HCX Protocol
v0.9
v0.9
  • Summary*
  • Glossary*
  • Context
  • Introduction to HCX*
  • Technical Specifications
    • Open Protocol
      • Registries*
        • QR Code Specifications*
      • Claims Data Exchange (HCX) Protocol
        • Message Flows*
          • Primary Message Flow
          • Additional Message Flows
            • Redirect
            • Forward
            • Intra Cycle Communication*
              • Seeking Supporting Information
              • Seeking Beneficiary Consent
              • Seeking Account Information
            • Relay
            • Third party Information sharing
          • Notifications
            • Categories
            • List of key topics
        • Message Structure
        • API Specifications*
          • Registry APIs
          • Primary Flow APIs
          • Supporting APIs
          • Notification APIs
        • Error Handling
      • Data Security and Privacy
        • Transport Security
        • Message Security and Integrity
        • API Security*
      • Audit and Reporting
    • Digital Network Policies
  • Domain Specifications
    • Domain Data Models
      • Handling Attachments
      • Handling Processing Errors
    • Terminologies
    • Domain Specific Languages (DSLs)
    • FHIR Implementation Guide*
  • Business Policy Specifications
    • Access Control (Roles)*
    • Guidelines for Participant Onboarding*
      • Sandbox process
      • Production onboarding (Go live)*
      • Potential De-boarding scenarios
    • Guidelines for Grievance Redressal
      • Scope of disputes
      • Involved participants
      • Guideline process for dispute resolution
      • Guidelines for leveraging FTA
      • Next steps
    • Guidelines for SLAs and ecosystem satisfaction
    • Guidelines for Operating charges
    • Guidelines for Beneficiary Authentication by Providers/Payors
    • Guidelines for Event audits
    • Reference Templates
      • HCX - Terms of use
      • Payer-Provider addendum
      • Payer-Policyholder addendum
    • Next steps
  • Use cases*
    • OPD
      • Typical Workflows
        • Cashless
        • Reimbursement
      • Mapping to the HCX protocol
        • Cashless
        • Reimbursement
    • IPD
      • Typical Workflows
        • Cashless
        • Reimbursement
      • Mapping to the HCX protocol
        • Cashless
        • Reimbursement
    • Implementation Considerations
  • Contributing to the protocol
  • Future Focus Areas*
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  1. Use cases*

OPD

Scope, Typical workflows and mapping to the protocol

The Outpatient Department (OPD) is a distinct component of a healthcare facility, such as a hospital or clinic, dedicated to delivering medical services to patients who do not necessitate overnight hospitalization.

Within the OPD setup, healthcare professionals provide diagnosis, treatment, consultations, and a wide array of medical services to individuals with conditions that can be effectively managed without requiring an extended stay in the healthcare facility.

Please note that the scope of OPD use cases has been limited to following key categories in the current version:

  1. Drugs/Pharmacy - High frequency, a large part of the OOO expenses, always needed as part of any OPD/IPD intervention.

  2. Diagnostics - Almost always needed in pre and post part of any IPD or OPD intervention, results in high OOP

  3. Consultations - Entry point of an OPD journey, medium frequency, crucial to start health journey

  4. Wellness - Wellness interventions involving Consultation, Diagnostics and Drugs/Pharmacy as they will be very similar to #1, #2, and #3 above (except that the policy could be issued by payers/sponsors other than insurance companies).

Prioritisation of above categories was done based on the following prioritisation criterions:

  1. Coverage - Services that cover most patients (using Pareto Principle)

  2. Critical - Services for which OPD insurance is most needed (cost, frequency, etc.)

  3. Ease of implementation - Well defined services & procedures and needing least implementation effort by the participants

  4. Core service - Most offered in current OPD products (Mostly covered in 1 & 2)

  5. Availability of insurance providers - Companies who are providing an OPD insurance to their existing consumers

Following subsections details out the typical workflows in the cashless anf reimbursement OPD claims usecase.

PreviousUse cases*NextTypical Workflows

Last updated 1 year ago

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