FHIR’s financial resources can be intimidating.
Especially if you’re new to the payment side of healthcare. Let’s try and break it down a little.
- A patient needs treatment
- An insurer agrees to pay some or all of that treatment
- Treatment is provided and a claim is made
- Payment happens (or doesn’t)
There are a multitude of steps in between each of these that make use of one or more of FHIR’s 13 financial resource types. These include:
- Claim and ClaimResponse
- CoverageEligibilityRequest and CoverageEligibilityResponse
- ExplanationOfBenefit
- PaymentNotice and PaymentReconciliation.
For a more detailed understanding take a look at the “relative order of use” table.
It documents the different steps in the claims and payment process alongside the FHIR resource types that relate to them.
The wording used to describe these steps varies country to country, as do the steps themselves.
The distinction between words such as “preauthorization”, “predetermination” and “adjudication” is not always obvious.
This short glossary of terms is helpful here and is worth bookmarking if you’re unfamiliar with the financial side of healthcare
Learn more about FHIR’s financial module: https://www.hl7.org/fhir/R4/financial-module.html
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