NPHIES Workflows¶

Overview¶

This document describes the standard workflows for NPHIES transactions including eligibility verification, prior authorization, claim submission, and payment reconciliation.

Core Workflows¶

1. Eligibility Verification¶

Purpose: Confirm patient insurance coverage before service.

sequenceDiagram
    participant P as Provider
    participant N as NPHIES
    participant I as Insurer

    P->>N: Eligibility Request
    N->>I: Forward Request
    I->>N: Eligibility Response
    N->>P: Coverage Details

Steps:

1. Request Generation
2. Patient identifier
3. Date of service

4. Service type (optional)

5. NPHIES Processing

6. Route to correct payer

7. Validate request

8. Payer Response

9. Coverage status
10. Benefit details

11. Copay/deductible

12. Provider Action

13. Confirm coverage
14. Inform patient of costs
15. Proceed with service

Request Example:

{
  "resourceType": "CoverageEligibilityRequest",
  "status": "active",
  "purpose": ["benefits"],
  "patient": {
    "reference": "Patient/123"
  },
  "servicedDate": "2024-01-15",
  "insurer": {
    "reference": "Organization/bupa"
  }
}

Response Interpretation:

2. Prior Authorization¶

Purpose: Obtain approval for services before delivery.

sequenceDiagram
    participant P as Provider
    participant N as NPHIES
    participant I as Insurer

    P->>N: Authorization Request
    N->>I: Forward Request
    I->>N: Auth Decision
    N->>P: Approval/Denial

    alt Approved
        P->>P: Provide Service
    else Denied
        P->>I: Appeal
    end

Steps:

1. Request Submission
2. Clinical justification
3. Proposed services

4. Supporting documentation

5. Payer Review

6. Medical necessity
7. Policy coverage

8. Network status

9. Decision

10. Approved
11. Denied (with reason)

12. Pended (need more info)

13. Provider Action

14. If approved: Schedule service
15. If denied: Appeal or inform patient
16. If pended: Provide additional info

Authorization Types:

3. Claim Submission¶

Purpose: Submit billing claims for adjudication.

sequenceDiagram
    participant P as Provider
    participant N as NPHIES
    participant I as Insurer

    P->>N: Submit Claim
    N->>N: Validate
    N->>I: Forward Claim
    I->>I: Adjudicate
    I->>N: ClaimResponse
    N->>P: Result

    alt Accepted
        I->>P: Payment
    else Rejected
        P->>P: Correct & Resubmit
    end

Steps:

1. Claim Generation
2. Patient demographics
3. Encounter details
4. Diagnoses (ICD-10)
5. Procedures (CPT/ACHI)

6. Charges

7. Validation

8. FHIR compliance
9. Business rules

10. Code validation

11. Adjudication

12. Benefit determination
13. Medical policy review

14. Payment calculation

15. Response Processing

16. Accept/reject handling
17. Remittance posting
18. Denial management

Claim Types:

4. Claim Status Inquiry¶

Purpose: Check status of submitted claims.

sequenceDiagram
    participant P as Provider
    participant N as NPHIES
    participant I as Insurer

    P->>N: Status Request
    N->>I: Query
    I->>N: Status Response
    N->>P: Current Status

Status Values:

5. Payment Reconciliation¶

Purpose: Match payments to claims.

sequenceDiagram
    participant I as Insurer
    participant N as NPHIES
    participant P as Provider

    I->>N: Payment Notification
    N->>P: ERA/835
    P->>P: Post Payment
    P->>P: Reconcile

Steps:

1. Payment Notice
2. Payment amount
3. Claim references

4. Adjustment reasons

5. ERA Processing

6. Parse payment details
7. Match to claims

8. Post to accounts

9. Reconciliation

10. Verify amounts
11. Identify discrepancies
12. Follow up on issues

Advanced Workflows¶

Pre-Determination¶

Purpose: Estimate coverage before service.

graph LR
    A[Request] --> B[Payer Review]
    B --> C[Estimate]
    C --> D[Patient Decision]

Claim Resubmission¶

Purpose: Correct and resubmit rejected claims.

graph LR
    A[Rejection] --> B[Analyze]
    B --> C[Correct]
    C --> D[Resubmit]
    D --> E{Accepted?}
    E -->|No| B
    E -->|Yes| F[Done]

Appeal Process¶

Purpose: Challenge denied claims.

graph TD
    A[Denial] --> B[Review Reason]
    B --> C{Appealable?}
    C -->|Yes| D[Gather Evidence]
    C -->|No| E[Accept/Write-off]
    D --> F[Submit Appeal]
    F --> G{Decision}
    G -->|Upheld| H[Escalate/Accept]
    G -->|Overturned| I[Payment]

Error Handling¶

Common Errors¶

Retry Strategy¶

1. Immediate retry - Network errors
2. Delayed retry - Rate limiting
3. Manual review - Business errors

Integration Timeline¶

Standard Processing Times¶

Related Documents¶

• NPHIES Overview
• FHIR R4 Profile
• API Reference
• Claim Lifecycle

Last updated: January 2025