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implementation-considerations.md

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description
Additional details for implementing OPD & IPD claim process using HCX protocol

Implementation Considerations

This section identifies the key workflow and data attribute considerations for implementing the cashless claims for both cashless and reimbursement in OPD and IPD usecases.

Workflow considerations

Scenario Remarks
Consent while submitting reimbursement claims Submission of reimbursement claim by the policyholder through a BSP platform may require submission of a verification token by policyholder (shared via a separate channel), does the claim data structure provide for that. Details for obtaining consent from the beneficiary added in the intra-cycle communication section.
Account information for reimbursement claims

This can be enabled via the Communication cycle between the payer and the BSP.
More details on the communication request/response codes and workflow are provided in the account information sub-section under intra-cycle communication section

{% hint style="info" %} Note : Seeking beneficiary consent is strongly recommended for the OPD/IPD reimbursement claims to increase beneficiary trust and prevent claim frauds. Ref : Intra cycle communication for more details.

Furthermore, it is advisable to implement use consent flow while processing the OPD cashless claim initiated by non-empanelled healthcare facilities. {% endhint %}

Data attributes considerations

Scenario Remarks
IPD vs OPD

Use the element “type” in the Claim object to identify whether the claim is an OPD or an IPD claim. The claim-type value set (bound to the “type” element) has codes “professional” & "diagnostics" which are meant to be used typically for outpatient claims from Physician, Psychological, Chiropractor, Physiotherapy, Speech Pathology, rehabilitative, consulting and diagnostic services.

ℹ This approach of claims categorization will require a discussion in subsequent protocol versions to articulate various claim categorizations through the claim.type and claim.subType elements. It is crucial to guarantee backward compatibility in future iterations in case the valueset definition undergoes changes following the review.
Submission of payment receipt in Claims object

In co-pay/partial-pay kind of scenarios, there could be a requirement to submit receipts of the payment made by the policyholder.


Claim Supporting Info Categories - use the following code:

  1. MB - medical bill

Claim Supporting Info Codes: use the following codes:

  1. Medicines Bill/Receipt
  2. Lab Tests Bill/Receipt
  3. Medical Services Bill/Receipt
Codes for denial due to consent declines by the policyholder Use code "AUTH-013: Patient consent is not provided or invalid" in HCX Claim Error Codes value set.

Typical data requirements

Data
Patient Information
  1. Name
  2. Bate of birth
  3. Policy number
  4. Unique identifiers associated with the insured individual.
Provider Information The payer needs details about the healthcare provider who is submitting the claim. This includes the provider's name, address, identification number (if applicable), and any other relevant information to identify the provider.
Itemised Bill The Healthcare Provider must provide an itemised bill that clearly outlines the individual charges for each service, test, or procedure performed during the outpatient intervention. This allows the payer to assess the appropriateness of the charges and determine the eligible insurance amount.
Treatment Details The payer requires a comprehensive breakdown of the treatment provided during the outpatient intervention. This includes the date of the intervention, the nature of the services or procedures performed, and any supporting medical documentation such as investigations, test results, and prescribed medications.
Pre-Authorization (if applicable) If the insurance policy requires pre-authorization for specific treatments, procedures, or specialist visits, the healthcare Provider needs to include the pre-authorization reference provided by the payer. This ensures that the claim aligns with the pre-approved services.

These inputs provide the necessary information for the payer to evaluate the claim and make an on-the-spot adjudication decision. By having access to patient information, treatment details, itemised billing, and network provider verification (if applicable), the payer can quickly assess the claim's validity and determine the coverage and reimbursement amounts accordingly.