Finance and Insurance Service (FAIS)
1.0.0 - trial-use
Finance and Insurance Service (FAIS)
1.0.0 - trial-use
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
Contents:
This page provides a list of the FHIR artifacts defined as part of this implementation guide.
The following artifacts define the specific capabilities that different types of systems are expected to have in order to comply with this implementation guide. Systems conforming to this implementation guide are expected to declare conformance to one or more of the following capability statements.
| Beneficiary Manager Actor |
CapabilityStatement for Beneficiary Manager Actor. The Beneficiary Manager processes requests from the Beneficiary Requestor actor. It follows internal business processes to enroll beneficiaries from the Beneficiary Requestor that are beyond the scope of this profile and will return the result of the enrollment. It also responds to queries about insurance plans. |
| Beneficiary Requestor Actor |
CapabilityStatement for Beneficiary Requestor Actor. The Beneficiary Requestor can enroll beneficiaries and optionally query insurance plans from a Beneficiary Manager. |
| Claims Manager Actor |
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. |
| Claims Requestor Actor |
CapabilityStatement for Claims Requestor Actor. The Claims Requestor files a pre-determination, pre-authorization, or claim for a patient, as well as cancel and re-process claims, and can query for responses when the result is queued. |
| Coverage Requestor Actor |
CapabilityStatement for Coverage Requestor Actor. The Coverage Requestor checks for what coverage a patient has and can query for responses when the result is queued. |
These are custom operations that can be supported by and/or invoked by systems conforming to this implementation guide.
| FAIS Claim $cancel |
The FAIS Claim $cancel operation to be used on a Claim instance when the Claim should be cancelled. This is called from the Claims Requestor to the Claims Manager. |
| FAIS Claim $reprocess |
The FAIS Claim $reprocess operation to be used on a Claim instance when the Claim should be re-processed. This is called from the Claims Requestor to the Claims Manager. |
| FAIS Claim $submit |
The FAIS Claim $submit operation to be used when the Claim is being submitted. This is called from the Claims Requestor to the Claims Manager. |
| FAIS Coverage Eligibility Request $submit |
The FAIS Coverage Eligibility Request $submit operation to be used when the CoverageEligibilityRequest is being submitted. This is called from the Coverage Requestor to the Claims Manager. |
| FAIS Enrollment Request $submit |
The FAIS Enrollment Request $submit operation to be used when the EnrollmentRequest is being submitted. This is called from the Beneficiary Requestor to the Beneficiary Manager. |
These define the properties by which a RESTful server can be searched. They can also be used for sorting and including related resources.
| SearchParameter for InsurancePlan on the coverage.benefit.type element |
This SearchParameter enables finding InsurancePlans by benefity type. |
| SearchParameter for InsurancePlan on the coverageArea element |
This SearchParameter enables finding InsurancePlans by coverageArea. |
| SearchParameter for InsurancePlan on the network element |
This SearchParameter enables finding InsurancePlans by network. |
These define constraints on FHIR resources for systems conforming to this implementation guide.
| Audit Event for Cancel Claim Transaction by the Claims Requestor and Claims Manager for Update |
Defines constraints on the AuditEvent Resource to record when a Cancel Claim Transaction happens to call the $cancel operation on a Claims Manager, as recorded by the Claims Requestor and Claims Manager. |
| Audit Event for Check Coverage Eligibility Status Transaction by the Coverage Requestor and Claims Manager for Query |
Defines constraints on the AuditEvent Resource to record when a Check Coverage Eligibility Status Transaction happens to query a CoverageEligibilityResponse, as recorded by the Coverage Requestor and Claims Manager. |
| Audit Event for Check Coverage Eligibility Status Transaction by the Coverage Requestor and Claims Manager for Read |
Defines constraints on the AuditEvent Resource to record when a Check Coverage Eligibility Status Transaction happens to read a CoverageEligibilityResponse, as recorded by the Coverage Requestor and Claims Manager. |
| Audit Event for Check Coverage Eligibility Transaction by the Coverage Requestor and Claims Manager for Create |
Defines constraints on the AuditEvent Resource to record when a Check Coverage Eligibility Transaction happens to call the $submit operation on a Claims Manager, as recorded by the Coverage Requestor and Claims Manager. |
| Audit Event for Check Enrollment Status Transaction by the Beneficiary Requestor and Beneficiary Manager for Query |
Defines constraints on the AuditEvent Resource to record when a Check Enrollment Status Transaction happens to query an EnrollmentResponse, as recorded by the Beneficiary Requestor and Beneficiary Manager. |
