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

Information Request

Overview

This use case allows Health Insurance Companies (HICs) to request additional information from Healthcare Providers (HCPs) when essential data is missing in a previously exchanged, and identified, financial transaction. This may include supporting documents such as radiology reports, laboratory results, or clinical images needed to adjudicate or validate a submitted transaction.

Workflow

1. The HIC or TPA sends an Information Request Message to the provider via nphies system to advise that a prior message from that system contained errors.
2. nphies validates the message and returns an Acknowledgement Message with a status of OK if the message is valid otherwise the acknowlegement contains an OperationOutcome resource indicating errors in the Information Request Message.
3. nphies stores the message if valid for return to the provider via Polling.

Message Structures

Information 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 = communication-request)
  Nphies CommunicationRequest
  Nphies Coverage
  Nphies Patient
  Nphies Organization (Provider)
  Nphies Organization (Insurer)
  [any additional resources]

Acknowledgement Message

See Acknowledgement Message.

Guidance

Insurers may determine before or during the processing of messages, typically claims and authorizations, that some additional information which it expect the provider to have, or to be readily able to retrieve, is required to support the adjudication or processing of the message. The insurer may then send via nphies to the provider an Information Request (CommunicationRequest) message identifying the providers request message in the CommunicationRequest.about element, for context, and the type of information the insurer is seeking to obtain in the CommunicationRequest.payload. The provider SHALL then fulfill then request with an Information Submission (Communication) message identifing the insurer's request message in the Communication.about and either providing the requested information or indicating that such information cannot be retrieved.

See also: Information Guides.

Full Message Examples

Key Extensions

None to report.

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 Status Response resource. Otherwise if nphies detects errors within the request it will return a Status 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.