Finance and Insurance Service (FAIS), published by IHE IT Infrastructure Technical Committee. This guide is not an authorized publication; it is the continuous build for version 1.0.1-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/ITI.Finance/ and changes regularly. See the Directory of published versions

2:3.121 Query Insurance Plan [ITI-121]

This section corresponds to transaction [ITI-121] of the IHE IT Infrastructure Technical Framework. Transaction [ITI-121] is used by the Beneficiary Manager and Beneficiary Requestor Actors. The Query Insurance Plan [ITI-121] transaction is used to discover insurance plans to be used when enrolling beneficiaries.

2:3.121.1 Scope

This transaction is used by the Beneficiary Requestor to find insurance plans based on criteria it provides in the query parameters of the request message, or to retrieve a specific insurance plan. The request is received by the Beneficiary Manager. The Beneficiary Manager processes the request and returns a response of the matching insurance plans.

2:3.121.2 Actor Roles

Table 2:3.121.2-1: Actor Roles

2:3.121.3 Referenced Standards

• HL7 FHIR standard R4 http://hl7.org/fhir/R4/index.html

2:3.121.4 Messages

2:3.121.4.1 Search Insurance Plan Request Message

The Search Insurance Plan message is a FHIR search interaction on the InsurancePlan Resource.

2:3.121.4.1.1 Trigger Events

A Beneficiary Requestor triggers a Search Insurance Plan Request to a Beneficiary Manager when it needs to know what plans are available to use to enroll a beneficiary [ITI-122].

2:3.121.4.1.2 Message Semantics

A Beneficiary Requestor initiates a search interaction using HTTP GET as defined at http://hl7.org/fhir/R4/http.html#search on the InsurancePlan resource. The query parameters are identified below. A Beneficiary Requestor MAY query any combination or subset of the parameters. The target is formatted as:

GET [base]/InsurancePlan?[parameter=value]

Where [base] is the URL of Beneficiary Manager.

A Beneficiary Manager SHALL support responding to a request for both the JSON and the XML messaging formats as defined in FHIR. A Beneficiary Requestor SHALL accept either the JSON or the XML messaging formats as defined in FHIR. See ITI TF-2: Appendix Z.6 for more details.

A Beneficiary Manager SHALL implement the parameters described below. A Beneficiary Manager MAY choose to support additional query parameters beyond the subset listed below. Any additional query parameters supported SHALL be supported according to the core FHIR specification.

See ITI TF-2: Appendix W for informative implementation material for this transaction.

2:3.121.4.1.2.1 Query Parameters

The Beneficiary Manager will support the search parameters as defined in the capability statement for InsurancePlan.

The Beneficiary Requestor will support the search parameters as defined in the capability statement for InsurancePlan

2:3.121.4.1.3 Expected Actions

The Beneficiary Manager SHALL process the query to discover the insurance plan(s) that match the search parameters given, and if successful, with an HTTP 200 (OK) and a Search Insurance Plan Response Message or an error as per http://hl7.org/fhir/R4/search.html#errors.

2:3.121.4.2 Search Insurance Plan Response Message

2:3.121.4.2.1 Trigger Events

The Beneficiary Manager found Insurance Plans matching the query parameters specified by the Beneficiary Requestor as a result of a Search Insurance Plan Request.

2:3.121.4.2.2 Message Semantics

The Beneficiary Manager SHALL support the search response message as defined at http://hl7.org/fhir/R4/http.html#search on the InsurancePlan, as defined at http://hl7.org/fhir/R4/insuranceplan.html

The “content-type” of the response will depend upon the requested response format indicated by the Beneficiary Requestor.

See ITI TF-2: Appendix Z.6 for more details on response format handling. See ITI TF-2: Appendix Z.7 for handling guidance for Access Denied.

2:3.121.4.2.2.1 FHIR InsurancePlan Resource Constraints

A InsurancePlan Resource returned by the Beneficiary Manager SHALL be further constrained as described in the FAIS InsurancePlan profile.

2:3.121.4.2.3 Expected Actions

The Beneficiary Requestor has received the response and continues with its workflow.

