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*
  2. OPD
  3. Mapping to the HCX protocol

Reimbursement

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Last updated 10 days ago

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The reimagined OPD reimbursement claims workflow leveraging HCX protocol help us understand how claim requests can processed timely and efficiently. Increased provider network coverage, real time updates and approval of the OPD claims will enhance adoption and trust in the system for policyholder.

Link to the typical OPD reimbursement claims workflow.

Important note : The work stream's original diagram representing the overall workflow of the reimagined OPD reimbursement flow using HCX is available . Based on initial feedback for improving the readability, the sections below detail it in multiple diagrams representing each stage separately.

OPD reimbursement claims

Coverage eligibility flow

Even in a reimbursement situation, an OPD service delivery and claims process could start with the beneficiary/policyholder checking their coverage eligibility using the BSP interface. This would serve as a pre-notification for the payer, and aid the beneficiary in obtaining the initial details regarding the coverage. The following diagram shows the steps and stakeholders involved in the coverage eligibility flow.

Pre-auth flow

After the coverage eligibility process, once the provider has decided on the services or treatment plan and the costs, the beneficiary could potentially send a preauthorisation to the payer. This could provide payers with an opportunity to assist the beneficiary with their treatment and expenses planning. The following diagram provides an overview of the steps and stakeholders involved in the pre-auth flow.

Claims flow

Once the services are provisioned and the beneficiary has completed payment, the Beneficiary/policyholder would initiate a reimbursement claim request with the payer through HCX, furnishing the necessary information for the claim adjudication. The beneficiary would use a BSP app to start the claim. Before processing a claim, the Payer would seek consent from the beneficiary to ensure claim authenticity. The following diagram describes the steps and stakeholders involved in the claims flow through HCX.

The next section details the important implementation considerations for OPD health claims.

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