Claims Out Integration Point

To support external services that require the full details of a claim as in claims transaction repository, Claims application provides the capability to get Claims Out in the following ways:

Claims Out Integration Point to get details of a single claim (online).
Claims Out Activity to get a file based delivery for multiple claims.

Store a finalized claim in Claims Transaction Repository (CTR), the CTR structure is a flatter structure designed to support external systems. Requests to the IP activity can result in a working copy claim and/or returning a claim transaction (that is, copy from CTR). When returning a working copy claim, it transforms into a claim transaction without version.

In effect, it is a preview of what the claim transaction for the claim would be if it were finalized at the time of the request. Doing this transformation using a transaction creation scenario in the same way of creating a claim transaction when finalizing a claim. For descriptions of the differences between the working copy and the claim transaction model as well as details on transaction creation scenarios, refer to the "Data Model" chapter of the Operations Guide.

Claims Out Integration Point

Request

To get a claim, the external system makes a GET request to http://[hostName]:[portNumber]/[api-context-root]/claimstransactionout/{claimcode}.

In response, Oracle Health Insurance provides the current claim, that is,

(1) the highest CTR version claim if the claim is currently finalized or

(2) the working copy if the claim is not currently finalized (that is, the claim has never been finalized or has been un-finalized and not yet re-finalized).

An external system can request a specific version of the claim by specifying the Version path parameter. To clarify, consider a request:

http://[hostName]:[portNumber]/[api-context-root]/claimstransactionout/{claimcode}/3

This will return the CTR version number 3.

It is possible to make a request for all the claim versions (including the working copy versions of claims that are now un-finalized or have never been finalized) using GET:

http://[hostName]:[portNumber]/[api-context-root]/claimstransactionout/{claimcode}/all

Here, it is possible to limit the versions of a claim by providing a data range.

dateFrom -

If specified it filters selection of the versions of a claim to those with a transaction date on or after datefrom
It also considers a working copy claim created or last updated on or after datefrom.

dateTo -

If specified it filters selection of the versions of a claim to those with a transaction date up to and including dateTo
It also considers a working copy claim created or last update up to and including dateto

The external system can provide finalizedonly query parameter to further filter out the contents of the response. This query parameter is available for the paths /{claimcode} and /{claimcode}/all :

Parameter Description

Parameter	Description
finalizedonly	Limits the selection to finalized claim versions For example, when making a request with version parameter set to `All` and finalizedonly set to Yes, then only the finalized versions of the claim are returned.

finalizedonly

Limits the selection to finalized claim versions

For example, when making a request with version parameter set to All and finalizedonly set to Yes, then only the finalized versions of the claim are returned.

The use of finalizedonly makes the following options possible:

Request	With Query Parameter finalizedonly	Output
…/{claimcode}	Y	Return the highest CTR version for the claim. Nothing is returned for claims that have never been finalized. Return the highest CTR version even for claims that are un-finalized.
…/{claimcode}	N or not specified	(1) the highest CTR version claim if the claim is currently finalized and (2) the working copy if the claim is not currently finalized (that is, the claim has never been finalized or has been un-finalized and not yet re-finalized).
…/{claimcode}/2	Not Applicable	This request returns a specific CTR Version of the claim.
…/{claimcode}/all	Y	Return all the finalized versions of claim (that is, working copy Version will not be returned if a claim is currently un-finalized or has never been finalized)
…/{claimcode}/all	N or not specified	Return all the versions of a claim including a working copy Version for un-finalized and never finalized claims
…/{claimcode}/all?datefrom=YYYY-MM-DD&&dateto=YYYY-MM-DD	N or not specified	Return all the versions of a claim including a working copy Version for un-finalized and never finalized claims that meet the date range selection criteria
…/{claimcode}/all?datefrom=YYYY-MM-DD&&dateto= YYYY-MM-DD	Y	Return all the finalized versions of a claim that meet the date range criteria

Request

With Query Parameter finalizedonly

Output

…/{claimcode}

Return the highest CTR version for the claim. Nothing is returned for claims that have never been finalized.

Return the highest CTR version even for claims that are un-finalized.

…/{claimcode}

N or not specified

(1) the highest CTR version claim if the claim is currently finalized and

(2) the working copy if the claim is not currently finalized (that is, the claim has never been finalized or has been un-finalized and not yet re-finalized).

…/{claimcode}/2

Not Applicable

This request returns a specific CTR Version of the claim.

