Financial - FHIR v0.4.0

This page is part of the FHIR Specification (v0.0.82: DSTU 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

h2>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.

Business Activity

Request Resource

Response Resource

Eligibility Check

EligibilityRequest

EligibilityResponse

Enrollment Update

EnrollmentRequest

EnrollmentResponse

Claim

Claim (type={discipline}, use=complete)

ClaimResponse

Pre-determination

Claim (type={discipline}, use=exploratory)

ClaimResponse

Pre-Authorization

Claim (type={discipline}, use=proposed)

ClaimResponse

Reversal

ProcessRequest (action=cancel, nullify=false)

ClaimResponse

Nullify

ProcessRequest (action=cancel, nullify=true)

ClaimResponse

Re-adjudication

Readjudication

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

SupportingDocumentation

ProcessResponse

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
Name	Aliases	Description
Contract		A formal agreement between parties regarding the conduct of business, exchange of information or other matters.
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.
ProcessRequest		This resource provides the target, request and response, and action details for an action to be performed by the target on or about existing resources.
ProcessResponse		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
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.

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.