| Audit Event for Check Enrollment Status Transaction by the Beneficiary Requestor and Beneficiary Manager for Read |
Defines constraints on the AuditEvent Resource to record when a Check Enrollment Status Transaction happens to read an EnrollmentResponse, as recorded by the Beneficiary Requestor and Beneficiary Manager. |
| Audit Event for Enroll Beneficiary Transaction by the Beneficiary Requestor and Beneficiary Manager for Create |
Defines constraints on the AuditEvent Resource to record when an Enroll Beneficiary Transaction happens to call the $submit operation on a Beneficiary Manager, as recorded by the Beneficiary Requestor and Beneficiary Manager. |
| Audit Event for Query Insurance Plan Transaction by the Beneficiary Requestor and Beneficiary Manager for Query |
Defines constraints on the AuditEvent Resource to record when a Query Insurance Plan Transaction happens to query an InsurancePlan, as recorded by the Beneficiary Requestor and Beneficiary Manager. |
| Audit Event for Query Insurance Plan Transaction by the Beneficiary Requestor and Beneficiary Manager for Read |
Defines constraints on the AuditEvent Resource to record when a Query Insurance Plan Transaction happens to read an InsurancePlan, as recorded by the Beneficiary Requestor and Beneficiary Manager. |
| Audit Event for Re-process Claim Transaction by the Claims Requestor and Claims Manager for Update |
Defines constraints on the AuditEvent Resource to record when a Re-process Claim Transaction happens to call the $reprocess operation on a Claims Manager, as recorded by the Claims Requestor and Claims Manager. |
| Audit Event for Submit Claim Transaction by the Claims Requestor and Claims Manager for Create |
Defines constraints on the AuditEvent Resource to record when a Submit Claim Transaction happens to call the $submit operation on a Claims Manager, as recorded by the Claims Requestor and Claims Manager. |
| Audit Event for Track Claim Transaction by the Claims Requestor and Claims Manager for Read |
Defines constraints on the AuditEvent Resource to record when a Track Claim Transaction happens to read a ClaimResponse, as recorded by the Coverage Requestor and Claims Manager. |
| Audit Event for Track Claim Transaction by the Coverage Requestor and Claims Manager for Query |
Defines constraints on the AuditEvent Resource to record when a Track Claim Transaction happens to query a ClaimResponse, as recorded by the Coverage Requestor and Claims Manager. |
| FAIS Claim Bundle Profile |
The FAIS Claim Bundle profile for a claim bundle to be POSTed to the Claim $submit operation when referenced resources are included with the claim submission. |
| FAIS Claim Profile |
The FAIS Claim profile for submitting claims. |
| FAIS ClaimResponse Bundle Profile |
The FAIS ClaimResponse Bundle profile for a claim response bundle to be returned from the claim operations:
|
| FAIS ClaimResponse Profile |
The FAIS ClaimResponse profile to be used as the response to the FAIS Claim $submit |
| FAIS CoverageEligibilityRequest Bundle Profile |
The FAIS CoverageEligibilityRequest Bundle profile for a coverage eligiblity request bundle to be POSTed to the CoverageEligibilityRequest $submit operation when referenced resources are included with the coverage eligibility submission. |
| FAIS CoverageEligibilityRequest Profile |
The FAIS CoverageEligibilityRequest profile for submitting coverage eligibility requests. |
| FAIS CoverageEligibilityResponse Bundle Profile |
The FAIS CoverageEligibilityResponse Bundle profile for a coverage eligiblity response bundle to be returned from the FAIS CoverageEligibilityRequest $submit when referenced resources are included with the coverage eligibility response. |
| FAIS CoverageEligibilityResponse Profile |
The FAIS CoverageEligibilityResponse profile to be used as the response to the FAIS CoverageEligibilityRequest $submit |
| FAIS EnrollmentRequest Bundle Profile |
The FAIS EnrollmentRequest Bundle profile for an enrollment request bundle to be POSTed to the EnrollmentRequest $submit operation when referenced resources are included with the enrollment submission. |
| FAIS EnrollmentRequest Profile |
The FAIS EnrollmentRequest profile for submitting enrollment requests. |
| FAIS EnrollmentResponse Bundle Profile |
The FAIS EnrollmentResponse Bundle profile for an enrollment response bundle to be returned from the FAIS EnrollmentRequest $submit when referenced resources are included with the enrollment response. |
| FAIS EnrollmentResponse Profile |
The FAIS EnrollmentResponse profile to be used as the response to the FAIS EnrollmentRequest $submit |
| FAIS InsurancePlan Profile |
The FAIS Insurance Plan profile for creating Coverage resources to enroll beneficiaries. |
These define constraints on FHIR data types for systems conforming to this implementation guide.
| Request Status Reason |
Captures the reason for the current state of the resource. |
These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like.
