Future Focus Areas*
Potential focus areas proposed in future versions
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Potential focus areas proposed in future versions
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Following are the list of potential enhancements envisioned/propsed by the community members for the future versions of the protocol.
Improvement in semantic interoperability (WIP) :
Defining higher confidence, harmonised valuesets based on ecosystem input
Valueset discoverability through terminology registry and services
Mechanism for challenging the claim adjudication process : Enabling beneficiaries/providers to dispute claim adjudication outcomes via the Health Claims Exchange (HCX). This would help beneficiaries/providers with a standard mechanism to raise disputes, and streamline the challenge process, fostering increased transparency and trust in the system.
Enabling multi payer - multi policy claim adjudication : Enabling beneficiaries/ providers to submit claims to multiple payers for a given episode, e.g. when the treatment expenses exceed coverage limits, or certain procedures are not included in a specific policy.
Analyse and expand for other OPD categories: Exploring other categories within the OPD use case, understanding their unique challenges, and enhancing the workflow to address specific nuances.
Analysing/enhancing the protocol for non-insurance benefits (Corporate wellness, health CSR, community/cooperatives benefits) : Broadening the scope of the Health Claims Exchange (HCX) to encompass a wider range of benefit scenarios, including corporate wellness, health CSR, and community/cooperative benefits. This strategic expansion aligns with our commitment to innovation and the realisation of the Universal Health Coverage (UHC) vision.
Claim initiation using QR Code (WIP) : Allowing consumers to initiate claims or pre-authorization flows conveniently by using QR codes, simplifying the initiation process. More details in the github comment.
Enhancing CommunicationRequest cycle to allow structured Queries : Enabling hospitals/payers to raise structured queries on the Healthcare Exchange (HCX) platform to payers/hospitals, improving communication and speeding up resolution for reimbursement-related inquiries.
Enhancement in Insurance Plan object : The existing profile only allows to declare limits at benefit level, but we cannot add conditions/rules of eligibility. Also, the values of limits could be expressions, not just values/constants always.
Multiple claims submission : Analysis the feasibility of allowing multiple claims submissions against a single pre-authorization.
Detailed approach on handling attachments/supporting information : Further elaboration on the multiple options to share the supporting information when not available in structured format.
Further detailing of the domain objects (descriptions, examples, etc.) : Enhancing IG to provide better description of the Profiles/Attributes/Valuesets and including more examples/use cases from the domain.
Examples of typical use cases : Adding real-life use cases of the medical episodes and insurance claims.
Guidelines on Technical Operations of the HCX switch(es)/network
Notification Delivery status API
Notification - Failure and retry policies
Consumers wanting to unsubscribe notification from a HIU/ISNP - Consumers may want to stop notifications from the HIUs (Like policy bazaar, etc.) or switch the HIU to get updates on their policies.
Workflow efficiency : Assigning turnaround time (TAT) to each workflow step to streamline the OPD process and ensure timely handling of claims.
Understanding Master policy holder (MPH) as stakeholder : Cater and engage with MPH as stakeholders to understand their specific use cases and analyse/prescribe/enhance the HCX workflow and specifications to serve their needs.
Fraud mitigation : Assessing the potential risks of fraudulent activities in the OPD claims and implementing measures. This is already being discussed under the policy workstream.
Insurance agent persona : Understanding the distinct needs of insurance agents as users of the platform and ensuring their requirements.
Digital contracting (WIP) : Hospital Tariff document (Schedule of Charges, etc…) standardisation and contract between hospital and insurer.
Further refinement of Provider onboarding process.
Enhancements in model business policies in various operational areas.