Finance and Insurance Service (FAIS)
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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 1.0.0-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

: Claims Requestor Actor - XML Representation

Active as of 2024-07-17

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<CapabilityStatement xmlns="http://hl7.org/fhir">
  <id value="IHE.FAIS.ClaimsRequestor"/>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: CapabilityStatement IHE.FAIS.ClaimsRequestor</b></p><a name="IHE.FAIS.ClaimsRequestor"> </a><a name="hcIHE.FAIS.ClaimsRequestor"> </a><a name="IHE.FAIS.ClaimsRequestor-en-US"> </a><h2 id="title">IHE FAIS Claims Requestor</h2><ul><li>Implementation Guide Version: 1.0.0-current </li><li>FHIR Version: 4.0.1 </li><li>Supported Formats: <code>application/fhir+xml</code>, <code>application/fhir+json</code></li><li>Supported Patch Formats: </li><li>Published on: 2024-07-17 </li><li>Published by: IHE IT Infrastructure Technical Committee </li></ul><blockquote class="impl-note"><p><strong>Note to Implementers: FHIR Capabilities</strong></p><p>Any FHIR capability may be 'allowed' by the system unless explicitly marked as 'SHALL NOT'. A few items are marked as MAY in the Implementation Guide to highlight their potential relevance to the use case.</p></blockquote><h2 id="rest">FHIR RESTful Capabilities</h2><div class="panel panel-default"><div class="panel-heading"><h3 id="mode1" class="panel-title">Mode: <code>client</code></h3></div><div class="panel-body"><div><p>FAIS Claims Requestor provides capability to submit claim requests and query for claim responses.</p>
</div><div class="lead"><em>Security</em></div><blockquote><div><p>Recommend <a href="https://profiles.ihe.net/ITI/TF/Volume1/ch-9.html">ATNA</a>, encouraged <a href="https://profiles.ihe.net/ITI/IUA/index.html">IHE-IUA</a> or <a href="http://www.hl7.org/fhir/smart-app-launch/">SMART-app-launch</a></p>
</div></blockquote><div class="lead"><em>Summary of System-wide Interactions</em></div><ul><li><strong>MAY </strong>support the <code>search-system</code>interaction.</li></ul></div></div><h3 id="resourcesCap1">Capabilities by Resource/Profile</h3><h4 id="resourcesSummary1">Summary</h4><p>The summary table lists the resources that are part of this configuration, and for each resource it lists:</p><ul><li>The relevant profiles (if any)</li><li>The interactions supported by each resource (<b><span class="bg-info">R</span></b>ead, <b><span class="bg-info">S</span></b>earch, <b><span class="bg-info">U</span></b>pdate, and <b><span class="bg-info">C</span></b>reate, are always shown, while <b><span class="bg-info">VR</span></b>ead, <b><span class="bg-info">P</span></b>atch, <b><span class="bg-info">D</span></b>elete, <b><span class="bg-info">H</span></b>istory on <b><span class="bg-info">I</span></b>nstance, or <b><span class="bg-info">H</span></b>istory on <b><span class="bg-info">T</span></b>ype are only present if at least one of the resources has support for them.