…/{claimcode}/all

Return all the finalized versions of claim (that is, working copy Version will not be returned if a claim is currently un-finalized or has never been finalized)

…/{claimcode}/all

N or not specified

Return all the versions of a claim including a working copy Version for un-finalized and never finalized claims

…/{claimcode}/all?datefrom=YYYY-MM-DD&&dateto=YYYY-MM-DD

N or not specified

Return all the versions of a claim including a working copy Version for un-finalized and never finalized claims that meet the date range selection criteria

…/{claimcode}/all?datefrom=YYYY-MM-DD&&dateto= YYYY-MM-DD

Return all the finalized versions of a claim that meet the date range criteria

The external system can also ask that if the reversal transaction needs to be excluded or if only the reversal transaction is need by using the reversaloption query parameter. This parameter is available for /{claimcode}/{version} and /claimcode/all paths.

By default, system always includes reversal (when available).

Parameter Description

Parameter	Description
reversaloption	If `E` (exclude), then no reversal transaction(s) will be in the response If `O` (only), then only the reversal transaction(s) (when available) of the versions in the selection will be in the response

reversaloption

If E (exclude), then no reversal transaction(s) will be in the response

If O (only), then only the reversal transaction(s) (when available) of the versions in the selection will be in the response

Response

The system returns the following response:

<claimsTransactionOutResponse> -- for details refer section Claims Transaction Response

In case of errors, the response is as specified in the "Response Messages" section in the HTTP API Integration Points part of the Common Features book for more details.

The following message can occur in the response:

Code	Sev	Internal message
CTR-IP-CLTO-001	Fatal	From date must be before to date
CTR-IP-CLTO-002	Fatal	Claim with the claim code as {code} does not exist
GEN-PROC-003	Fatal	No applicable CTR transaction scenario found for claim with code {0} and id {1}

Code

Sev

Internal message

CTR-IP-CLTO-001

Fatal

From date must be before to date

CTR-IP-CLTO-002

Fatal

Claim with the claim code as {code} does not exist

GEN-PROC-003

Fatal

No applicable CTR transaction scenario found for claim with code {0} and id {1}

Claims Out Activity

This activity delivers requested claim transactions by placing them in a data file. Claim transactions are returned grouped by claim code and version, in the <claims> element. Description of the message format is in the section Claims Transaction Response.

This activity type has the following parameters:

Name Description

Name	Description
Claim Code	List of semi-colon separated claim codes
Service Entity Type
Service Entity Code	If specified, this limits selection of claims to the ones where the serviced person or object at the claim level matches.
Include Finalized Only	If specified as Yes, it limits the selection to finalized claim versions.
Include All Version	If specified as Yes and Include Finalized Only set to Yes - Return all the finalized versions of claims (that is, working copy Version will not be returned if a claim is currently un-finalized or has never been finalized) Include Finalized Only set to No (or not specified) - Return all the versions of claims including a working copy Version for un-finalized and never finalized claims If specified as No (or not specified) and Include Finalized Only set to Yes - Return the highest CTR version for the claim. Nothing is returned for claims that have never been finalized. Return the highest CTR version even for claims that are un-finalized. Include Finalized Only set to No (or not specified) - (1) the highest CTR version claim if the claim is currently finalized and (2) the working copy if the claim is not currently finalized (that is, the claim has never been finalized or has been un-finalized and not yet re-finalized).
Reversal Option	If `E` (exclude), then no reversal transaction(s) will be in the response If `O` (only), then only the reversal transaction(s) of each version in the selection will be in the response. If not specified then include reversals (when available)

Claim Code

List of semi-colon separated claim codes

Service Entity Type

Service Entity Code

If specified, this limits selection of claims to the ones where the serviced person or object at the claim level matches.

Include Finalized Only

If specified as Yes, it limits the selection to finalized claim versions.

Include All Version

If specified as Yes and

Include Finalized Only set to Yes - Return all the finalized versions of claims (that is, working copy Version will not be returned if a claim is currently un-finalized or has never been finalized)
Include Finalized Only set to No (or not specified) - Return all the versions of claims including a working copy Version for un-finalized and never finalized claims

If specified as No (or not specified) and

Include Finalized Only set to Yes - Return the highest CTR version for the claim. Nothing is returned for claims that have never been finalized. Return the highest CTR version even for claims that are un-finalized.
Include Finalized Only set to No (or not specified) -

(1) the highest CTR version claim if the claim is currently finalized and

(2) the working copy if the claim is not currently finalized (that is, the claim has never been finalized or has been un-finalized and not yet re-finalized).

Reversal Option

If E (exclude), then no reversal transaction(s) will be in the response

If O (only), then only the reversal transaction(s) of each version in the selection will be in the response. If not specified then include reversals (when available)

It is mandatory to provide at least one selection criterion from claim code or serviced entity.

Messages

The following messages can occur during this activity.

