Future Focus Areas*

Potential focus areas proposed in future versions

Following are the list of potential enhancements envisioned/propsed by the community members for the future versions of the protocol.

Please note that this is a tentative list and that the community may revise and prioritise it according to the ecosystem needs.

  1. Improvement in semantic interoperability (WIP) :

    • Defining higher confidence, harmonised valuesets based on ecosystem input

    • Valueset discoverability through terminology registry and services

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. 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 here in the github comment.

  7. 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.

  8. 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.

  9. Multiple claims submission : Analysis the feasibility of allowing multiple claims submissions against a single pre-authorization.

  10. Detailed approach on handling attachments/supporting information : Further elaboration on the multiple options to share the supporting information when not available in structured format.

  11. 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.

  12. Examples of typical use cases : Adding real-life use cases of the medical episodes and insurance claims.

  13. Guidelines on Technical Operations of the HCX switch(es)/network

  14. Notification Delivery status API

  15. Notification - Failure and retry policies

  16. 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.

  1. Workflow efficiency : Assigning turnaround time (TAT) to each workflow step to streamline the OPD process and ensure timely handling of claims.

  2. 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.

  3. 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.

  4. Insurance agent persona : Understanding the distinct needs of insurance agents as users of the platform and ensuring their requirements.

  5. Digital contracting (WIP) : Hospital Tariff document (Schedule of Charges, etc…) standardisation and contract between hospital and insurer.

  6. Further refinement of Provider onboarding process.

  7. Enhancements in model business policies in various operational areas.

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