Eligibility Inquiries Processing through the FHIR Channel

The FHIR channel is used when a submitter (a patient) uses software that submits inquires in the FHIR format. The insurer works on FHIR servers, but the back-end system is HIPAA-compliant and processes EDI files. In this case, the submitter (a patient, a provider) submits the FHIR eligibility request to the FHIR server.

In this scenario, XES Module for FHIR does the following:

Step 1: Monitors the FHIR server for new CoverageEligibilityRequest resources. Once a new resource is detected, XES Module for FHIR collects all the required resources and converts these resources into an EDI 270 file. For more information, see Eligibility Mapping Rules. During conversion, XES Module for FHIR adds the TRN segment to the EDI 270 file with TRN.02 = CoverageEligilbilityRequest.id and TRN.03 = “9EDIFECS”.

Example

TRN*1* 26*9EDIFECS

Step 2: Once the EDI 271 response is received from the back-end, XES Module for FHIR does the following:

Extracts the TRN.02 value from the TRN segment where TRN.03=”9EDFIECS“ to link the response to the request.
Verifies that the patient in the submitted EDI 270 request and in the received EDI 271 response is the same. To do this, XES Module for FHIR compares the following key fields:

First name
Last name
Date of birth

If one of these fields does not match, the EDI 271 file is rejected.

Step 3: Maps the EDI 271 to FHIR resources. For more information, see Eligibility Mapping Rules. The patient information from the EDI 271 updates the existing patient information on the FHIR server. The request field of CoverageEligibilityResponse uses the TRN.02 value of the TRN segment where TRN.03=”9EDFIECS “ is linked to CoverageEligibilityRequest.

Example

</CoverageEligibilityResponse>

Step 4: Maps all TRN segments from the EDI 271 transactions to identifier. TRN.02 is used to set the value, and TRN.03 is used to set the system.