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

2:3.YY6 Track Claim [ITI-YY6]

This section corresponds to transaction [ITI-YY6] of the IHE IT Infrastructure Technical Framework. Transaction [ITI-YY6] is used by the Claims Manager and Claims Requestor Actors. The Track Claim [ITI-YY6] transaction is used to get the status of a claim.

2:3.YY6.1 Scope

This transaction is used by the Claims Requestor to get the status of a claim based on criteria it provides in the query parameters of the request message, or to retrieve a specific claim response. The request is received by the Claims Manager. The Claims Manager processes the request and returns a response of the matching claim responses.

2:3.YY6.2 Actors Roles

Table 2:3.YY6.2-1: Actor Roles

2:3.YY6.3 Referenced Standards

• HL7 FHIR standard R4 http://hl7.org/fhir/R4/index.html

2:3.YY6.4 Messages

2:3.YY6.4.1 Search Claim Response Request Message

The Search Claim Response message is a FHIR search interaction on the ClaimResponse Resource.

2:3.YY6.4.1.1 Trigger Events

A Claims Requestor triggers a Search Claim Response Request to a Claims Manager according to the business rules for the search. These business rules are outside the scope of this transaction.

2:3.YY6.4.1.2 Message Semantics

A Claims Requestor initiates a search interaction using HTTP GET as defined at http://hl7.org/fhir/R4/http.html#search on the ClaimResponse resource. The query parameters are identified below. A Claims Requestor MAY query any combination or subset of the parameters. The target is formatted as:

GET [base]/ClaimResponse?[parameter=value]

Where [base] is the URL of Claims Manager.

A Claims Manager SHALL support responding to a request for both the JSON and the XML messaging formats as defined in FHIR. A Claims Requestor SHALL accept either the JSON or the XML messaging formats as defined in FHIR. See ITI TF-2: Appendix Z.6 for more details.

A Claims Manager SHALL implement the parameters described below. A Claims Manager MAY choose to support additional query parameters beyond the subset listed below. Any additional query parameters supported SHALL be supported according to the core FHIR specification.

See ITI TF-2: Appendix W for informative implementation material for this transaction.

2:3.YY6.4.1.2.1 Query Parameters

The Claims Manager SHALL support the following search parameters as defined at http://hl7.org/fhir/R4/search.html#all and http://hl7.org/fhir/R4/claimresponse.html#search.

_id
_lastUpdated
status
request
patient

The Claims Manager SHALL also support the following prefixes for the _lastUpdated parameter: gt, lt, ge, le, sa, and eb.

2:3.YY6.4.1.3 Expected Actions

The Claims Manager SHALL process the query to retrieve the claim response(s) that match the search parameters given, and if successful, with an HTTP 200 (OK) and a Search Claim Response Response Message or an error as per http://hl7.org/fhir/R4/search.html#errors.

2:3.YY6.4.2 Search Claim Response Response Message

2:3.YY6.4.2.1 Trigger Events

The Claims Manager found Claim Responses matching the query parameters specified by the Claims Requestor as a result of a Search Claim Response Request.

2:3.YY6.4.2.2 Message Semantics

The Claims Manager SHALL support the search response message as defined at http://hl7.org/fhir/R4/http.html#search on the ClaimResponse, as defined at http://hl7.org/fhir/R4/claimresponse.html.

The “content-type” of the response will depend upon the requested response format indicated by the Claims Requestor.

See ITI TF-2: Appendix Z.6 for more details on response format handling. See ITI TF-2: Appendix Z.7 for handling guidance for Access Denied.

2:3.YY6.4.2.2.1 FHIR ClaimResponse Resource Constraints

A ClaimResponse Resource returned by the Claims Manager SHALL be further constrained as described in the FAIS ClaimResponse profile.

2:3.YY6.4.2.3 Expected Actions

The Claims Requestor has received the response and continues with its workflow.

2:3.YY6.4.3 Read Claim Response Request Message

This message represents an HTTP GET from the Claims Requestor to the Claims Manager and provides a mechanism for retrieving a single ClaimResponse with a known resource id.

2:3.YY6.4.3.1 Trigger Events

When the Claims Requestor possesses the id of ClaimResponse (either through query, database lookup, or other mechanism) for which it requires additional or new information, it issues a Read Claim Response Request.

2:3.YY6.4.3.2 Message Semantics

A Claims Requestor initiates a read interaction using HTTP GET as defined at http://hl7.org/fhir/R4/http.html#read on the ClaimResponse Resource. The target is formatted as:

GET [base]/ClaimResponse/[resourceId]

Where [base] is the URL of Claims Manager.

The resourceId included in the request always represents the unique id for the ClaimResponse within the scope of the URL. For example, while http://example1.org/ihe/ClaimResponse/1 and http://example2.com/ihe/ClaimResponse/1 both contain the same [resourceId], they reference two different resource instances.

Note: The use of “http” or “https” in URL does not override requirements to use TLS for security purposes.

A Claims Manager SHALL support responding to a request for both the JSON and the XML messaging formats as defined in FHIR. A Claims Requestor SHALL accept either the JSON or the XML messaging formats as defined in FHIR. See ITI TF-2: Appendix Z.6 for more details.

See ITI TF-2: Appendix W for informative implementation material for this transaction.

2:3.YY6.4.3.3 Expected Actions

The Claims Manager SHALL process the request to retrieve the ClaimResponse that matches the given resource id, and if successful, with an HTTP 200 (OK) and a response as defined at http://hl7.org/fhir/R4/http.html#read with the Read Claim Response Response Message or an error code as defined at http://hl7.org/fhir/R4/http.html#Status-Codes.

2:3.YY6.4.4 Read Claim Response Response Message

2:3.YY6.4.4.1 Trigger Events

The Claims Manager found a ClaimResponse Resource matching the resource identifier specified by the Claims Requestor.

2:3.YY6.4.4.2 Message Semantics

The Read Claim Response Response is sent from the Claims Manager to the Claims Requestor as a single ClaimResponse, as defined at http://hl7.org/fhir/R4/claimresponse.html and constrained by the FAIS ClaimResponse profile.

The “content-type” of the response will depend upon the requested response format indicated by the Claims Requestor.

See ITI TF-2: Appendix Z.6 for more details on response format handling. See ITI TF-2: Appendix Z.7 for handling guidance for Access Denied.

2:3.YY6.4.4.3 Expected Actions

The Claims Requestor has received the response and continues with its workflow.

2:3.YY1.5 CapabilityStatement Resource

Server implementing this transaction SHALL provide a CapabilityStatement Resource as described in ITI TF-2x: Appendix Z.3 indicating the transaction has been implemented.

• Requirements CapabilityStatement for Claims Requestor
• Requirements CapabilityStatement for Claims Manager

2:3.YY6.6 Security Considerations

See FAIS Security Considerations

2:3.YY6.6.1 Security Audit Considerations

Note that the same audit message is recorded by both the Claims Requestor and Claims Manager. The difference being the Audit Source element. Both sides record to show consistency between the message sent by the Claims Requestor and the action taken at the Claims Manager.

The actors performing the Track Claim Query message SHALL record audit events according to the Audit Event for Track Claim Query Transaction. See Audit Example for Track Claim search from the Claims Manager.

The actors performing the Track Claim Read message SHALL record audit events according to the Audit Event for Track Claim Read Transaction. See Audit Example for Track Claim read message from the Claims Requestor.