The initial set of draft workflows are FHIR-based workflows leveraging Health Financing and FHIR workflows and ongoing work on Integrating openIMIS into the OpenHIE Landscape.
Beneficiary Enrollment
Check enrollment status
title Check enrollment status PoS->PoS: [1] Register patient PoS->IOL: [2] FHIR Coverage resource search IOL->IOL: [3] Validate FHIR resource IOL->openIMIS: [4] Search for beneficiary openIMIS->IOL: [5] Return beneficiary details IOL->PoS: [6] Return FHIR Coverage resource PoS->PoS: [7] Add details to patient record
Enrol beneficiary
title Enrol beneficiary PoS->PoS: [1] Fetch / Register patient PoS->IOL: [2] Submit FHIR EnrollmentRequest resource IOL->IOL: [3] Validate FHIR resource IOL->openIMIS: [4] Submit enrollment details openIMIS->openIMIS: [5] Process enrollment openIMIS->IOL: [6] Return enrollment response IOL->PoS: [7] Return FHIR EnrollmentResponse resource PoS->PoS: [8] Add details to patient record
Claim Submission
Check beneficiary validity
title Check beneficiary validity PoS->PoS: [1] Fetch claims data PoS->IOL: [2] Submit FHIR EligibilityRequest resource IOL->IOL: [3] Validate FHIR resource IOL->openIMIS: [4] Query patient eligibility openIMIS->IOL: [5] Return patient eligibility details IOL->PoS: [6] Return FHIR EligibilityResponse resource PoS->PoS: [7] Process response
Check beneficiary balance/treatment options
title Check beneficiary balance/treatment options PoS->PoS: [1] Fetch claims data PoS->IOL: [2] Submit FHIR Claim {use=exploratory} resource IOL->IOL: [3] Validate FHIR resource IOL->openIMIS: [4] Query patient balance/treatment options openIMIS->IOL: [5] Return treatment options/reimbursement details IOL->PoS: [6] Return FHIR ClaimResponse resource PoS->PoS: [7] Process response
Preauthorization of claim
title Preauthorization of claim PoS->PoS: [1] Fetch claims data PoS->IOL: [2] Submit FHIR Claim {use=proposed} resource IOL->IOL: [3] Validate FHIR resource IOL->openIMIS: [4] Submit claim to reserve funds alt Acknowledgement of preauthorization openIMIS->IOL: [5] Return acknowledgement of preauthorization IOL->PoS: [6] Return FHIR ClaimResponse resource PoS->PoS: [7] Process response else Additional information requested openIMIS->IOL: [5] Request for additional information IOL->PoS: [6] Return FHIR CommunicationRequest resource PoS->PoS: [7] Process response and fetch claims data PoS->IOL: [8] Submit FHIR Communication resource IOL->IOL: [9] Validate FHIR resource IOL->openIMIS: [10] Submit supporting information openIMIS->IOL: [11] Return adjudicated response IOL->PoS: [12] Return FHIR ClaimResponse resource PoS->PoS: [13] Process response end
Track status of claim
title Track status of claim PoS->PoS: [1] Fetch claims data alt Check claim status PoS->IOL: [2] Submit FHIR ProcessRequest {action=status} resource else Poll on claim status loop text PoS->IOL: [2] Submit FHIR ProcessRequest {action=poll} resource end end IOL->IOL: [3] Validate FHIR resource IOL->openIMIS: [4] Submit claim status check openIMIS->IOL: [6] Return claim status IOL->PoS: [7] Return FHIR ProcessResponse resource PoS->PoS: [8] Process response
Submit claim
title Submit claim PoS->PoS: [1] Fetch patient visit data PoS->IOL: [2] Submit FHIR Claim {use=complete} resource IOL->IOL: [3] Validate FHIR resource IOL->openIMIS: [4] Submit patient claim openIMIS->openIMIS: [5] Process claim openIMIS->IOL: [6] Return claim outcomes IOL->PoS: [7] Return FHIR ClaimResponse resource PoS->PoS: [8] Process response