Cancellation

Healthcare Financial Services IG Edition 1 - Local Development build (v0.3.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Overview
Workflow
Message Structures
Guidance
Full Message Examples
Error Handling

Overview

The provider may cancel a request, such as an authorization or claim request, regardless of whether it has been fully processed by the insurer as long as it has not already been responded to with errors. The provider SHALL supply the business identifier of the request message to be cancelled in the Task.focus element. The insurer SHALL make their best effort to not process the request message identified for cancellation if not already processed and if already processed SHALL reverse the effect of the adjudication of the request message including removal of service history and the usage of funds.

Workflow

Provider sends a Cancel Request Message to the nphies system.
nphies validates the request and, if valid, proceeds to Step 3. Otherwise, it generates an error response.
nphies forwards the request to the designated insurer or TPA.
The insurer or TPA adjudicates the request and returns a Cancel Response Message.
nphies validates the response and, if valid, proceeds to Step 6; otherwise, an Error-Notice Message is generated.
nphies returns the Cancel Response Message with approval, denial, or additional information requests, or errors, to the provider.

This is a REAL TIME use case. In addition to returning the success of the requested requested cancellation in Task.status (‘completed’ or ‘error’), nphies will provide the Meta Tag: queued-messages should any messages remain in the queue.

If nphies is unable to deliver the request to the insurer, or TPA, then nphies will pend the request for later delivery to the insurer, or TPA, and generate a response to the provider indicating that the request was received without errors, as far as nphies could detect, and that nphies will deliver the authorization request to the insurer once the exchange issue is resolved.
In the event that nphies is not able to successfully deliver the Request Message to the HIC within less than one minute, or nphies generates a ‘pended’ message or an error message as documented above, then nphies will generate a response message, with a bundle.meta.tag to identifiy that the message has been issued by nphies, see Meta Tag: nphies-generated.
Delayed responses, those not issued directly in the same session as the request, are stored on nphies and, if not containing errors detected by nphies, are stored (pended) for the provider. The provider can retrieve the valid response via Polling.

Message Structures

Cancel Request Message

The key resources for the message are provided below and all require nphies-profiled resources as provided in the Artifacts. Note: the MessageHeader resource must be the first .entry in the bundle and any other resources may follow in any order.

Nphies Bundle (.type = message )
  Nphies MessageHeader (.eventCoding = cancel-request)
  Nphies Task (.code.coding.code = cancel)
  Nphies Organization (Provider)
  Nphies Organization (Insurer)

Cancel Response Message

Nphies Bundle (.type = message )
  Nphies MessageHeader (.eventCoding = cancel-response)
  Nphies Task (.code.coding.code = cancel)
  Nphies Organization (Provider)
  Nphies Organization (Insurer)

Guidance

A Cancel Request uses a Task resource to provide the parameter of the request message for which the intended action is to be cancelled is requested in the Task.focus.identifier element. The response to such a request is a Cancel Response which is also a Task resource providing the result of the cancellation of the requested message in Task.status ( ‘completed’ or ‘error’) and if ‘error’ by including a Task.output element with Task.output.type = ‘error’ and providing an error code in the Task.output.valueCodeableConcept element in the responce message.

When a message is cancelled its effect is removed or reversed but the transaction may still be listed in summaries of messages processed with the status of ‘cancelled’. There are, however, circumstances where the message should be cancelled and never disclosed in any form other than internal audit or legal review, in this case the provider should request to nullify the original messages by including Task.input.type = ‘nullify’ and Task.input.valueBoolean = ‘true’.

Full Message Examples

Example	Description
Example #1 Request	Cancel Request - simple request to cancel a Professional Authorization.
Example #1 Response	Cancel Response responding to request #1 for the cancellation of a Professional Authorization.

Error Handling

If nphies detects errors in the request message such that the request cannot be processed then the response message will contain an OperationOutcome resource rather than a business-level Cancel Response resource. Otherwise if nphies detects errors within the request it will return a Cancel Response with errors (Task.output.type = ‘error’) and an extension indicating where the error occurred.

Like all other response messages the provider receives from nphies, if there are other messages queued at nphies which have not been delivered to the provider then this will be reflected in the presence of a MessageHeader.meta.tag.