| Audit example for ITI-121 for Beneficiary Manager for query. |
Audit example for a Beneficiary Manager requesting a query on an InsurancePlan for ITI-121. |
| Audit example for ITI-121 for Beneficiary Requestor for read. |
Audit example for a Beneficiary Requestor requesting a read on an InsurancePlan for ITI-121. |
| Audit example for ITI-122 for Beneficiary Requestor for submit. |
Audit example for a Beneficiary Requestor requesting a submit on an EnrollmentRequest for ITI-122. |
| Audit example for ITI-123 for Beneficiary Manager for query. |
Audit example for a Beneficiary Manager requesting a query on an EnrollmentResponse for ITI-123. |
| Audit example for ITI-123 for Beneficiary Requestor for read. |
Audit example for a Beneficiary Requestor requesting a read on an EnrollmentResponse for ITI-123. |
| Audit example for ITI-124 for Coverage Requestor for submit. |
Audit example for a Coverage Requestor requesting a submit on a CoverageEligibilityRequest for ITI-124. |
| Audit example for ITI-125 for Beneficiary Manager for query. |
Audit example for a Beneficiary Manager requesting a query on a CoverageEligibilityResponse for ITI-125. |
| Audit example for ITI-125 for Claims Manager for read. |
Audit example for a Claims Manager requesting a read on a CoverageEligibilityResponse for ITI-125. |
| Audit example for ITI-126 for Claims Requestor for submit. |
Audit example for a Claims Requestor requesting a submit on a Claim for ITI-126. |
| Audit example for ITI-127 for Claims Requestor for cancel. |
Audit example for a Claims Requestor requesting a cancel on a Claim for ITI-127. |
| Audit example for ITI-128 for Claims Requestor for re-process. |
Audit example for a Claims Requestor requesting a re-process on a Claim for ITI-128. |
| Audit example for ITI-129 for Claims Manager for query. |
Audit example for a Claims Manager requesting a query on a ClaimResponse for ITI-129. |
| Audit example for ITI-129 for Claims Requestor for read. |
Audit example for a Claims Requestor requesting a read on a ClaimResponse for ITI-129. |
| Device Example - FAIS Beneficiary Manager |
Device Example for FAIS Beneficiary Manager |
| Device Example - FAIS Beneficiary Requestor |
Device Example for FAIS Beneficiary Requestor |
| Device Example - FAIS Claims Manager |
Device Example for FAIS Claims Manager |
| Device Example - FAIS Claims Requestor |
Device Example for FAIS Claims Requestor |
| Device Example - FAIS Coverage Requestor |
Device Example for FAIS Coverage Requestor |
| Example Coverage |
Example Coverage for the example beneficiary |
| Example Coverage Eligibility Request |
Example request to check coverage eligibility. |
| Example Coverage Eligibility Request Bundle |
Example Bundle of coverage eligibility request resources. |
| Example Coverage Eligibility Response |
Example Coverage Eligibility Response |
| Example Enrollment Request |
Example Enrollment Request |
| Example Enrollment Request Bundle |
Example Bundle of enrollment request resources. |
| Example Enrollment Response |
Example Enrollment Response |
| Example Insurer |
Example insurer organization. |
| Example Patient Beneficiary |
Example Beneficiary patient for enrollment and claims. |
| Use Case 1 - Example Coverage |
Example Coverage for use case 1 The Beneficiary Requestor will create the Coverage resource for the Beneficiary based on the InsurancePlan and send it as part of the enrollment request bundle to the Beneficiary Manager. |
| Use Case 1 - Example Enrollment Request |
Example Enrollment Request for use case 1. The Benficiary Requestor will create the EnrollmentRequest to send to the Beneficiary Manager at the EnrollmentRequest $submit operation. |
| Use Case 1 - Example Enrollment Request Bundle |
Example Bundle of enrollment request resources for use case 1. The Beneficiary Requestor can submit this bundle to the EnrollmentRequest $submit operation. |
| Use Case 1 - Example Enrollment Response |
Example Enrollment Response for use case 1. The Beneficiary Manager may respond with the EnrollmentResponse from the EnrollmentRequest $submit operation. |
| Use Case 1 - Example Enrollment Response Bundle |
Example Enrollment Response for use case 1. The Beneficiary Manager may respond with the EnrollmentResponse Bundle from the EnrollmentRequest $submit operation. |
| Use Case 1 - Example Insurance Plan |
Example Insurance Plan for enrollment for use case 1 |
| Use Case 1 - Example Insurer: National Health Insurance Scheme |
Example insurer organization for use case 1. |
| Use Case 1 - Example Network: National Health Hospital System |
Example healthcare organization for use case 1. |
| Use Case 1 - Example Patient Beneficiary |
Example Beneficiary patient for enrollment for use case 1. |
| Use Case 2 - Example Coverage Eligibility Request |
