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

2:3.126 Submit Claim [ITI-126]

This section corresponds to transaction [ITI-126] of the IHE IT Infrastructure Technical Framework. Transaction [ITI-126] is used by the Claims Requestor and Claims Manager Actors. The Submit Claim [ITI-126] transaction is used to submit a claim for a patient.

2:3.126.1 Scope

This transaction is used by the Claims Requestor to submit a claim for a patient. The request is received by the Claims Manager. The Claims Manager processes the request and returns a response with the status of the request.

2:3.126.2 Actor Roles

Table 2:3.126.2-1: Actor Roles

2:3.126.3 Referenced Standards

FHIR-R4 HL7 FHIR Release 4.0

2:3.126.4 Messages

2:3.126.4.1 Submit Claim Request Message

This message uses the HTTP POST method on the target Claims Manager endpoint that is a FAIS Claim $submit operation. It is sent from a Claims Requestor.

2:3.126.4.1.1 Trigger Events

When a Claims Requestor needs to submit a claim for a Patient to the Claims Manager, it submits the Submit Claim Message. This claim can be for one of three uses: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

2:3.126.4.1.2 Message Semantics

The Claims Requestor invokes the FAIS Claim $submit operation on the Claims Manager. The operation is invoked by submitting an HTTP POST request to the Claims Manager at the path:

POST [base]/Claim/$submit

The HTTP body SHALL consist of either a FHIR Claim resource conforming to the FAIS Claim profile or a Claim Bundle including referenced resources conforming to the FAIS Claim Bundle profile.

The Claim resource will set the use code according to table 2:3.126.4.1.2-1.

Table 2:3.126.4.1.2-1: Claim Use Codes

2:3.126.4.1.3 Expected Actions

The Claims Manager SHALL process the Claim and respond as per http://hl7.org/fhir/R4/operations.html#response, and if successful, with an HTTP 201 (CREATED) and a Submit Claim Response Message.

The Claims Manager SHALL persist the Claim resource and include a reference to it in the ClaimResponse resource.

2:3.126.4.2 Submit Claim Response Message

2:3.126.4.2.1 Trigger Events

The Claims Manager has a response or errors to report to the Claims Requestor. This MAY include a queued response.

2:3.126.4.2.2 Message Semantics

The Submit Claim Response conforms to the FAIS ClaimResponse profile and is sent from the Claims Manager to the Claims Requestor. If the disposition of the claim can’t be handled synchronously, then the outcome element SHALL be set to queued and ClaimResponse SHALL include an id and persist on the Claims Manager so that the ITI-129 Track Claim transaction can be used to get updates on the response.

2:3.126.4.2.3 Expected Actions

How the Claims Requestor processes the response is determined by the implementation and beyond the scope of this profile.

2:3.126.5 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 Claims Requestor
• Requirements CapabilityStatement for Claims Manager

2:3.126.6 Security Considerations

See FAIS Security Considerations.

2:3.126.6.1 Security Audit Considerations

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

The actors involved SHALL record audit events according to the Audit Event for Submit Claim Transaction. See Audit Example for Submit Claim from the Claims Requestor.