Overview
The following table lists the integration points, and gives some main characteristics.
An Integration Point is Outbound, if the message originates in the Oracle Health Insurance application and is sent to an external system. An Integration Point is inbound if the message originates in the external system and is sent to the Oracle Health Insurance application.
An Integration Point can have both Inbound and Outbound characteristics, for example an inbound one sends on outbound notification when the processing is complete. |
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Integration Point | Purpose | Inbound or Outbound | Realtime or Batch |
---|---|---|---|
Activity |
Start and monitor activities |
Inbound. Outbound notification |
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 |
Outbound callout. Inbound callout response |
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 |
Inbound |
Realtime |
Claims Reprocessing |
To reprocess pended claims (in bulk and also as a request) to re-adjudicate; against; changed configuration or reference data. |
Inbound. Outbound notification |
Both |
Claims Out |
Ask for claims information in finalized state |
Outbound |
Both |
Claims Update |
Update claims |
Inbound |
Request |
Counters |
Read and write consumptions on counters |
Inbound |
Both |
Current Properties |
Shows currently set properties and their values |
Inbound |
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 |
Inbound |
Realtime or Asynchronous |
Enrollment Status Callout |
Ask for realtime enrollment data |
Outbound |
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 |
Inbound |
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 Claims is the system of record to Product Definition. |
Outbound |
Batch |
Product Service Consumption |
Return current limit counter values for a person’s service option |
Inbound |
Realtime |
Property Definitions |
Retrieve all available system property definitions |
Inbound |
Realtime |
Providers In |
Create and update provider (individual and organization) information |
Inbound |
Both |
Provisioning |
Provision Claims with user and user roles |
Inbound |
Request |
Purge Authorizations Data |
Purge (Claims) authorizations |
Inbound |
Request |
Purge Claims Data |
Purge Claims |
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 Procedures |
Produces a list of contracted procedures based on a provider code or identifier, date and part of the procedure description |
Inbound |
Request |
Retrieve Contracted Providers |
Produces a list of contracted providers based on a service code, date and user defined criteria |
Inbound |
Request |
Technical Error |
To notify an external system when the claims flow runs into a technical error |
Outbound |
Realtime |
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 |
Inbound |
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 | Mandatory or Optional |
---|---|---|
Activity |
Frequently to start financial processing for example. |
Mandatory |
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 |
Mandatory |
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 |
Mandatory |
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 Callout |
Frequently |
Optional |
Fee Schedule |
Incidentally |
Optional |
Financial Hold |
Incidentally |
Optional |
Financial Message |
Frequently |
Mandatory |
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 |
Mandatory |
Purge Authorizations Data |
Incidentally |
Optional |
Purge Claims Data |
Incidentally |
Optional |
Reference Sheet Line |
Incidentally |
Optional |
Registration |
Incidentally |
Optional |
Relations In |
Incidentally |
Optional |
Retrieve Contracted Procedures |
Frequently |
Optional |
Retrieve Contracted Providers |
Frequently |
Optional |
Resend Financial Message |
Incidentally |
Optional |
Un-send Financial Message |
Incidentally |
Optional |
User Information |
Frequently |
Mandatory |
Workflow Event |
Incidentally |
Optional |
Details about individual integration points can be found in the Developer Guide of Claims.