This page is part of the FHIR Specification (v3.0.2: STU 3). (v3.5.0: R4 Ballot #2). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3

Work Group Financial Management

Ballot Status : Informative

13.0 Financial Module

13.0.1 Introduction

The Financial module covers the resources and services provided by FHIR to support the costing, financial transactions and billing which occur within a healthcare provider as well as the eligibility, enrollment, authorizations, claims and payments which occur between healthcare providers and insurers and the reporting and notification between insurers and subscribers and patients.

See also the Administration and WorkFlow modules.

13.0.2 Index

Account Coverage EligibilityRequest CoverageEligibilityRequest EligibilityResponse CoverageEligibilityResponse

EnrollmentRequest EnrollmentResponse Claim ClaimResponse

PaymentNotice PaymentReconciliation ExplanationOfBenefit

13.0.2.1 Support

Administrative

Name	Aliases	Description
Account	Cost center	A financial tool for tracking value accrued for a particular purpose. In the healthcare field, used to track charges for a patient, cost centers, etc.
Coverage		Financial instrument which may be used to reimburse or pay for health care products and services.
EligibilityRequest CoverageEligibilityRequest		The EligibilityRequest CoverageEligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an EligibilityResponse, CoverageEligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.
EligibilityResponse CoverageEligibilityResponse		This resource provides eligibility and plan details from the processing of an Eligibility CoverageEligibilityRequest resource.
EnrollmentRequest		This resource provides the insurance enrollment details to the insurer regarding a specified coverage.
EnrollmentResponse		This resource provides enrollment and plan details from the processing of an Enrollment resource.

13.0.2.2 Billing

Claims, processing and responses

Name	Aliases	Description
Claim		A provider issued list of services and products provided, or to be provided, to a patient which is provided to an insurer for payment recovery.
ClaimResponse	Remittance Advice	This resource provides the adjudication details from the processing of a Claim resource.

13.0.2.3 Payment

Used to support service payment processing and reporting

Name	Aliases	Description
PaymentNotice		This resource provides the status of the payment for goods and services rendered, and the request and response resource references.
PaymentReconciliation		This resource provides payment details and claim references supporting a bulk payment.

13.0.2.4 Other

Patient reporting and other purposes

Name	Aliases	Description
ExplanationOfBenefit	EOB	This resource provides: the claim details; adjudication details from the processing of a Claim; and optionally account balance information, for informing the subscriber of the benefits provided.

Additional Resources will be added in the future. A list of hypothesized resources can be found on the HL7 wiki . Feel free to add any you think are missing or engage with one of the HL7 Work Groups to submit a proposal to define a resource of particular interest.

13.0.3 Security and Privacy

Financial information in general and in particular when related to or including health information, such as claims data, are typically considered Protected Health Information and as such must be afforded the same protection and safeguards as would be afforded to purely clinical identified health data.

The Security and Privacy measures associated with FHIR, such as the use of Security labels and tags in the resource.meta, is encouraged as are encouraged in addition to the use of whatever measures for authorization and encryption are supported by the chosen exchange model, e.g. FHIR REST, Web Services, Direct, MLLP, SMTP and others.

For more general considerations, see the Security and Privacy module .

13.0.4 Glossary

Financial information in general and in particular when related to or including health information, such as claims data, are typically considered Protected Health Information and as such must be afforded the same protection and safeguards as would be afforded to purely clinical identified health data.

