Finance and Insurance Service (FAIS)
1.0.0-comment - ballot
This page is part of the IHE ITI Finance and Insurance Services (v1.0.0-comment: Publication Ballot 1) 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
This section corresponds to transaction [ITI-YY1] of the IHE ITI Technical Framework. Transaction [ITI-YY1] is used by the Beneficiary Requestor and Beneficiary Manager Actors. The Enroll Beneficiary [ITI-YY1] transaction is used to enroll a patient in a particular coverage offered by the insurance plan.
This transaction is used by the Beneficiary Requestor to request that a patient be enrolled with a given coverage. The request is received by the Beneficiary Manager. The Beneficiary Manager processes the request and returns a response with the status of the request.
Table2:3.YY1.2-1: Actor Roles
Actor | Role |
---|---|
Beneficiary Requestor | Sends the enrollment request to the Beneficiary Manager. |
Beneficiary Manager | Receives and processes the request and returns a response to the Beneficiary Requestor |
FHIR-R4 HL7 FHIR Release 4.0
This message uses the HTTP POST method on the target Beneficiary Manager endpoint that is a FAIS EnrollmentRequest $submit operation. It is sent from a Beneficiary Requestor.
When a Beneficiary Requestor needs to enroll a Patient with a given Coverage on the Beneficiary Manager, it submits the Enrollment Request Message. The Coverage resource MAY be created by the Beneficiary Requestor based on the InsurancePlan the beneficiary is enrolling in. The Coverage MAY also be created by any other method that is beyond the scope of this profile. The Insurance Plan MAY be retrieved from the Beneficiary Manager using the Query Insurance Plan [ITI-YY2] Transaction.
The Beneficiary Requestor invokes the FAIS EnrollmentRequest $submit operation on the Beneficiary Manager. The operation is invoked by submitting an HTTP POST request to the Beneficiary Manager at the path:
POST [base]/EnrollmentRequest/$submit
The HTTP body SHALL consist of either a FHIR EnrollmentRequest resource conforming to the FAIS EnrollmentRequest profile or an EnrollmentRequest Bundle including referenced resources conforming to the FAIS EnrollmentRequest Bundle profile.
The Beneficiary Manager SHALL process the EnrollmentRequest and respond as per http://hl7.org/fhir/R4/operations.html#response, and if successful, with an HTTP 201
(CREATED) and an Enroll Beneficiary Response Message.
The Beneficiary Manager SHALL persist the EnrollmentRequest resource and include a reference to it in the EnrollmentResponse resource.
The Beneficiary Manager has a response or errors to report to the Beneficiary Requestor. This MAY include a queued response.
The Enroll Beneficiary Response conforms to the FAIS EnrollmentResponse profile and is sent from the Beneficiary Manager to the Beneficiary Requestor. If the disposition of the enrollment can’t be handled synchronously, then the outcome
element SHALL be set to queued
and EnrollmentResponse SHALL include an id
and persist on the Beneficiary Manager so that the ITI-YY3 Check Enrollment Status transaction can be used to get updates on the response.
How the Beneficiary Requestor processes the response is determined by the implementation and beyond the scope of this profile.
Server implementing this transaction SHALL provide a CapabilityStatement Resource as described in ITI TF-2x: Appendix Z.3 indicating the transaction has been implemented.
See FAIS Security Considerations
Note that the same audit message is recorded by both the Beneficiary Requestor and Beneficiary Manager. The difference being the Audit Source element. Both sides record to show consistency between the message sent by the Beneficiary Requestor and the action taken at the Beneficiary Manager.
The actors involved SHALL record audit events according to the Audit Event for Enroll Beneficiary Transaction. See Audit Example for Enroll Beneficiary from the Beneficiary Requestor.