VetEnvoy Insurance Claims integration

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Development Project Status: Under Discussion

Due date for completion of this stage: 
10/01/2015
Project funding: 

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Project description: 

Overview

This project is an extension to the Patient Insurance project, allowing claims to be submitted to insurers that use the VetEnvoy eClaims service.

VetEnvoy supports insurance e-claims in the UK, US and Canada.

 

Claim Submission

Any Insurance Claim that is finalised will automatically be submitted to the VetEnvoy eClaims service, if the Insurer linked to the Policy Type is a party.supplierInsurerVetEnvoy (see below).

When finalised:

  • the claim and and any of its attachments will be submitted to VetEnvoy
  • the submitted claim will include all patient Clinical Notes created prior to the claim.
  • the Insurer Claim Id field will be updated with the id assigned by VetEnvoy

On successful submission, the Claim status will be updated to Submitted.

If submission fails, e.g. due to connection timeouts, then the Claim status will remain as Finalised. A Submit button will be enabled to submit the remainder of the Claim.

Claim Workflow

Once a claim has been submitted, the Insurer sends status updates. These are obtained by polling the VetEnvoy service (see Polling Job below). The Insurance Claim will be updated with the status:

  • Processing - the insurer is processing the claim
  • Settled -  the insurer has settled the claim
  • Declined - the insurer has declined the claim

If a claim is submitted via VetEnvoy, the Process Claim, Settle Claim and Decline Claim buttons will be disabled.

Cancelling Claims

If a claim has been submitted to VetEnvoy, and is subsequently cancelled, a cancellation notification will be sent to VetEnvoy.

Polling Job

A job will be provided that periodically polls the VetEnvoy web service for claim updates.

Claim Mapping

 

The following shows how OpenVPMS archetypes will be mapped to the InsuranceClaim schema used by VetXML. Note that this includes elements from InsuranceClaim 1.10 which is not yet live.

Claim Field Mapping
Identification  

OwnerID

party.customerperson/id

PracticeID

party.organisationPractice/id

PracticeClaimRef

act.patientInsuranceClaim/id

InsurerID

Our ID or their ID?
InfoFromPolicyHolder  

PolicyDetails

 

PolicyNumber

act.patientInsurancePolicy/policyNumber

PolicyholderName

party.customerperson/name

Address

party.customerperson/contact.location

Postcode

party.customerperson/contact.location

AddressDifferentFromPolicy

false - policy address must be the same as the customer address

DaytimePhone

Defaults to customer phone number without HOME classification, if any.

EveningPhone

Defaults to customer phone number with HOME classification, if any.

MobilePhone

Defaults to customer phone number with MOBILE classification, if any.

EmailAddress

party.customerperson/contact.email

PreferredContactBy

leave empty

AnimalInsuredWithCurrentProviderBefore

True if there is an act.patientInsurancePolicy for the patient dated before the current policy.

OtherInsurersCoveringAnimal

not supported

Insurer

not supported

AnimalDetails

 

Name

party.patientpet/name

PedigreeName

not supported

Species

party.patientpet/species

Breed

party.patientpet/breed

DateOfBirth

party.patientpet/dateOfBirth

Gender

party.patientpet/sex

Colour

party.patientpet/colour

MicrochipNumber

party.patientpet/entityIdentity.microchip

Conditions

not supported

Condition

not supported

Description

not supported

DateFirstNoticed

not supported

RepeatIllnessInjury

not supported

DeathDueToIllnessInjury

not supported

DateOfDeath

not supported

PreviousVets

not supported

PreviousVet

not supported

PracticeID

not supported

Name

not supported

Address

not supported

Postcode

not supported

DateFrom

not supported

DateTo

not supported

Financial

 

PayVet

act.patientInsuranceClaim/payVet

PayClaimTo

if PayVet is true, the practice name is used, otherwise the customer name is used

ElectronicPayment

 

AccountName

act.patientInsuranceClaim/accountName

Bank

act.patientInsuranceClaim/bank

SortCode

act.patientInsuranceClaim/branch

AccountNumber

act.patientInsuranceClaim/accountNumber

InfoFromVet

 

Miscellaneous

 