Term	Alias	Resource Type	Description
Adjudication	Claim, Preauthorization or Predetermination Processing	ClaimResponse	The processing by an insurer of a claim, preauthorization or predetermination to determine under the insurance plan what if any benefits are or would be payable.
Assignment of Benefit	Assignment	n/a	When a Beneficiary directs that any benefit they receive from the adjudication of a claim may be paid to the service provider who issued the claim.
Attachment		Communication	A collection of information objects sent to a party to support their understanding or processing of another resource such as a claim.
Beneficiary	Patient	Patient	The party who's health care expenses may be covered by a policy issued by an Insurer.
Benefit Amount	Benefit	n/a	The amount payable under an insurance policy for a given expense incurred by a patient.
Claim	Claim	Claim	A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any.
Coordination of Benefit	COB	n/a	The the rules, usually regionally defined, which govern the order of application of multiple Insurance coverages or SelfPay to a given suite of health care expenses.
Dependent		Patient, RelatedPerson	A person who receives their coverage via a policy which is own or subscribed to by another. Typically these include spouses, partners and minor children but may also include students, parents and disabled persons.
Insurer	Payer, Payor	Organization	A public or private insurer which will adjudicate Claims for health care goods and services to determine if the there is any benefit payable, amount due, under the policy which covers the patient.
Network		n/a	An insurer defined grouping of Providers for which the Beneficiary's plan preferentially covers the costs of treatment, eg. closed, rental, etc.
Payer	Payor, Insurer	Organization	A public or private insurer.
Payor	Payer, Insurer	Organization	A public or private insurer.
Policy		Contract	A contract between an Insurer and an individual or other entity such as an employer to reimburse covered parties (Beneficiaries) for some or all of a prescribed suite of health-related goods and services.
Policy Holder	Policy owner	Patient, RelatedPerson, Organization	The party which owns the policy. It may be the employer for work-related policies or the individual for purchased or public policies.
Preauthorization	Prior Authorization, Pre-Auth	Claim	A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted.
Predetermination	Pre-Determination, PreD	Claim	A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.
Solicited Attachment		Communication	An attachment sent to provide supporting information in response to having received a request for additional information.
Subscriber		Patient, RelatedPerson	The person who signs-up for the coverage. May be an employee or person with dependents.
Unsolicited Attachment		Communication	An attachment sent to provide supporting information without first having received a request for additional information.

13.0.5 Common Use Cases

The table below details various common business activities which occur in the financial realm, and the focal resources which may be exchanged, along with supporting resources, to accomplish the business activities. Whether the resources specified are actually needed requires consideration of the business itself and the exchange methodology and transport being used.

For example: If a content model is not required to obtain the appropriate status element then a SEARCH (GET) may be used, however if a content model is required to support the request for information then the content model will need to be CREATEd (POST). Alternately, if FHIR Operations are being used then the specified focal resource may be employed as one of the Operation parameters or may might not be required.

Business Activity	Request Resource	Response Resource
Eligibility Check	EligibilityRequest CoverageEligibilityRequest	EligibilityResponse CoverageEligibilityResponse
Enrollment Update	EnrollmentRequest	EnrollmentResponse
Claim	Claim (type={discipline}, use=complete) use=claim)	ClaimResponse
Pre-determination Predetermination	Claim (type={discipline}, use=exploratory) use=predetermination)	ClaimResponse
Pre-Authorization Preauthorization	Claim (type={discipline}, use=proposed) use=preauthorization)	ClaimResponse
Reversal	ProcessRequest (action=cancel, nullify=false)	ClaimResponse
Nullify	ProcessRequest (action=cancel, nullify=true)	ClaimResponse
Re-adjudication	ProcessRequest (action=reprocess)	ClaimResponse
Status Check	ProcessRequest (action=status)	ProcessResponse
Pended Check (Polling)	ProcessRequest (action=poll)	{Resource} or ProcessResponse
Payment Notice	PaymentNotice	ProcessResponse
Payment Reconciliation	ProcessRequest (action=poll, include= PaymentReconciliation )	PaymentReconciliation
Send Attachments	Communication	ProcessResponse
Request Attachments	ProcessRequest (action=poll, include= CommunicationRequest )	CommunicationRequest
Request an Explanation of Benefits	ProcessRequest (action=poll, include= ExplanationOfBenefit )	ExplanationOfBenefit

{discipline} means the type of claim: OralHealth, Vision, Pharmacy, Professional or Institutional.

{Resource} means any pended or undelivered resource subject to the selection details specified in the request.