</li><li><span>The required, recommended, and some optional search parameters (if any). </span></li><li>The linked resources enabled for <code>_include</code></li><li>The other resources enabled for <code>_revinclude</code></li><li>The operations on the resource (if any)</li></ul><div class="table-responsive"><table class="table table-condensed table-hover"><thead><tr><th><b>Resource Type</b></th><th><b>Profile</b></th><th class="text-center"><b title="GET a resource (read interaction)">R</b></th><th class="text-center"><b title="GET all set of resources of the type (search interaction)">S</b></th><th class="text-center"><b title="PUT a new resource version (update interaction)">U</b></th><th class="text-center"><b title="POST a new resource (create interaction)">C</b></th><th><b title="Required and recommended search parameters">Searches</b></th><th><code><b>_include</b></code></th><th><code><b>_revinclude</b></code></th><th><b>Operations</b></th></tr></thead><tbody><tr><td><a href="#Claim1-1">Claim</a></td><td>Supported Profiles<br/>  <a href="StructureDefinition-IHE.FAIS.Claim.html">FAIS Claim Profile</a></td><td class="text-center"></td><td class="text-center"></td><td class="text-center"></td><td class="text-center"></td><td></td><td/><td/><td><code>$submit</code>, <code>$cancel</code>, <code>$reprocess</code></td></tr><tr><td><a href="#ClaimResponse1-2">ClaimResponse</a></td><td>Supported Profiles<br/>  <a href="StructureDefinition-IHE.FAIS.ClaimResponse.html">FAIS ClaimResponse Profile</a></td><td class="text-center">y</td><td class="text-center">y</td><td class="text-center"></td><td class="text-center"></td><td>_lastUpdated, _id, status, request, patient, requestor</td><td/><td/><td/></tr></tbody></table></div><hr/><div class="panel panel-default"><div class="panel-heading"><h4 id="Claim1-1" class="panel-title"><span style="float: right;">Resource Conformance: supported </span>Claim</h4></div><div class="panel-body"><div class="container"><div class="row"><div class="col-lg-4"><span class="lead">Core FHIR Resource</span><br/><a href="http://hl7.org/fhir/R4/claim.html">Claim</a></div><div class="col-lg-4"><span class="lead">Reference Policy</span><br/></div><div class="col-lg-4"><span class="lead">Interaction summary</span><br/><ul/></div></div><p/><div class="row"><div class="col-6"><span class="lead">Supported Profiles</span><p><a href="StructureDefinition-IHE.FAIS.Claim.html">FAIS Claim Profile</a></p></div></div><p/><div class="row"><div class="col-12"><span class="lead">Documentation</span><blockquote><div><p>Supports these transactions:</p>
<ul>
<li><a href="ITI-126.html">Submit Claim [ITI-126]</a></li>
<li><a href="ITI-127.html">Cancel Claim [ITI-127]</a></li>
<li><a href="ITI-128.html">Re-process Claim [ITI-128]</a></li>
</ul>
</div></blockquote></div></div><div class="row"><div class="col-12"><span class="lead">Extended Operations</span><table class="table table-condensed table-hover"><thead><tr><th>Conformance</th><th>Operation</th><th>Documentation</th></tr></thead><tbody><tr><td><b>SHALL</b></td><td><a href="OperationDefinition-IHE.FAIS.Claim.Submit.html">$submit</a></td><td><div><p>Submits a claim.  FAIS Submit Claim transaction <a href="ITI-126.html">[ITI-126]</a>.</p>
</div></td></tr><tr><td><b>SHALL</b></td><td><a href="OperationDefinition-IHE.FAIS.Claim.Cancel.html">$cancel</a></td><td><div><p>Cancels a claim.  FAIS Cancel Claim transaction <a href="ITI-127.html">[ITI-127]</a>.</p>
</div></td></tr><tr><td><b>SHALL</b></td><td><a href="OperationDefinition-IHE.FAIS.Claim.Reprocess.html">$reprocess</a></td><td><div><p>Re-processes a claim.  FAIS Re-process Claim transaction <a href="ITI-128.html">[ITI-128]</a>.</p>
