Operations Overview
The following FHIR Operations are in scope for processing claim messages. For consistency across all implementations, a FHIR messaging paradigm will be used. Note: Some implementers may prefer to create a separate endpoint for Claim Reversals.
The GET totals and details queries are invoked by using the $daily-totals operation or the $daily-details operation. These are designed as a custom operations rather than a query because key data in the message header can be re-used in an operation, which is more efficient for mapping to CPHA3.
The operation is invoked using an HTTP GET and responds with either an OperationOutcome (if errors exist) or a Parameters OUT instance containing the result.
The Daily Totals and Daily Details use the same message, the Parameters IN resource, Bundle and Message Header Request profiles. The responses will be either a Daily Totals or Adjudication Details Parameters OUT Resource.
| Functionality | Operation | Definition | Response |
|---|---|---|---|
| Submit Claims | [base]Claim/$submit |
Bundle with Message Header, focus=Claim or ProffClaim or Reversal Request | Bundle, Message Header, focus=Claim Response |
| Submit Claim Reversal | [base]Claim/$reversal |
Bundle with Message Header, focus=ParametersIn for Reversal | Bundle, Message Header, focus=Parameters:Out Claim Reversal |
| Get Totals Date Range |
[base]/$daily-totals | Bundle with Message Header, focus= Parameters:In resource. Custom FHIR Operation/Parameters:In resource | Bundle, Message Header, focus= Parameters:Out Totals by Date |
| Get Detail Records, Date Range |
[base]/$adjudication-details | Bundle with Message Header, focus = Parameters:In resource. Custom FHIR Operation/Parameter resource | Bundle, Message Header, focus= Parameters:Out Detailed Record by Date |
FHIR Messaging, Using Parameters
As described in the FHIR specification , FHIR allows a message with the use of the Parameters resource to invoke an operation. This allows for the consistent use of messaging for all transactions and is therefore the favourable approach.
Following is an excerpt from the FHIR standard (https://build.fhir.org/messaging.html#operations)
A message can be used to invoke an operation as defined for a RESTful interface using an operation definition. To invoke an operation using a message:
- The requester sends a message (a bundle with type = message, and a message header resource)
- The message header has an event.system of urn:ietf:rfc:3986
- The event.code is the URL from the operation definition OperationDefinition.url
- The MessageHeader.focus refers to a Parameters resource
- The parameters resource is populated appropriately as specified by the nominated operation definition
- The recipient executes the operation as specified, and then:
The receiver sends a message (a bundle with type = message, and a message header resource)
- The message header has the same event as the original message
- The MessageHeader contains a response that refers to the original request message, and a code for the outcome, with details if the operation failed
- The MessageHeader.focus refers to a Parameters resource
- The parameters resource is populated appropriately as specified for the response by the nominated operation definition If the operation definition specifies a single return, then this is returned as the target of the MesssageHeader.focus directly
MVP Scope - New Features and Functionality
A complete list of new features and functionality is available in the MVP Scope section, links below:
Also refer to the FHIR Message Structure section which provides an overview of the message structure for each message type, and profile links to the details.
| Message | Link to MVP Scope, Featues & Functions | - |
|---|---|---|
| Claim Request - Dispense | Claim Request - Dispense Features | |
| Claim Request - Professional Services | Claim Professional Services Features | |
| Claim Response - Dispense & Professional services | Claim Response Features | |
| Claim Reversal Request | Claim Reversal Request Features | |
| Claim Reversal Response | Claim Reversal Response Features | - |
| Request for Totals and Details | Request for Totals and Details Features | |
| Daily Totals Response | Daily Totals Response Features | |
| Adjudication Details Response | Adjudication Details Response Features |