Domain Specific Languages (DSLs)
There are two key DSLs being considered for the Health Claims Exchange - Policy Markup Language (PML) and Bill Markup Language (BML). These are currently work in progress and are expected to be released in the later version of HCX specifications after substantial proof of concept development with various members of domain working groups.
Policy Markup Language (PML)
As indicated in the previous version of the protocol, policy markup language was being envisioned by the working groups to provide a digital encoding mechanism to payers such that the policies can be encoded in machine readable format, thereby helping with the accurate communication of plan details to various ecosystem actors that could help with use cases like:
Intuitive UIs for provider/TPAs to help patients navigate policy information
Allow providers to validate their submissions and help reduce multiple roundtrip for a valid claim submission
Potential automation of coverage eligibility checks
Automation of claim submission and adjudication processes, etc.
In earlier discussions, PML was being thought of as a single DSL to express Insurance Plans (products) and Policies/rules around these plans. However, further analysis with various groups suggested that needs from PML can be unbundled into the following keys asks:
Plan/Product details - Publically shareable generic details of plan e.g. procedures covered, limits etc. that are not specific to a subscriber.
Constraints (including pre-submission validations) - Key constraints on various plan elements. These may include:
Document checklist against procedure/package
Informational/compliance messages against procedure/package
Procedure specific questionnaires
Requirements for Proof of identification and Proof of Presence
Inclusion/exclusion constraints.
Routing information - Information of where to send claims related to the plan and details of various processing stages/entities if a plan supports multi party processing
This version of the protocol has focused on digitally encoding the Insurance Plan (usually called Product) by the payers. In order to keep it consistent with rest of the domain specifications, protocol proposes to use a combination of FHIR resources and FHIR DSLs to express plans (#1 above) and most prevalent constraints (a large part of #2 above).
The policies that are derived from the products specific to the individual or a group, would be planned in the future versions. Insurance Plan information is expected to be available publicly as it is not specific to any subscriber or group.
The basic plan details required for admistrative purposes - Most of the basic details like name, IRDA UIN as identifier, validity, etc.. are covered in InsurancePlan profile.
The benefits that are covered under the plan - The InsurancePlan.plan.specificCost is used to describe the individual benefits. A benefit could be expressed against a procedure, a package (in the context of Indian Health Insurance industry), a diagnosis, a physical good or a service. For each benefit, the cost and the count upto which the benefit would be reimbursed could be specified.
The inclusion and exclusion constraints against a particular benefit or a group of benefits (Not covered in this version)
The routing information to determine the right recipient for a claim (Not covered in this version)
Bill markup Language
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