2:3.121.4.3 Read Insurance Plan Request Message

This message represents an HTTP GET from the Beneficiary Requestor to the Beneficiary Manager and provides a mechanism for retrieving a single InsurancePlan with a known resource id.

2:3.121.4.3.1 Trigger Events

When the Beneficiary Requestor possesses the id of InsurancePlan (either through query, database lookup, or other mechanism) for which it requires additional or new information, it issues a Read Insurance Plan Request.

2:3.121.4.3.2 Message Semantics

A Beneficiary Requestor initiates a read interaction using HTTP GET as defined at http://hl7.org/fhir/R4/http.html#read on the InsurancePlan Resource. The target is formatted as:

GET [base]/InsurancePlan/[resourceId]

Where [base] is the URL of Beneficiary Manager.

The resourceId included in the request always represents the unique id for the InsurancePlan within the scope of the URL. For example, while http://example1.org/ihe/InsurancePlan/1 and http://example2.com/ihe/InsurancePlan/1 both contain the same [resourceId], they reference two different resource instances.

Note: The use of “http” or “https” in URL does not override requirements to use TLS for security purposes.

A Beneficiary Manager SHALL support responding to a request for both the JSON and the XML messaging formats as defined in FHIR. A Beneficiary Requestor SHALL accept either the JSON or the XML messaging formats as defined in FHIR. See ITI TF-2: Appendix Z.6 for more details.

See ITI TF-2: Appendix W for informative implementation material for this transaction.

2:3.121.4.3.3 Expected Actions

The Beneficiary Manager SHALL process the request to retrieve the InsurancePlan that matches the given resource id, and if successful, with an HTTP 200 (OK) and a response as defined at http://hl7.org/fhir/R4/http.html#read with the Read Insurance Plan Response Message or an error code as defined at http://hl7.org/fhir/R4/http.html#Status-Codes.

2:3.121.4.4 Read Insurance Plan Response Message

2:3.121.4.4.1 Trigger Events

The Beneficiary Manager found a InsurancePlan Resource matching the resource identifier specified by the Beneficiary Requestor.

2:3.121.4.4.2 Message Semantics

The Read Insurance Plan Response is sent from the Beneficiary Manager to the Beneficiary Requestor as a single InsurancePlan, as defined at http://hl7.org/fhir/R4/insuranceplan.html and constrained by the FAIS InsurancePlan profile.

The “content-type” of the response will depend upon the requested response format indicated by the Beneficiary Requestor.

See ITI TF-2: Appendix Z.6 for more details on response format handling. See ITI TF-2: Appendix Z.7 for handling guidance for Access Denied.

If the Beneficiary Manager is unable to produce a response in the requested format, it SHALL respond with an HTTP 4xx error indicating that it was unable to fulfill the request. The Beneficiary Manager MAY be capable of servicing requests for response formats not listed, but SHALL, at minimum, be capable of producing XML and JSON encodings.

2:3.121.4.4.3 Expected Actions

The Beneficiary Requestor has received the response and continues with its workflow.

2:3.122.5 CapabilityStatement Resource

Server implementing this transaction SHALL provide a CapabilityStatement Resource as described in ITI TF-2: Appendix Z.3 indicating the transaction has been implemented.

• Requirements CapabilityStatement for Beneficiary Requestor
• Requirements CapabilityStatement for Beneficiary Manager

2:3.121.6 Security Considerations

See FAIS Security Considerations.

2:3.121.6.1 Security Audit Considerations

Note that the same audit message is recorded by both the Beneficiary Requestor and Beneficiary Manager. The difference being the Audit Source element. Both sides record to show consistency between the message sent by the Beneficiary Requestor and the action taken at the Beneficiary Manager.

The actors performing the Query Insurance Plan message SHALL record audit events according to the Audit Event for Query Insurance Plan Query Transaction. See Audit Example for Query Insurance Plan search from the Beneficiary Requestor.

The actors performing the Read Insurance Plan message SHALL record audit events according to the Audit Event for Query Insurance Plan Read Transaction. See Audit Example for Query Insurance Plan read message from the Beneficiary Requestor.