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

Payment Reconciliation

Overview

This use case enables Health Insurance Companies (HICs) to notify Healthcare Providers (HCPs) that payment for one or more adjudicated claims has been issued. The HIC provides detailed allocation information regarding the payment using a PaymentReconciliation resource. This transaction ensures transparency and traceability of claim settlements between payers and providers.

Workflow

1. The HIC or TPA sends an Payment Reconciliation 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 Payment Reconciliation Message.
3. nphies stores the message if valid for return to the provider via Polling.

Message Structures

Payment Reconciliation 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 = payment-reconciliation)
  Nphies Payment Reconciliation
  Nphies Organization (Provider)
  Nphies Organization (Insurer)
  For each payment detail: 
     [Nphies Organization (Provider) Submitter]
     [Nphies Organization (Provider) Payee]

Acknowledgement Message

See Acknowledgement Message.

Guidance

The PaymentReconciliation is used by HIC to advise HCP how the HIC allocates funds within a payment from the insurer to the provider, regarding:

• advances;
• specific payments against claims (may be full or partiel payment);
• reversals of payments due to overpayment or claim cancellation; and
• any other financial adjustments.

Payments may also include spcification of adjusting factors such as nphies fees, a service fee levied for the nphies service, or early payment fees, a service fee levied by the insurer or payment issued in a 'shorter than normal' payment cycle.

See also: Information Guides.

Full Message Examples

Key Extensions

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.