User Journeys & Workflows

To integrate successfully with the HIE, you must consider all the possible workflows or the specific workflows that apply to your facility. The HIE supports three distinct claim flows:

1. Primary Healthcare Fund (PHC): Covers outpatient services at lower-level facilities (Level 2 & 3). Funded by government and grants. This flow applies for capitation and basic fee-for-service interventions. Involves simplified consent, no preauthorization, direct submission after consent.
2. Social Health Insurance Fund (SHIF): For contributing members, available at hospital level 3 and above. This flow applies for comprehensive inpatient/outpatient care. It has mandatory biometric consent(With OTP for whitelisted members), preauthorization for select services, full billing and discharge processes.
3. Emergency Chronic Critical Illness Fund (ECCIF): For emergency, critical, chronic, and palliative care. This flow applies when immediate treatment is required. Claims can be created without initial consent, supports unidentified patients, and uses emergency protocols (bundled tariffs).

Which Flow Should I Use?

Use this flowchart to determine the correct API path for your current patient visit.

Implementation Checklist

1. Start Visit: Use POST /start_visit and validate the OTP/Biometrics to get a consent_token.
2. Preauth (If needed): Call POST /submit_preauth.
   • Action: Poll GET /preauth/{id}/status until it returns FINALISED.
3. Billing: Use standard intervention codes (SHA-XX) via POST /add_claim_line.

Scenario C: PHC (Primary Healthcare)

Designed for: Dispensaries, Health Centres (Level 2 & 3).

A simplified workflow for basic outpatient services (PCF). It skips preauthorization logic and focuses on capitation and basic fee-for-service items.

Key Features

• Restricted Scope: Only allows interventions permitted for Level 2/3 facilities.
• Simplified Billing: No preauths. Direct submission after consent.

Implementation Checklist

1. Eligibility: Ensure the patient is assigned to your facility (Capitation) or eligible for PHC benefits via POST /check_eligibility.
2. Interventions: Use POST /add_virtual_claim_line with PHC-specific intervention codes.