Stream: implementers
Topic: Patient generated Claim
Kevin Mayfield (May 24 2019 at 08:08):
I'm working on a use where an illness/condition can start a Social ('Insurance') Benefit claim.
The claim can be started by a Patient or Practitioner but mostly a Patient.
I'm presuming this would map to FHIR Claim? That seems correct (I've not worked in the financial or benefits area before), if so I'm not sure about provider, wording seems to imply who started the claim (but not allowing Patient). If it's medical organisation, would it be top level health provider (so for Uk this is either NHS England, Wales or Scotland or HSCNI)
Lloyd McKenzie (May 24 2019 at 14:51):
Are you seeking a transfer of funds or are you seeking eligibility for coverage?
Kevin Mayfield (May 24 2019 at 15:01):
Seeking eligibility for coverage? Citizen has illness and is seeking income support from government.
Andy Stechishin (May 24 2019 at 16:56):
@Kevin Mayfield I think I understand your question. I think the Claim is the correct resource for your use case. In this case, there are some options for what you would enter for provider, depending on your particular needs. If this was for general support, such as reimbursement through some sort of social program, I would see you using an organization in the provider attribute and supplying NHS England, etc. In many cases the provider is the person/organization that performed the service or provided the item (dentist who did the filling, pharmacy that dispensed the medication).
Hopefully this helps
Paul Knapp (May 24 2019 at 18:21):
Hi Kevin: @Kevin Mayfield If the patient already has coverage with a public health program, eg. NHS/Medicare/etc., or private commercial health insurance then that insurer could have a web site or app which the patient, that is the covered party, may enter a Claim providing the details of the services which were rendered, the provider etc. and perhaps an image of the bill from the provider. The Claims resource is appropriate for that purpose
If however, the situation is that the future care need of someone who doesn't have health insurance/coverage causes them so seek income or social benefits then that would be opening a 'case' not submission of a health insurance claim - but one they have that sought after coverage and receive the health service if the provider doesn't submit the claim on their behalf then they could as described above.
It would be a similar situation to the above if the person was injured on the job and now needs to open a Workers Compensation Case where that program would reimburse the patient for health-related claims.
The current claims resources are intended only for health claims, to match HL7's scope, not auto, adverse event or personal injury claims.
Kevin Mayfield (May 27 2019 at 08:45):
Thanks.
It's a Bevan based system so 'no' concept of health insurance as found in Bismark and health insurance systems but I don't think this matters (at the moment). I did a quick mock up diagram and looks like a fit, I may have an issue over Patient (I may need to link to MPI Person but that's an issue down the line) DWP-Data-Model.jpg
Lloyd McKenzie (May 27 2019 at 13:19):
You never point to Person. Person is only ever used as a linking resource. All people involved in healthcare are referenced either as Patient, Practitioner or RelatedPerson.
Kevin Mayfield (May 28 2019 at 09:02):
Thanks. I need to evaluate if that is an issue, in the logical model I do have generic Citizen (what I've called Person). I'm seeing in the Claim, this citizen can be a Patient/RelatedPerson/Practitioner depending on the role they are in (roles looking like claimant/non professional carer/carer).
Last updated: Apr 12 2022 at 19:14 UTC
