-authorization adjudication | READ or ProcessRequest {action=poll} |
| Provider provides treatment | |
| Provider submits patient's claim for reimbursement | Claim {use=claim} |
| Insurer responds with claim adjudication | ClaimResponse |
| Patient leaves treatment setting | |
| Patient requests an Explanation of Benefit for their Personal Health Record application | READ or ProcessRequest {action=poll} |
| Insurer responds with Explanation of Benefit | ExplanationOfBenefit |
| Provider requests the payment details associated with a bulk payment | SEARCH or ProcessRequest {action=poll} |
| Insurer responds with a Payment Reconciliation | PaymentReconciliation |
| Insurer notifies provider that payment has been issued | PaymentNotice |
| Insurer notifies parties that payment funds have been received | PaymentNotice |
In addition to their primary use of conveying patient billing information to insurers for reimbursement either to the subscriber or the provider (assignment of benefit), many of the financial resources, such as Claim and ExplanationOfBenefit, may be used to export data to other agencies to support reporting and analytics.
There is often a need to provide supporting information, commonly referred to as attachments, to document the need for a service and/or to confirm that the good or service was authorized or rendered. This information may be in many forms, including: scanned documents, PDFs, word processing files, XRays, images, CDAs and FHIR Resources.
Supporting information may be provided, as a reference or the actual material, to support the Claim (complete claim or Pre-Authorization) or ExplanationOfBenefit in a variety of manners:
The Financial Management Work Group (FM) is responsible for two subdomains:
Financial Accounts and Billing (FIAB) - resources for accounts, charges (internal costing transactions) and patient billing, and
Financial Claims and Reimbursement (FICR) - insurance information, enrollment, eligibility, predetermination, preauthorization, claims, patient reporting and payments.
To date FM has been focusing on the resources required to support the exchange of claims and related information between health care providers and insurers. The first draft of this work is nearing completion with the release of the first Financial Standard for Trial Use in STU3 of FHIR. Over the next year further refinements will be expected as we begin developing regional profiles and begin live pilots with resources.
Once the above is well underway FM can then look to developing the Enrollment-related resources and the resources to support the FIAB functions.
In many cases an example valueset has been provided in this release. Financial Management will be devoting effort in the preparation to Release 4 of FHIR to develop more representative example sets and to determine where global codesets exist such that some of the valuesets may be elevated in strength to extensible or required.
®© HL7.org 2011+. FHIR Mixed Nomative/Trial Use Ballot #2 (v3.5.0-14907) generated on Sun, Aug 19, 2018 21:54+1000. QA Page
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