13.0.5 13.0.6 Relative Order of Use

The table below details the relative order of events and use of financial resources for patient care during the care cycle. Not all steps or information exchanges may occur, and supporting information may be required more frequently than has been depicted below.

Business Activity	Focal Resource
Patient visits Provider
Provider checks for valid insurance coverage	EligibilityRequest CoverageEligibilityRequest
Insurer responds with coverage status and optional plan details	EligibilityResponse CoverageEligibilityResponse
Provider examines Patient and reviews treatment options
Provider submits Pre-determination(s) Predetermination(s) for treatment options to determine potential reimbursement	Claim {use=exploratory} {use=predetermination}
Insurer responds with potential reimbursement	ClaimResponse
Provider and Patient determine treatment plan
Treatment plan submitted to Insurer to reserve funds	Claim {use=proposed} {use=preauthorization}
Insurer acknowledges receipt of pre-authorization preauthorization	ClaimResponse
Insurer requests additional information	CommunicationRequest
Provider submits supporting information	Communication
Insurer provides adjudicated response to pre-authorization	ClaimResponse
Provider checks on status of pre-authorization processing	ProcessRequest {action=status}
Insurer responds indicating adjudication is ready	ProcessResponse
Provider retrieves pre-authorization adjudication	READ or ProcessRequest {action=poll}
Provider provides treatment
Provider submits patient's claim for reimbursement	Claim {use=complete} {use=claim}
Insurer responds with claim adjudication	ClaimResponse
Patient leaves treatment setting
Patient requests an Explanation of Benefit for their Personal Health Record application	READ or ProcessRequest {action=poll}
Insurer responds with Explanation of Benefit	ExplanationOfBenefit
Provider requests the payment details associated with a bulk payment	SEARCH or ProcessRequest {action=poll}
Insurer responds with a Payment Reconciliation	PaymentReconciliation
Insurer notifies provider that payment has been issued	PaymentNotice
Insurer notifies parties that payment funds have been received	PaymentNotice

13.0.6 13.0.7 Secondary Uses

In addition to their primary use of conveying patient billing information to insurers for reimbursement either to the subscriber or the provider (assignment of benefit), many of the financial resources, such as Claim and ExplanationOfBenefit , may be used to export data to other agencies to support reporting and analytics.

13.0.7 13.0.8 Attachments - Supporting Information

There is often a need to provide supporting information, commonly referred to as attachments , to document the need for a service and/or to confirm that the good or service was authorized or rendered. This information may be in many forms, including: scanned documents, PDFs, word processing files, XRays, images, CDAs and FHIR Resources.

Supporting information may be provided, as a reference or the actual material, to support the Claim (complete claim or Pre-Authorization) or ExplanationOfBenefit in a variety of manners:

• Included : in the {resource} .information section;
• Unsolicited : in a Communication which refers to the Claim or Explanation Of Benefit; or
• Solicited : in a Communication in response to a CommunicationRequest from the insurer requesting more information; or
• Input : in the input parameters of a FHIR operation or Task.input element if a Task resource is used.

13.0.8 13.0.9 Developmental Roadmap

The Financial Management Work Group (FM) is responsible for two subdomains:

Financial Accounts and Billing (FIAB) - resources for accounts, charges (internal costing transactions) and patient billing, and
Financial Claims and Reimbursement (FICR) - insurance information, enrollment, eligibility, pre-authorization, predetermination, preauthorization, claims, patient reporting and payments.

To date FM has been focusing on the resources required to support the exchange of claims and related information between healthcare health care providers and insurers. The first draft of this work is nearing completion with the release of the first Financial Standard for Trial Use in STU3 of FHIR. Over the next year further refinements will be expected as we begin developing regional profiles and begin live pilots with resources.

Once the above is well underway FM can then look to developing the Enrollment-related resources and the resources to support the FIAB functions.

13.0.9 13.0.10 Terminology

In many cases an example valueset has been provided in this release. Financal Financial Management will be devoting effort in the preparation to Release 4 of FHIR to develop more representative example sets and to determine where global codesets exist such that some of the valuesets may be elevated in strength to extensible or required.