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-YY9] of the IHE IT Infrastructure Technical Framework. Transaction [ITI-YY9] is used by the Claims Requestor and Claims Manager Actors. The Re-process Claim [ITI-YY9] transaction is used to re-process a claim for a patient.
This transaction is used by the Claims Requestor to re-process a claim for a patient. The request is received by the Claims Manager. The Claims Manager processes the request and returns a response with the status of the request.
Table 2:3.YY9.2-1: Actor Roles
Actor | Role |
---|---|
Claims Requestor | Sends the re-process request to the Claims Manager. |
Claims Manager | Receives and processes the request and returns a response to the Claims Requestor |
FHIR-R4 HL7 FHIR Release 4.0
This message uses the HTTP POST method on the target Claims Manager endpoint that is a FAIS Claim $reprocess operation. It is sent from a Claims Requestor.
When a Claims Requestor needs to re-process a claim for a Patient to the Claims Manager, it submits the Re-process Claim Message.
The Claims Requestor invokes the FAIS Claim $reprocess operation on the Claims Manager. The operation is invoked by submitting an HTTP GET request to the Claims Manager at the path:
GET [base]/Claim/<resourceId>/$reprocess
Where
The Claims Manager SHALL re-process the claim and respond as per http://hl7.org/fhir/R4/operations.html#response, and if successful, with an HTTP 200
(OK) and a Re-process Claim Response Message.
The Claims Manager SHALL update the requested Claims resource as defined by internal business rules.
The Claims Manager has a response or errors to report to the Claims Requestor. This MAY include a queued response.
The Re-process Claim Response conforms to the FAIS ClaimResponse profile and is sent from the Claims Manager to the Claims Requestor. If the disposition of the claim can’t be handled synchronously, then the outcome
element SHALL be set to queued
and ClaimResponse SHALL include an id
and persist on the Claims Manager so that the ITI-YY6 Track Claim transaction can be used to get updates on the response.
How the Claims 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 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 involved SHALL record audit events according to the Audit Event for Re-process Claim Transaction. See Audit Example for Re-process Claim from the Claims Requestor.