Primary Flow APIs
Details of the APIs that facilitate the claims exchange flow
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Details of the APIs that facilitate the claims exchange flow
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Eligibility check
/coverageeligibility/check (provider->HCX, HCX->payor)
/coverageeligibility/on_check (payor->HCX, HCX->provider)
PreDetermination submission
/predetermination/submit (provider->HCX, HCX->payor)
/predetermintation/on_submit (payor->HCX, HCX->provider)
PreAuth submission
/preauth/submit (provider->HCX, HCX->payor)
/preauth/on_submit (payor->HCX, HCX->provider)
Claim submission
/claim/submit (provider->HCX, HCX->payor)
/claim/on_submit (payor->HCX, HCX->provider)
Payment notice and acknowledgement
/paymentnotice/request (payor>HCX, HCX->provider-)
/paymentnotice/on_request (provider->HCX, HCX->payor)
Following details these APIs in detail. These API specs can be opened in swagger editor via this .
This API is for providers to check the eligibility of a beneficiary with the payors via HCX. This API should be used to request whether the patient's coverage is in force, whether it is valid at this or specified date, and/or for requesting the benefits & plan details associated with the coverage.
Providers should send the following details in the request body while making a call for coverage eligibility check:
Overall, the request body (header attributes and the FHIR document) should be sent in the form of a JWE token (RFC-7516) using the steps defined in HCX specs.
The response to this API could be one of the following:
If the request is successfully accepted by the HCX gateway and forwarded to the recipient (i.e. the payor), the provider (who made the Coverage Eligibility Request API call) should expect the response via a call back to Coverage Eligibility Response API asynchronously. The response API payload may either contain the requested coverage details or error details in case of any errors during processing.
An alternate scenario is when the Payor might respond with a redirect instruction asking the Provider to submit the same request to another Payor.
This object is used as payload in the HCX protocol APIs that require the request body to sent in JWE format (as defined in RFC-7516).
This is a callback API is for payors/proessors to send the response for a coverage eligibility request from the providers/originator. In case of a successful scenario, this API payload should contain the eligibilitydetails (in the CoverageEligibilityResponse bundle) and plan url (in the domain header) of the beneficiary for whom the details are requested for.
Payors/Processors should send the following details as the request payload in this callback API:
The responder shall send a ProtocolResponse object (derived from ProtocolHeader) as the request payload in the following scenarios:
In case coverage eligibility request could be processed, responder should send a JWEPayload derived from protected ProtocolHeader and CoverageEligibilityResponse bundle as prescribed for the use case by the domain specifications. CoverageEligibilityResponse resource inside the bundle would contain details about the domain/business processing outcome as follows as per FHIR specifications for the resource.
Object to be returned as payload of the callback API (on_* APIs) in case there are any protocol related errors while processing the request or send a redirection instruction to the original sender of the request.
This API is for providers to submit pre-determination requests (and resubmit updated request) to HCX gateway and for HCX gateway to route the same request to payors.
Payload for this API has to be created as per the Claim Request Bundle defined in HCX Specifications and serialized as per the guidelines in HCX Specifications.
This object is used as payload in the HCX protocol APIs that require the request body to sent in JWE format (as defined in RFC-7516).
This is a callback API is for payors/proessors to send the response for a Pre-Determination request from the providers/originator.
Payors/Processors should send the following details as the request payload in this callback API:
The responder shall send a ProtocolResponse object (derived from ProtocolHeader) as the request payload in the following scenarios:
In case Pre-Determinationrequest could be processed, responder should send a JWEPayload derived from protected ProtocolHeader and ClaimResponse bundle as prescribed for the use case by the domain specifications. ClaimResponse resource inside the bundle would contain details about the domain/business processing outcome as follows as per FHIR specifications for the resource.
Object to be returned as payload of the callback API (on_* APIs) in case there are any protocol related errors while processing the request or send a redirection instruction to the original sender of the request.
This API is for providers to submit pre-authorization requests (and resubmit updated request) to HCX gateway and for HCX gateway to route the same request to payors.
Payload for this API has to be created as per the Claim Request Bundle defined in HCX Specifications and serialized as per the guidelines in HCX Specifications.
This object is used as payload in the HCX protocol APIs that require the request body to sent in JWE format (as defined in RFC-7516).
This is a callback API is for payors/proessors to send the response for a Pre-Authorization request from the providers/originator.
Payors/Processors should send the following details as the request payload in this callback API:
The responder shall send a ProtocolResponse object (derived from ProtocolHeader) as the request payload in the following scenarios:
In case Pre-Authorization request could be processed, responder should send a JWEPayload derived from protected ProtocolHeader and ClaimResponse bundle as prescribed for the use case by the domain specifications. ClaimResponse resource inside the bundle would contain details about the domain/business processing outcome as follows as per FHIR specifications for the resource.
Object to be returned as payload of the callback API (on_* APIs) in case there are any protocol related errors while processing the request or send a redirection instruction to the original sender of the request.
This API is for providers to submit claim requests (and resubmit updated request) to HCX gateway and for HCX gateway to route the same request to payors.
Payload for this API has to be created as per the Claim Request Bundle defined in HCX Specification and serialized as per the guidelines in HCX Specifications.
This object is used as payload in the HCX protocol APIs that require the request body to sent in JWE format (as defined in RFC-7516).
This is a callback API is for payors/proessors to send the response for a Claims request from the providers/originator.
Payors/Processors should send the following details as the request payload in this callback API:
The responder shall send a ProtocolResponse object (derived from ProtocolHeader) as the request payload in the following scenarios:
In case Claims request could be processed, responder should send a JWEPayload derived from protected ProtocolHeader and ClaimResponse bundle as prescribed for the use case by the domain specifications. ClaimResponse resource inside the bundle would contain details about the domain/business processing outcome as follows as per FHIR specifications for the resource.
Object to be returned as payload of the callback API (on_* APIs) in case there are any protocol related errors while processing the request or send a redirection instruction to the original sender of the request.
This API is for Payors to send Payment notification/reconciliation objects to Providers via the HCX gateway. This API is available on HCX gateways and Provider systems.
Payload for this API has to be created as per the Payment Notice defined in HCX Specifications and serialized as JWE json as per the guidelines in HCX Specifications.
This object is used as payload in the HCX protocol APIs that require the request body to sent in JWE format (as defined in RFC-7516).
This is a callback API is for service providers to send the response for a Payment notice request from the payor/processors.
Service providers should send the following details as the request payload in this callback API:
The responder shall send a ProtocolResponse object (derived from ProtocolHeader) as the request payload in the following scenarios:
In case Payment Notice request could be processed, responder should send a JWEPayload derived from protected ProtocolHeader and ClaimResponse bundle as prescribed for the use case by the domain specifications. PaymentNotice resource inside the bundle would contain details about the domain/business processing outcome as follows as per FHIR specifications for the resource.
Object to be returned as payload of the callback API (on_* APIs) in case there are any protocol related errors while processing the request or send a redirection instruction to the original sender of the request.