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

2:3.128 Re-process Claim [ITI-128]

This section corresponds to transaction [ITI-128] of the IHE IT Infrastructure Technical Framework. Transaction [ITI-128] is used by the Claims Requestor and Claims Manager Actors. The Re-process Claim [ITI-128] transaction is used to re-process a claim for a patient.

2:3.128.1 Scope

This transaction is used by the Claims Requestor to re-process 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.

2:3.128.2 Actors Roles

Table 2:3.128.2-1: Actor Roles

2:3.128.3 Referenced Standards

FHIR-R4 HL7 FHIR Release 4.0

2:3.128.4 Messages

2:3.128.4.1 Re-process Claim Request Message

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

2:3.128.4.1.1 Trigger Events

When a Claims Requestor needs to re-process a claim for a Patient to the Claims Manager, it submits the Re-process Claim Message.

2:3.128.4.1.2 Message Semantics

The Claims Requestor invokes the FAIS Claim $reprocess 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/<resourceId>/$reprocess

Where is the resource id of the claim to be re-processed.

The HTTP body MAY be 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. If included, the Claim resource SHALL have the id element set to the being re-processed.

2:3.128.4.1.3 Expected Actions

The Claims Manager SHALL re-process the claim and respond as per http://hl7.org/fhir/R4/operations.html#response, and if successful, with an HTTP 200 (OK) and a Re-process Claim Response Message.

The Claims Manager SHALL update the requested Claims resource as defined by internal business rules.

2:3.128.4.2 Re-process Claim Response Message

2:3.128.4.2.1 Trigger Events

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

2:3.128.4.2.2 Message Semantics

The Re-process 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.

2:3.128.4.2.3 Expected Actions

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

2:3.128.5 CapabilityStatement Resource

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

• Requirements CapabilityStatement for Claims Requestor
• Requirements CapabilityStatement for Claims Manager

2:3.128.6 Security Considerations

See FAIS Security Considerations

2:3.128.6.1 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 Re-process Claim Transaction. See Audit Example for Re-process Claim from the Claims Requestor.