Code	Sev	Internal Message
CTR-ACT-CLTO-001	Fatal	Serviced entity code {code} with type {code} is unknown
CTR-ACT-CLTO-002	Fatal	Claim with the claim code as {code} does not exist
CTR-ACT-CLTO-003	Fatal	It is mandatory to specify at least one selection criterion (claim code/date range/serviced entity)
GEN-PROC-003	Fatal	No applicable CTR transaction scenario found for claim with code {0} and id {1}

Code

Sev

Internal Message

CTR-ACT-CLTO-001

Fatal

Serviced entity code {code} with type {code} is unknown

CTR-ACT-CLTO-002

Fatal

Claim with the claim code as {code} does not exist

CTR-ACT-CLTO-003

Fatal

It is mandatory to specify at least one selection criterion (claim code/date range/serviced entity)

GEN-PROC-003

Fatal

No applicable CTR transaction scenario found for claim with code {0} and id {1}

Claims Out File Delivery Integration Point

The File Based Delivery Integration Point provides an option to write all the claims transactions to a data file and make the data file available for download. The following common notification will be sent to the configured endpoint. The endpoint to send notification can be configured using ohi.claimsout.datafile.notification.endpoint'.

If the endpoint requires Authentication, use Authentication Use Case: ClaimsTransactionOutNotificationClient to set authentication. Please see section "Outbound RESTful Service Invocations" in Security Guide for the process and more properties.:

<notification correlationId="" workId="{activityId}" status="">
   <links>
     <link rel="file" href="http://host:port/api/datafilesets/{datafilesetcode}/datafile/{datafilecode}/data"/>
     <link rel="file" href="http://host:port/api/datafilesets/{datafilesetcode}/datafile/{datafilecode}/data"/>
     ...
    </links>
</notification>

The data file can be downloaded by using the Get details of a data file request from the data file set integration point.

URI : /datafilesets/{datafilesetcode}/datafile/{datafilecode}/data will initiate a request to download the financial message data file.

File Contents

The claims transaction out message file will have the following structure:

<claimsTransactionOutResponse>
  <claimList>
    <claim code="">
      <ctrclaimList>
        <ctrclaim/>
        <ctrclaim/>
      </ctrclaimList>
      <externalClaimsData/>
      <financialHoldList/>
    </claim>
    ...
  </claimList>
</claimsTransactionOutResponse>

Claims Out Response

The claims out response has the following structure:

<claimsTransactionOutResponse>
  <claimList>
    <claim code ="">
      <ctrclaimList>
        <ctrclaim> -- includes attributes from CTR Claim + status (see note below)
          <ctrTransactionLabelList> -- includes attributes from CTR Transaction Label
          <ctrStatusHistoryList>
            <ctrstatushistory> -- includes attributes from CTR Status History
              <ctrPendReasonHistoryList/> -- includes attributes from CTR Pend Reason History
              <ctrCalloutHistoryList/> -- includes attributes from CTR Callout History
            </ctrstatushistory>
            ...
          </ctrStatusHistoryList>
          <ctrClaimUnfinalizeReasonList>
            <ctrclaimunfinalizereason> -- includes attributes from CTR Claim Unfinalize Reason
            ...
          </ctrClaimUnfinalizeReasonList>
          <ctrClaimPolicyProductList/> -- includes attributes from CTR Claim Policy Product
          <financialTransaction> -- includes attributes from Financial Transactions
            </financialTransactionProcessData>
            <financialTransactionDetailList>
              <financialTransactionDetail> -- Claim level financial transaction details
                </financialTransactionDetailProcessData>
              </financialTransactionDetail>
              ...
            </financialTransactionDetailList>
          </financialTransaction>
          <financialHoldList> -- financial transaction level holds
            <financialHold/>
          </financialHoldList>
          <externalClaimsData/>
          <ctrClaimLineList>
            <ctrClaimLine/> -- includes attributes from CTR Claim Line
              <ctrClaimLineAppliedParameterList/> -- includes attributes from CTR Claim Line Applied Parameters
              <ctrClaimLineBenefitSpecificationList/> -- includes attributes from CTR Claim Line Benefit Specification
              <ctrClaimLineProviderPricingClauseList/> -- includes attributes from CTR Claim Line Provider Pricing Clause
                                         (i.e. "Applied provider pricing clauses")
              <ctrClaimLineCoverageList>
                <ctrClaimLineCoverage> -- includes attributes from CTR Claim Line Coverage
                <financialTransactionDetailList>
                  <financialTransactionDetail> -- includes attributes from Financial Transaction Detail
                    </financialTransactionDetailProcessData> -- includes attributes from FT Process Data + invoiceID, invoiceLineId, accountingDetailID
                  </financialTransactionDetail>
                 </financialTransactionDetailList>
                </ctrClaimLineCoverage>
                ...
              </ctrClaimLineCoverageList>
              <ctrClaimLineDiagnosisList/> -- includes attributes from CTR Claim Line Diagnosis
              <ctrClaimLineMessageList/> -- includes attributes from CTR Claim Line Message
              <ctrClaimLineModifierList/> -- includes attributes from CTR Claim line Modifier
              <ctrClaimSubLineList/> -- includes attributes from CTR Claim Sub Line
            </ctrClaimLine>
            ...
          </ctrClaimLineList>
        </ctrclaim>
        ...
      </ctrclaimList>
      <externalClaimsData
      settlementReasonCode="">
      </externalClaimsData>
      <financialHoldList> -- claim level financialholds
        <financialHold/>
      </financialHoldList>
   </claim>
   ...
  </claimList>
</claimsTransactionOutResponse>

