Availity FHIR R4 Financial API

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The MuleSoft Accelerator for Healthcare now enables call center agents and care staff to perform real-time benefits and eligibility verification. Providers can electronically verify a patient’s insurance coverage in real-time for medical treatment.



This asset is a component of MuleSoft Accelerator for Healthcare.

MuleSoft Accelerator for Healthcare enables healthcare providers to unlock critical patient data to build a patient 360 within Salesforce Health Cloud, faster and easier than ever before. The solution includes pre-built APIs, connectors, integration templates, and a prescriptive end-to-end reference architecture to bring patient demographics information and COVID-19 test results from any EHR into Health Cloud using HL7 V2 or FHIR standards.

The solution also provides a library of United States Core Data for Interoperability (USCDI) and FHIR R4 resources to help healthcare developers adhere to interoperability needs and jumpstart the development of healthcare digital transformation initiatives.

The Financial module covers the resources and services provided by FHIR to support the costing, financial transactions and billing which occur within a healthcare provider as well as the eligibility, enrollment, authorizations, claims and payments which occur between healthcare providers and insurers and the reporting and notification between insurers and subscribers and patients.

The Financial API specification provides resources for the following FHIR R4 Profiles:

AccountAccount is a financial tool for tracking value accrued for a particular purpose. In the healthcare field, used to track charges for a patient, cost centers, etc.
ContractContract allows for the instantiation of various types of legally enforceable agreements or policies as shareable, consumable, and executable artifacts as well as precursory content upon which instances may be based or derivative artifacts supporting management of their basal instance.
CoverageCoverage is intended to provide the high-level identifiers and descriptors of an insurance plan, typically the information which would appear on an insurance card, which may be used to pay, in part or in whole, for the provision of health care products and services.
CoverageEligibilityRequestCoverageEligibilityRequest provides patient and insurance coverage information to an insurer for them to respond, in the form of an CoverageEligibilityResponse, with information regarding whether the stated coverage is valid and in-force and optionally to provide the insurance details of the policy.
CoverageEligibilityResponseCoverageEligibilityResponse provides eligibility and plan details from the processing of an CoverageEligibilityRequest resource. It combines key information from a payor as to whether a Coverage is in-force, and optionally the nature of the Policy benefit details as well as the ability for the insurer to indicate whether the insurance provides benefits for requested types of services or requires preauthorization and if so what supporting information may be required.
EnrollmentRequestEnrollmentRequest allows for the addition and removal of plan subscribers and their dependents to health insurance coverage.
EnrollmentResponseEnrollmentResponse provides enrollment and plan details from the processing of an Enrollment resource.
VisionPrescriptionVisionPrescription is intended to support the information requirements for a prescription for glasses and contact lenses for a patient. Corrective optical lenses are considered a controlled substance and therefore a prescription is typically required for the provision of patient-specific lenses.
ClaimClaim is used by providers and payors, insurers, to exchange the financial information, and supporting clinical information, regarding the provision of health care services with payors and for reporting to regulatory bodies and firms which provide data analytics. The primary uses of this resource is to support eClaims, the exchange of information relating to the proposed or actual provision of healthcare-related goods and services for patients to their benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.
ClaimResponseClaimResponse provides application level adjudication results, or an application level error, which are the result of processing a submitted Claim resource where that Claim may be the functional corollary of a Claim, Predetermination or a Preauthorization.This resource is the only appropriate response to a Claim which a processing system recognizes as a Claim resource.
PaymentNoticePaymentNotice indicates the resource for which the payment has been indicated and reports the current status information of that payment. The payment notice may be used by providers and payers to advise the provider or regulatory bodies of the state of a payment (check in the mail/EFT sent, payment cashed, payment canceled). Employers or Insurance Exchanges may use this to advise payers of premium payment.
PaymentReconciliationPaymentReconciliation provides the bulk payment details associated with a payment by the payor for receivable amounts, such as for goods and services rendered by a provider to patients covered by insurance plans offered by that payor. These are the payment reconciliation details which may align to the individual payment amounts indicated on discrete ClaimResponses or Invoices for example.
ExplanationOfBenefitExplanationOfBenefit combines key information from a Claim, a ClaimResponse and optional Account information to inform a patient of the goods and services rendered by a provider and the settlement made under the patient's coverage in respect of that Claim. The ExplanationOfBenefit resource may also be used as a resource for data exchange for bulk data analysis, as the resource encompasses Claim, ClaimResponse and Coverage/Eligibility information.


Published by
MuleSoft Solutions
Published onOct 12, 2023
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