Eligibility Check Workflow Guide
Eligibility Process: Eligibility Check Workflow
1. Overview: Patient Eligibility Check
This guide provides information on the Eligibility Check Workflow, a core workflow within the Eligibility Process. It helps to provide a one-stop solution to immediately determining a patient's current healthcare coverage status and entitlements under the Social Health Authority (SHA).
This workflow combines essential identity verification and coverage status checks to provide information on whether a specific patient is currently covered by SHA on what services and the coverage validity period. It returns a clear status of their coverage and the fundamental details of their entitlement.
1.1. What This Workflow Does
The Eligibility Check Workflow performs two critical functions:
- Patient Identification: Accurately identifies the patient using their provided identifier (e.g., National ID) against the central Client Registry.
- Contribution Status Verification: Immediately verifies the patient's coverage status under SHA and validity period for this coverage.
The primary outcome is the patient's SHA coverage status and key details of their enrollment and coverage. This is the simplest, fastest way to confirm a patient's eligibility to receive services.
1.2. Why This Workflow Is Critical
- Instant Verification: Provides an instant way to check a patient's coverage status in one place.
- Billing Assurance: Offers a preliminary confirmation of SHA coverage, reducing financial risk for healthcare providers.
- Service Triage: Enables providers to quickly determine the appropriate funding scheme for a patient (e.g., UHC, PMF) and any subsequent services they can access.
2. Workflow Details: Eligibility Check
2.1. Workflow Description
This workflow is simpler and more direct than the full multi-step eligibility process, focusing only on identification and key contribution standing information with SHA.
- Input Reception: The system receives the patient's identification details. This involved the type of identifier being used and it's value e.g.
National IDand the ID number. - Patient Search & Validation: The system queries the Client Registry to verify the existence and identity of the patient, converting the input identifier into a verified Client Registry ID (CR ID).
- Contribution Status Check: The system checks the patient's CR ID and gets the SHA coverage to determine their active contribution status.
- Outcome Delivery: The system returns the official SHA coverage status and related entitlement details.
2.2. Key Validations: System Checks
| Validation Check | Description | Why It Matters |
|---|---|---|
| Valid Identification Type: | The id_type (e.g., National ID, Birth Certificate) must be a supported type recognized by the Client Registry. Refer to the types from Patient Search docs | Ensures the system attempts to search using a known, queryable format. |
| Valid Identification Value: | The id_value must be present and correctly formatted (e.g., a specific length or alphanumeric pattern). | Critical for accurately locating the patient in the Client Registry. |
| Patient Must Be Found: | The system must successfully match the provided ID to an active patient profile in the Client Registry to retrieve the CR ID. | Without a verified identity (CR ID), no coverage check can be performed. |
2.3. Workflow Data Dictionary
| Field Name | Description | Data Type | Required | Purpose |
|---|---|---|---|---|
| Identification Type | The type of identifier being used (Options include Temporary ID,Alien ID, Refugee ID, Mandate Number, Birth Certificate, National ID, Birth Notification). | String | Yes | Tells the system which index to search for the patient. |
| Identification Value | The specific value of the patient's identifier (e.g., "12345678"). | String | Yes | The actual search query to locate the patient. |
2.4. Expected Outcomes
| Outcome | Description |
|---|---|
| Eligible / Active Coverage: | The patient is successfully identified and their contribution status is confirmed as active and compliant with SHA. Coverage details are returned. |
| Ineligible / Not Active: | The patient is identified, but their contribution status is not compliant, or their coverage has lapsed. |
| Patient Not Found: | The provided id_type and id_value did not match any entry in the Client Registry. |
| Input Error: | Missing or invalid required fields (e.g., missing id_value or invalid id_type). |
3. Critical Success Factors for Integration
- Accurate ID Input: Ensure user-provided ID types and values are validated on your end before being passed to this API. Junk data in means failure out.
- Handle All Outcomes: Design your user interface to clearly distinguish between "Patient Not Found" (identity issue) and "Ineligible" (financial/status issue), as they require different responses from the facility staff.
- Audit Compliance: Always ensure that the
Facility IdentifierandFacility Identifier Typeare correctly passed for every request, as this ensures all checks are properly audited for security and compliance.