Claim status will not be stored in the CTR; however, it is included in claim out <ctrclaim status>. For finalized claims (retrieved from the CTR) it always has status FINALIZED. For working copy claims that are retrieved for return via claim out, it is set to the current status of the claim.

Description of the mapping from a Claim to a Claim Transaction is in Repository Model. The response includes all the attributes described in Repository Model along with the attributes related to auditing and dynamic fields or records.

Auditing Information

A number of elements in the response message include attributes that contain audit information. These attributes are:

createdBy
creationDate
lastUpdatedBy
lastUpdatedDate

The attributes createdBy and lastUpdatedBy specify a user login name; creationDate and lastUpdatedDate specify a time stamp. Include these four attributes in the following elements: <ctrclaim>, <ctrclaimLine>, message at clam, and claim line level, diagnosis at both claims and claim line level, subLine, un-finalizeReason, statusHistory, modifier, and external claims data.

The element <ctrClaim> has the additional attributes: objectLastUpdatedBy and objectLastUpdatedDate. These attributes hold the user and time stamp of the last change to the claim or any underlying detail.

It is possible that the user in the audit columns no longer has an account in the Claims application. In this scenario, id of the account record will be returned, rather than the login name of that user.

For finalized claims, values of the attributes will be drawn from the claim transaction. For un-finalized claims, values will be drawn from the working copy claim audit fields.

Dynamic Fields and Records

Extension of some entities of the repository may be with dynamic fields and dynamic records. The values for these fields and records will be included in messages in a standard. For details refer to the concepts in the Developer Guide

External Claims Data

Claim transaction elements that are for a specific version of a claim include their version’s corresponding version specific external claim data. Claim transaction elements that contain the working copy Version of a claim do not include any external claims data.

Claim elements contain their claim’s non-version specific external claim data.

This structure reflects the principle that non-version specific external claim data is relevant to all versions of a claim.

In both cases (version specific and non-version specific), use the same element structure. The structure consists of a part for fixed attributes of external claims data, dynamic attributes, and dynamic records. Dynamic attributes and dynamic records will be included in the standard way as mentioned above.

Returning Financial Transactions and Financial Transaction Details

Financial information can be recorded on 3 levels on a claim transaction and its related coverage lines:

CTR Claim: Financial transactions and related financial transaction process data are related to a single claim transaction. Report these attributes in the <ctrClaim> element.
Claim Line Coverage: Financial transaction details and related financial transaction detail process data can be related to a single claim line transaction. Report these attributes in the <ctrClaimLineCoverage> element within the <claimLine> element.
Claim Transaction Level Financial Transaction Details: It is possible that financial transaction details are not related to a coverage claim line. Report the attributes of these financial transaction details and related financial transaction process data as a separate element in the <ctrClaim> element.

<financialTransaction/> element has the following attributes:

reversal
totalAmount
totalAmountCurr

<financialTransactionProcessData/> element has the following attributes:

dueDate
financialMessageMandatory
finMessageHandledDatetime
finMessageResult
finMessageId
finMessageBulkingGroup
internalRemarks
penaltyDate
superseded

<financialTransactionDetail/> element has the following attributes:

claimLineCode
componentCode
amount
amountCurr
numberOfUnits
productBrandCode
productCode

<financialTransactionDetailProcessData> element has the following attributes:

accountingBulkingGroup
counterPartyCode
counterPartyQualifier
generalLedgerAccount
internalRemarks
indInvoice
invoiceBulkingGroup
indInvoiceLineGrouping
indAccountDetailGrouping
invoiceLineBulkingGroup
payFromBankAccount
paymentBeneficiaryFlexCodeDefinitionCode
paymentBeneficiaryCode
invoiceId
invoiceLineId
accountingDetailId

Returning Financial Holds

The complete history of financial holds will be reported by this integration point. Financial holds will be reported for claim level financial holds and financial transaction level financial holds.

<financialHold/> element has the following attributes:

holdType
heldBy
startDatetime
releasedBy
releaseDatetime
expirationDatetime
remarks
releaseRemarks