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HCX Protocol
v0.6
v0.6
  • Context
  • Introduction to HCX
  • Open Specifications
    • Design Principles
    • Key Specifications
    • Governance
  • Technical Specifications
    • Open Protocol
      • Key Design Considerations
      • Registries
      • Health Claims Exchange (HCX) Protocol
      • Data Security and Privacy
        • Transport Security
        • Message Security and Integrity
        • API Security
        • Audit and Reporting
    • Appendix A - HCX Relay example
  • Domain Specifications
    • Domain Data Specifications
      • Domain Data Models
        • eObjects
        • Implementation Guide
      • Terminologies (Code sets or Metadata standards)
      • Domain Specific Languages (DSLs)
    • Healthcare Operations Policies
      • Access Control (Roles)
      • Guidelines for Participant Onboarding
      • Guidelines for Grievance Redressal
      • Guidelines for Event audits
      • Guidelines for Beneficiary Authentication by Providers/Payors
  • Future roadmap
  • How to submit responses?
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  • Coverage Eligibility Request
  • Coverage Eligibility Response
  • Claim Request
  • Claim Response
  • Payment Notice
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  1. Domain Specifications
  2. Domain Data Specifications
  3. Domain Data Models

eObjects

This version of the HCX specification defines the domain model specifications required for the following eObjects:

  • Coverage Eligibility Request and Coverage Eligibility Response

  • Claim Request and Claim Response: These objects will be used for both Pre-Authorization and Claim use cases (and for Pre-Determination also in future).

  • Payment Notice and Payment Reconciliation

As mentioned in the design considerations for domain specification, the eObjects leverage HL7/FHIR4 specification and extend it, wherever required.

Coverage Eligibility Request

As per the design considerations and guidelines listed in the previous sections, the coverage eligibility request payload has to be created as an FHIR document bundle. The bundle should have the following resources:

Resource

Description

Composition

type: should be a code representing Coverage Eligibility Request document type.

section: The document shall have one section with a single entry having reference to CoverageEligibilityRequest resource.

CoverageEligibilityRequest

The document must contain a CoverageEligibilityRequest resource.

Patient

FHIR Profile details:

  1. Patient resources should mandatorily have an NDHM identifier.

  2. Patient resources can also have a hospital Id (Medical record number).

  3. Patient resources can also have an insurance id (PMJAY ID).

  4. Patient resources can also have employee IDs and other business identifiers.

Coverage

FHIR Profile details:

  • Coverage resources should mandatorily have an identifier for the policy ID issued by the insurer.

Domain Headers:

Key

Description

Search Parameters:

Key

Description

Coverage Eligibility Response

Resource

Description

Composition

type: should be a code representing Coverage Eligibility Response document type.

section: The document shall have one section with a single entry having reference to CoverageEligibilityResponse resource.

CoverageEligibilityResponse

The document must contain a CoverageEligibilityResponse resource.

Coverage

The document should contain one or more Coverage resources with minimal information of the policy about which the information is being returned.

FHIR Profile details:

  • Coverage resources should mandatorily have an identifier for the policy ID issued by the insurer.

Domain Headers:

Key

Description

Search Parameters:

Key

Description

Claim Request

Claim object is used by providers to submit pre-authorization and claim requests to the payers. The same eObject can be used for both these use cases and the usage can be differentiated by the value of “claim.use” element. The value of this element should be set as “preauthorization” for Pre-Authorization requests and as “claim” for Claim requests.

Resource

Description

Composition

type: should be a code representing Claim Request document type.

section: The document shall have one section with multiple entries having references to Claim and Signature resources.

Claim

The document must contain a Claim resource.

Coverage

The document should contain one or more Coverage resources with minimal information on the policy about which the information is being returned.

FHIR Profile details:

  • Coverage resources should mandatorily have an identifier for the policy ID issued by the insurer.

Encounter

Details of the Encounters during which this Claim was created or to which the creation of this Claim is associated.

Condition

Details of the health conditions relevant to this Claim request.

Signature resources

List of signatures by Hospital, Doctor and Patient associated with this Claim request.

Domain Headers:

Key

Description

usage

“preauthorization” or “claim”, to indicate the use case this eObject is being used for.

Search Parameters:

Key

Description

Claim Response

ClaimResponse object is used by payers to send the response for pre-authorization and claim requests to the providers. The same eObject can be used for both these use cases and the usage can be differentiated by the value of “ClaimResponse.use” element. The value of this element should be set as “preauthorization” for Pre-Authorization responses and as “claim” for Claim responses.

Resource

Description

Composition

type: should be a code representing Claim Response document type.

section: The document shall have one section with a single entry having reference to ClaimResponse resource.

ClaimResponse

The document must contain a ClaimResponse resource.

Domain Headers:

Key

Description

usage

“preauthorization” or “claim”, to indicate the use case this eObject is being used for.

Search Parameters:

Key

Description

Payment Notice

Resource

Description

Composition

type: should be a code representing Payment Notice document type.

section: The document shall have one section with a single entry having reference to PaymentNotice resource.

PaymentNotice

The document must contain a PaymentNotice resource.

PaymentReconciliation

The document should contain a PaymentReconciliation resource with information about the payment related to this payment notice.

Domain Headers:

Key

Description

Search Parameters:

Key

Description

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Last updated 3 years ago

structure definition:

FHIR Profile:

structure definition:

The document should contain a Patient resource with minimal required information about the patient (refer to rows #38-42 in the “” sheet).

structure definition:

The document should contain one or more Coverage resources with minimal information of the policy about which the information is requested (refer to row#30 in the “” sheet).

structure definition:

structure definition:

FHIR Profile:

structure definition:

structure definition:

structure definition:

FHIR Profile:

structure definition:

structure definition:

FHIR Profile:

structure definition:

FHIR Profile:

structure definition:

structure definition:

structure definition:

FHIR Profile:

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FHIR Profile:

structure definition:

FHIR Profile:

structure definition:

CoverageEligibilityRequest Document
link
CoverageEligibilityRequest
Coverage eligibility check
Patient
Coverage eligibility check
Coverage
CoverageEligibilityResponse Document
link
CoverageEligibilityResponse
Coverage
ClaimRequest Document
link
Claim
Coverage
link
Encounter
link
Condition
Signature
ClaimResponse Document
link
ClaimResponse
link
PaymentNotice
link
PaymentReconciliation