</div></td></tr></tbody></table></div></div></div></div></div><div class="panel panel-default"><div class="panel-heading"><h4 id="ClaimResponse1-2" class="panel-title"><span style="float: right;">Resource Conformance: MAY </span>ClaimResponse</h4></div><div class="panel-body"><div class="container"><div class="row"><div class="col-lg-4"><span class="lead">Core FHIR Resource</span><br/><a href="http://hl7.org/fhir/R4/claimresponse.html">ClaimResponse</a></div><div class="col-lg-4"><span class="lead">Reference Policy</span><br/></div><div class="col-lg-4"><span class="lead">Interaction summary</span><br/><ul><li><strong>MAY</strong> support <code>read</code>, <code>search-type</code>.</li></ul></div></div><p/><div class="row"><div class="col-6"><span class="lead">Supported Profiles</span><p><a href="StructureDefinition-IHE.FAIS.ClaimResponse.html">FAIS ClaimResponse Profile</a></p></div></div><p/><div class="row"><div class="col-12"><span class="lead">Documentation</span><blockquote><div><p>FAIS Track Claim transaction <a href="ITI-129.html">[ITI-129]</a></p>
</div></blockquote></div></div><div class="row"><div class="col-lg-7"><span class="lead">Search Parameters</span><table class="table table-condensed table-hover"><thead><tr><th>Conformance</th><th>Parameter</th><th>Type</th><th>Documentation</th></tr></thead><tbody><tr><td><b>MAY</b></td><td>_lastUpdated</td><td><code>date</code></td><td><div><p>When the resource version last changed.  The values for this shall support these prefixes: gt, lt, ge, le, sa, and eb.</p>
</div></td></tr><tr><td><b>MAY</b></td><td>_id</td><td><code>token</code></td><td><div><p>Logical id of this artifact</p>
</div></td></tr><tr><td><b>MAY</b></td><td>status</td><td><code>token</code></td><td><div><p>The status of the response</p>
</div></td></tr><tr><td><b>MAY</b></td><td>request</td><td><code>reference</code></td><td><div><p>The coverage eligiblity request</p>
</div></td></tr><tr><td><b>MAY</b></td><td>patient</td><td><code>reference</code></td><td><div><p>The beneficiary</p>
</div></td></tr><tr><td><b>MAY</b></td><td>requestor</td><td><code>reference</code></td><td><div><p>The provider making the request</p>
</div></td></tr></tbody></table></div><div class="col-lg-5"> </div></div></div></div></div></div>
  </text>
  <url
       value="https://profiles.ihe.net/ITI/FAIS/CapabilityStatement/IHE.FAIS.ClaimsRequestor"/>
  <version value="1.0.0-current"/>
  <name value="IHE_FAIS_ClaimsRequestor"/>
  <title value="IHE FAIS Claims Requestor"/>
  <status value="active"/>
  <experimental value="false"/>
  <date value="2024-07-17"/>
  <publisher value="IHE IT Infrastructure Technical Committee"/>
  <contact>
    <telecom>
      <system value="url"/>
      <value value="https://www.ihe.net/ihe_domains/it_infrastructure/"/>
    </telecom>
  </contact>
  <contact>
    <telecom>
      <system value="email"/>
      <value value="iti@ihe.net"/>
    </telecom>
  </contact>
  <contact>
    <name value="IHE IT Infrastructure Technical Committee"/>
    <telecom>
      <system value="email"/>
      <value value="iti@ihe.net"/>
    </telecom>
  </contact>
  <description
               value="CapabilityStatement for [Claims Requestor Actor](volume-1.html#claims-requestor).

