Finance and Insurance Service (FAIS)
1.0.0 - trial-use International flag

This page is part of the IHE ITI Finance and Insurance Services (v1.0.0: Publication) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

CapabilityStatement: Claims Manager Actor

Official URL: https://profiles.ihe.net/ITI/FAIS/CapabilityStatement/IHE.FAIS.ClaimsManager Version: 1.0.0
Active as of 2024-07-17 Computable Name: IHE_FAIS_ClaimsManager

CapabilityStatement for Claims Requestor Actor.

The Claims Manager processes claims requests from the Claims Requestor. It follows internal business processes to create the claim that are beyond the scope of this profile. It also responds to claim tracking requests to return the status of the requested claim.

Raw OpenAPI-Swagger Definition file | Download

Generated Narrative: CapabilityStatement IHE.FAIS.ClaimsManager

IHE FAIS Claims Manager

  • Implementation Guide Version: 1.0.0
  • FHIR Version: 4.0.1
  • Supported Formats: application/fhir+xml, application/fhir+json
  • Supported Patch Formats:
  • Published on: 2024-07-17
  • Published by: IHE IT Infrastructure Technical Committee

Note to Implementers: FHIR Capabilities

Any FHIR capability may be 'allowed' by the system unless explicitly marked as 'SHALL NOT'. A few items are marked as MAY in the Implementation Guide to highlight their potential relevance to the use case.

FHIR RESTful Capabilities

Mode: server

FAIS Claims Manager rovides capability to receive claim submissions and respond to queries for claim responses.

Security

Recommend ATNA, encouraged IHE-IUA or SMART-app-launch

Summary of System-wide Interactions
  • SHALL support the search-systeminteraction.

Capabilities by Resource/Profile

Summary

The summary table lists the resources that are part of this configuration, and for each resource it lists:

  • The relevant profiles (if any)
  • The interactions supported by each resource (Read, Search, Update, and Create, are always shown, while VRead, Patch, Delete, History on Instance, or History on Type are only present if at least one of the resources has support for them.
  • The required, recommended, and some optional search parameters (if any).
  • The linked resources enabled for _include
  • The other resources enabled for _revinclude
  • The operations on the resource (if any)
Resource TypeProfileRSUCSearches_include_revincludeOperations
CoverageEligibilityRequestSupported Profiles
  FAIS CoverageEligibilityRequest Profile		$submit
CoverageEligibilityResponseSupported Profiles
  FAIS CoverageEligibilityResponse Profile		yy_lastUpdated, _id, status, request, patient, requestor
ClaimSupported Profiles
  FAIS Claim Profile		$submit, $cancel, $reprocess
ClaimResponseSupported Profiles
  FAIS ClaimResponse Profile		yy_lastUpdated, _id, status, request, patient, requestor

Resource Conformance: supported CoverageEligibilityRequest

Core FHIR Resource
CoverageEligibilityRequest
Reference Policy
Interaction summary

    Supported Profiles

    FAIS CoverageEligibilityRequest Profile

    Documentation

    FAIS Check Coverage Eligibility transaction [ITI-124]

    Extended Operations
    ConformanceOperationDocumentation
    SHALL$submit

    Submits a coverage eligibility request to check the coverage of a beneficiary. FAIS Check Coverage Eligibility transaction [ITI-124].

    Resource Conformance: SHALL CoverageEligibilityResponse

    Core FHIR Resource
    CoverageEligibilityResponse
    Reference Policy
    Interaction summary
    • SHALL support read, search-type.

    Supported Profiles

    FAIS CoverageEligibilityResponse Profile

    Documentation

    FAIS Check Coverage Eligibility Status transaction [ITI-125]

    Search Parameters
    ConformanceParameterTypeDocumentation
    SHALL_lastUpdateddate

    When the resource version last changed. The values for this shall support these prefixes: gt, lt, ge, le, sa, and eb.

    SHALL_idtoken

    Logical id of this artifact

    SHALLstatustoken

    The status of the response

    SHALLrequestreference

    The coverage eligiblity request

    SHALLpatientreference

    The beneficiary

    SHALLrequestorreference

    The provider making the request

     

    Resource Conformance: supported Claim

    Core FHIR Resource
    Claim
    Reference Policy
    Interaction summary

      Supported Profiles

      FAIS Claim Profile

      Documentation
      Extended Operations
      ConformanceOperationDocumentation
      SHALL$submit

      Submits a claim. FAIS Submit Claim transaction [ITI-126].

      SHALL$cancel

      Cancels a claim. FAIS Cancel Claim transaction [ITI-127].

      SHALL$reprocess

      Re-processes a claim. FAIS Re-process Claim transaction [ITI-128].

      Resource Conformance: SHALL ClaimResponse

      Core FHIR Resource
      ClaimResponse
      Reference Policy
      Interaction summary
      • SHALL support read, search-type.

      Supported Profiles

      FAIS ClaimResponse Profile

      Documentation

      FAIS Track Claim transaction [ITI-129]

      Search Parameters
      ConformanceParameterTypeDocumentation
      SHALL_lastUpdateddate

      When the resource version last changed. The values for this shall support these prefixes: gt, lt, ge, le, sa, and eb.

      SHALL_idtoken

      Logical id of this artifact

      SHALLstatustoken

      The status of the response

      SHALLrequestreference

      The coverage eligiblity request

      SHALLpatientreference

      The beneficiary

      SHALLrequestorreference

      The provider making the request