Claims Integration Point Overview
The following table lists the integration points, and gives some main characteristics:
Integration Point | Purpose | Inbound or Outbound | Realtime or 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 Call-out |
Execution of claims call-out 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 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 Policies |
Inbound |
Batch |
Data Set Operations or 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 or Asynchronous |
Enrollment Status Call-out |
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 Call-out |
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 Claims 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 Claims 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 |
Un-send Financial Message |
Un-send 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 |
Request |
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 Call-out |
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 or Config Migration |
Incidentally when configuration needs to change |
Recommended |
Diagnosis |
Incidentally |
Optional |
Draft Provider Pricing Clause |
Incidentally |
Optional |
Eligibility Check |
Incidentally |
Optional |
Enrollment Status Call-out |
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 Call-out |
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 |
Un-send 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 Claims.