Claims Integration Point Overview

The following table lists the integration points, and gives some main characteristics:

Integration Point	Purpose	Inbound/Outbound	Realtime/Batch
Activity	Start and monitor activities	Inbound	Realtime
Adjudication Case	Start and End Adjudication Cases	Inbound	Realtime
Authorization	Creates, updates and deletes authorizations	Inbound	Realtime
Base View Generation	Starts the generation of base views	N.A.	Request
Claim Callout	Execution of claims callout rules	Both	Realtime/Batch
Claim Event	Publish claim event messages	Outbound	Request
Claims In	Claims Insert or Update	Inbound	Request
Claims Pre-Finalized Out	Ask for claims information in pre-finalized state	Outbound	Realtime
Claims Reprocessing	To reprocess pended claims (in bulk and also as as a request) to re-adjudicate ;against ;changed configuration or reference data.	Inbound	Both
Claims Out	Ask for claims information in finalized state	Outbound	Both
Claims Update	Update claims ;	Inbound	Request
Contract Reference	Create, Update and delete contract references	Inbound	Realtime
Counters	Read and write consumptions on counters	Both	Both
Current Properties	Shows currently set properties and their values	Outbound	Realtime
Data Access Group	Create and update data access group information	Inbound	Realtime
Data File Set	Uploading of files	Inbound	Both
Data Replication of Persons	Replicate changes in person data from Ohi Policy Administration	Inbound	Batch
Data Set Operations / Config Migration	Creates, updates and deletes configuration.	Both	Batch
Diagnosis	Create and update diagnosis information	Inbound	Both
Draft Provider Pricing Clause	Create and update of draft provider pricing clauses	Inbound	Realtime
Eligibility Check	Create and eligibility check and send out the outcome of the check	Both	Realtime/Asynchronous
Enrollment Status Callout	Ask for realtime enrollment data	Both	Realtime
Episodes	Create, Update or delete episodes	Inbound	Realtime
Fee Schedule	Create, update fee schedule and fee schedule lines	Inbound	Both
Financial Hold	Initiate or release a financial hold	Inbound	Realtime
Financial Message	Send a notification message to an external system once all the financial messages for a financial transaction set are written to the data file	Outbound	Request
Financial Transaction Process Data	Update financial transaction process data and financial transaction detail process data	Inbound	Realtime
Insurable Object	Create and update insurable object information	Inbound	Both
Note	Retrieve, create and update claim notes	Both	Request
Payment Status Callout	Ask for payment status information	Both	Asynchronous
Pend Resolution	Resolve pended claims ;	Inbound	Both
Procedure	Create and update procedure information	Inbound	Both
Product Benefit Specification	Create and update product benefit specification information	Inbound	Batch
Product Building Block	Send out information for which Ohi Claims Adjudication is the system of record to Product Definition.	Outbound	Batch
Product Service Consumption	Sends out current limit counter values for a person’s service option	Outbound	Realtime
	Property Definitions	Retrieve all available system property definitions	Outbound
Realtime	Providers In	Create and update provider (individual and organization) information	Inbound
Both	Provisioning	Provision OHI Claims Adjudication with user and user roles	Inbound
Request	Reference Sheet Line	Create, update ;and delete reference sheet lines	Inbound
Both	Registration	Create and update payment and bill registrations	Inbound
Batch	Relations In	Create and update relation (person and organizations) information	Inbound
Both	Resend Financial Message	Resend financial messages	Outbound
Both	Retrieve Contracted Providers	Produces a list of contracted providers based on a service code, date and user defined criteria	Inbound
Request	Unsend Financial Message	Unsend financial messages	Inbound
Both	User Information	Provides the ability to fetch the user information (user preferences, access restriction grants, etc.) and to update the user preferences of the logged in user	Both
Request	Workflow Event	Send out workflow event when a claim gets pended	Outbound

The following table lists additional usage characteristics of those integration points and places them into context:

Integration Point	Usage Frequency	Must Have or Option
Activity	Frequently to start financial processing for example.	Must Have
Adjudication Case	Incidentally	Optional
Authorization	Incidentally	Optional
Base View Generation	Incidentally	Optional
Claim Callout	Incidentally	Optional
Claim Event	Frequently, to send out events	Optional
Claims In	Frequently	Optional
Claims Pre Finalised Out	Frequently, to get the state of the claims	Optional
Claims Reprocessing	Frequently, to bulk process the claims	Must Have
Claims Out	Frequently if enabled	Optional
Claims Update	Incidentally	Optional
Contract Reference	Incidentally	Optional
Counters	Incidentally	Optional
Data Access Group	Incidentally	Optional
Data File Set	Frequently	Must Have
Data Replication of Persons	Incidentally	Optional
Data Set Operations / Config Migration	Incidentally when configuration needs to change	Recommended
Diagnosis	Incidentally	Optional
Draft Provider Pricing Clause	Incidentally	Optional
Eligibility Check	Incidentally	Optional
Enrollment Status Callout	Frequently	Optional
Episodes	Incidentally	Optional
Fee Schedule	Incidentally	Optional
Financial Hold	Incidentally	Optional
Financial Message	Frequently	Must Have
Financial Transaction Process Data	Incidentally	Optional
Insurable Object	Incidentally	Optional
Note	Incidentally	Optional
Payment Status Callout	Incidentally	Optional
Pend Resolution	Incidentally	Optional
Procedure	Incidentally	Optional
Product Benefit Specification	Incidentally	Optional
Product Building Block	Incidentally	Optional
Product Service Consumption	Incidentally	Optional
Providers In	Incidentally	Optional
Provisioning	Incidentally, to give new users access to the system	Must Have
Reference Sheet Line	Incidentally	Optional
Registration	Incidentally	Optional
Relations In	Incidentally	Optional
Retrieve Contracted Providers	Frequently	Optional
Resend Financial Message	Incidentally	Optional
Unsend Financial Message	Incidentally	Optional
User Information	Frequently	Must Have
Workflow Event	Incidentally	Optional

Details about individual integration points can be found in the implementation and integration guides of OHI Claims Adjudication.