The Claims Requestor files a pre-determination, pre-authorization, or claim for a patient, as well as cancel and re-process claims, and can query for responses when the result is queued."/>
  <jurisdiction>
    <coding>
      <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
      <code value="001"/>
    </coding>
  </jurisdiction>
  <kind value="requirements"/>
  <fhirVersion value="4.0.1"/>
  <format value="application/fhir+xml"/>
  <format value="application/fhir+json"/>
  <rest>
    <mode value="client"/>
    <documentation
                   value="FAIS Claims Requestor provides capability to submit claim requests and query for claim responses."/>
    <security>
      <description
                   value="Recommend [ATNA](https://profiles.ihe.net/ITI/TF/Volume1/ch-9.html), encouraged [IHE-IUA](https://profiles.ihe.net/ITI/IUA/index.html) or [SMART-app-launch](http://www.hl7.org/fhir/smart-app-launch/)"/>
    </security>
    <resource>
      <type value="Claim"/>
      <supportedProfile
                        value="https://profiles.ihe.net/ITI/FAIS/StructureDefinition/IHE.FAIS.Claim"/>
      <documentation
                     value="Supports these transactions:
* [Submit Claim [ITI-126]](ITI-126.html)
* [Cancel Claim [ITI-127]](ITI-127.html)
* [Re-process Claim [ITI-128]](ITI-128.html)"/>
      <operation>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/capabilitystatement-expectation">
          <valueCode value="SHALL"/>
        </extension>
        <name value="submit"/>
        <definition
                    value="https://profiles.ihe.net/ITI/FAIS/OperationDefinition/IHE.FAIS.Claim.Submit"/>
        <documentation
                       value="Submits a claim.  FAIS Submit Claim transaction [[ITI-126]](ITI-126.html)."/>
      </operation>
      <operation>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/capabilitystatement-expectation">
          <valueCode value="SHALL"/>
        </extension>
        <name value="cancel"/>
        <definition
                    value="https://profiles.ihe.net/ITI/FAIS/OperationDefinition/IHE.FAIS.Claim.Cancel"/>
        <documentation
                       value="Cancels a claim.  FAIS Cancel Claim transaction [[ITI-127]](ITI-127.html)."/>
      </operation>
      <operation>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/capabilitystatement-expectation">
          <valueCode value="SHALL"/>
        </extension>
        <name value="reprocess"/>
        <definition
                    value="https://profiles.ihe.net/ITI/FAIS/OperationDefinition/IHE.FAIS.Claim.Reprocess"/>
        <documentation
                       value="Re-processes a claim.  FAIS Re-process Claim transaction [[ITI-128]](ITI-128.html)."/>
      </operation>
    </resource>
    <resource>
      <type value="ClaimResponse"/>
      <supportedProfile
                        value="https://profiles.ihe.net/ITI/FAIS/StructureDefinition/IHE.FAIS.ClaimResponse"/>
      <documentation
                     value="FAIS Track Claim transaction [[ITI-129]](ITI-129.html)"/>
      <interaction>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/capabilitystatement-expectation">
          <valueCode value="MAY"/>
        </extension>
        <code value="read"/>
      </interaction>
      <interaction>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/capabilitystatement-expectation">
          <valueCode value="MAY"/>
        </extension>
        <code value="search-type"/>
      </interaction>
      <searchParam>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/capabilitystatement-expectation">
          <valueCode value="MAY"/>
        </extension>
        <name value="_lastUpdated"/>
        <type value="date"/>
        <documentation
                       value="When the resource version last changed.  The values for this shall support these prefixes: gt, lt, ge, le, sa, and eb."/>
      </searchParam>
      <searchParam>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/capabilitystatement-expectation">
          <valueCode value="MAY"/>
        </extension>
        <name value="_id"/>
        <type value="token"/>
        <documentation value="Logical id of this artifact"/>
      </searchParam>
      <searchParam>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/capabilitystatement-expectation">
          <valueCode value="MAY"/>
        </extension>
        <name value="status"/>
        <type value="token"/>
        <documentation value="The status of the response"/>
      </searchParam>
      <searchParam>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/capabilitystatement-expectation">
          <valueCode value="MAY"/>
        </extension>
        <name value="request"/>
        <type value="reference"/>
        <documentation value="The coverage eligiblity request"/>
      </searchParam>
      <searchParam>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/capabilitystatement-expectation">
          <valueCode value="MAY"/>
        </extension>
        <name value="patient"/>
        <type value="reference"/>
        <documentation value="The beneficiary"/>
      </searchParam>
      <searchParam>
        <extension
                   url="http://hl7.org/fhir/StructureDefinition/capabilitystatement-expectation">
          <valueCode value="MAY"/>
        </extension>
        <name value="requestor"/>
        <type value="reference"/>
        <documentation value="The provider making the request"/>
      </searchParam>
    </resource>
    <interaction>
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/capabilitystatement-expectation">
        <valueCode value="MAY"/>
      </extension>
      <code value="search-system"/>
    </interaction>
  </rest>
</CapabilityStatement>