Example request to check coverage eligibility. The Coverage Requestor may submit this or a bundle to the CoverageEligibilityRequest $submit operation on the Claims Manager. |
| Use Case 2 - Example Coverage Eligibility Request Bundle |
Example Bundle of coverage eligibility request resources for use case 2. The Coverage Requestor can submit this bundle to the CoverageEligibilitiyRequest $submit operation on the Claims Manager. |
| Use Case 2 - Example Coverage Eligibility Response |
Example Coverage Eligibility Response for use case 2. The Claims Manager may return this or a bundle from the CoverageEligibilityRequest $submit operation to the Beneficiary Requestor. |
| Use Case 2 - Example Coverage Eligibility Response Bundle |
Example Bundle of coverage eligibility response resources for use case 2. The Claims Manager may return this from the CoverageEligibilityRequest $submit operation to the Beneficiary Requestor. |
| Use Case 2 - Example Doctor |
Example Doctor for use case 2. |
| Use Case 2 - Local Hospital |
Example local hospital for use case 2. |
| Use Case 3 - Example accepted claim response |
Example accepted claim response for use case 3. The Claims Manager can return this or a claim response bundle from the Claim $submit operation to the Claims Requestor. |
| Use Case 3 - Example accepted claim response bundle |
Example accepted claim response bundle for use case 3. The Claims Manager can return this bundle from the Claim $submit operation to the Claims Requestor. |
| Use Case 3 - Example cancelled claim |
Example cancelled claim for use case 3. The Claims Manager received a cancellation from the Claims Requestor at Claim $cancel operation and updated the Claim to be cancelled |
| Use Case 3 - Example claim |
Example claim for use case 3. The Claims Requestor can submit this or a claim bundle to the Claim $submit operation on the Claims Manager. |
| Use Case 3 - Example claim bundle |
Example claim bundle for use case 3. The Claims Requestor can submit this bundle to the Claim $submit operation on the Claims Manager. |
| Use Case 3 - Example denied claim response |
Example denied claim response for use case 3. The Claims Manager can return this or a claim response bundle from the Claim $submit operation to the Claims Requestor. |
| Use Case 3 - Example queued claim response |
Example queued claim response for use case 3. The Claims Manager can return this or a claim response bundle from the Claim $submit operation to the Claims Requestor. |
| Use Case 4 - Example accepted pre-determination response |
Example accepted pre-determination response for use case 4. The Claims Manager can return this or a claim response bundle from the Claim $submit operation to the Claims Requestor. |
| Use Case 4 - Example pre-determination claim |
Example pre-determination claim for use case 4. The Claims Requestor can submit this or a claim bundle to the Claim $submit operation on the Claims Manager. |
| Use Case 5 - Example accepted pre-determination response |
Example accepted pre-determination response for use case 5. The Claims Manager can return this or a claim response bundle from the Claim $submit operation to the Claims Requestor. |
| Use Case 5 - Example pre-authorization claim |
Example pre-authorization claim for use case 5. The Claims Requestor can submit this or a claim bundle to the Claim $submit operation on the Claims Manager. |
These are resources that are used within this implementation guide that do not fit into one of the other categories.
| Testing Feature File for ITI 121 |
Gherkin Feature file for testing the Query Insurance Plan [ITI-121] transaction. |
| Testing Feature File for ITI 122 |
Gherkin Feature file for testing the Enroll Beneficiary [ITI-122] transaction. |
| Testing Feature File for ITI 123 |
Gherkin Feature file for testing the Check Enrollment Status [ITI-123] transaction. |
| Testing Feature File for ITI 124 |
Gherkin Feature file for testing the Check Coverage Eligibility [ITI-124] transaction. |
| Testing Feature File for ITI 125 |
Gherkin Feature file for testing the Check Coverage Eligibility Status [ITI-125] transaction. |
| Testing Feature File for ITI 126 |
Gherkin Feature file for testing the Submit Claim [ITI-126] transaction. |
| Testing Feature File for ITI 127 |
Gherkin Feature file for testing the Cancel Claim [ITI-127] transaction. |
| Testing Feature File for ITI 128 |
Gherkin Feature file for testing the Re-process Claim [ITI-128] transaction. |
| Testing Feature File for ITI 129 |
Gherkin Feature file for testing the Track Claim [ITI-129] transaction. |
IG © 2024+ IHE IT Infrastructure Technical Committee. Package ihe.iti.fais#1.0.0 based on FHIR 4.0.1. Generated 2024-11-13
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