AnimalRegistered

not supported

LastVaccination

not supported

MicrochipNumber

party.patientpet/entityIdentity.microchip

GeneralRemarks

act.patientInsuranceClaim/clinicalNotes

ClaimHandler

 

Name

act.patientInsuranceClaim/author
 

Phone

act.patientInsuranceClaim/location/contact.phoneNumber

Email

act.patientInsuranceClaim/location/contact.email

Vet

 

VetSurname

act.patientInsuranceClaim/clinician

VetForenames

act.patientInsuranceClaim/clinician

VetPosition

not supported

VetEmailAddress

act.patientInsuranceClaim/location/contact.email

PracticeName

act.patientInsuranceClaim/location/name

PracticeID

Our ID or their ID?

PracticeAddress

act.patientInsuranceClaim/location/contact.location

PracticePostcode

act.patientInsuranceClaim/location/contact.location

PracticePhone

act.patientInsuranceClaim/location/contact.phoneNumber

AnimalClinicalHistory

All act.patientClinicalNote instances, up to the time of the claim.

Entry

 

Date

act.patientClinicalNote/startTime

Time

act.patientClinicalNote/startTime

EnteredBy

act.patientClinicalNote/author

TextEntry

act.patientClinicalNote/note

Conditions

All of the act.patientInsuranceClaimItem instances linked to the claim

Condition

 

ConditionCode

Use lookup.diagnosis code?

DiagnosisOrSigns

act.patientInsuranceClaimItem/diagnosis

ClaimContinuation

not supported

ClaimReferenceNumber

not supported - set to unknown

Started

act.patientInsuranceClaimItem/startTime

DeathOrEuthenasia

act.patientInsuranceClaimItem/status <> ALIVE

PutDownByRecommendation

act.patientInsuranceClaimItem/status = EUTHANASED

OngoingCondition

act.patientInsuranceClaimItem/ongoingCondition

CremationCost

not supported

EuthanasiaReason

act.patientInsuranceClaimItem/euthanasiaReason

TreatmentDates

 

    DateFrom

act.patientInsuranceClaimItem/startTime
 

    DateTo

act.patientInsuranceClaimItem/endTime

SeenBeforeRelated

not supported

Description

not supported

TreatmentDates

not supported

    DateFrom

not supported

    DateTo

not supported

HouseVisitAndOOH

not supported

HouseVisit

not supported

HouseVisitReason

not supported

OutOfHours

not supported

OutOfHoursReason

not supported
 

Financial

All of  the act.patientInsuranceClaimItem instances linked to the claim

TotalExVAT

act.patientInsuranceClaimItem/total - act.patientInsuranceClaimItem/tax

VAT

act.patientInsuranceClaimItem/tax
 

TotalIncVat

act.patientInsuranceClaimItem/total

InvoiceItems

All of  the act.customerAccountInvoiceItem instances linked to the Claim Item

    Item

 

        Description

act.customerAccountInvoiceItem/product

        Type

act.customerAccountInvoiceItem/product/type ?

        AmountExVat

act.customerAccountInvoiceItem/total - act.customerAccountInvoiceItem/tax

        InvoiceNumber

act.customerAccountInvoiceItem/id

        Date

act.customerAccountInvoiceItem/startTime

        VAT

act.customerAccountInvoiceItem/tax
 

        Quantity

act.customerAccountInvoiceItem/quantity

Remarks

act.patientInsuranceClaim/notes

Referrals

All referrals linked to the patient

Referral

 

ReferralType

one of From or To

ReferralReason

party.patientpet/referrals/reason

ReferralPractice

Referral vet practice, or vet if the referral vet has no practice configured.

PracticeID

Our ID or their ID?

Name

party.supplierVeterinaryPractice/name or party.supplierVeterinarian/name

Address

party.supplierVeterinaryPractice/contact.location or party.supplierVeterinarian/contact.location

Postcode

party.supplierVeterinaryPractice/contact.location or party.supplierVeterinarian/contact.location

Phone

party.supplierVeterinaryPractice/contact.phoneNumber or party.supplierVeterinarian/contact.location

ReferralDate

party.patientpet/referrals/activeStartTime

Attachments

All attachments linked to the claim items

Attachment

 

AttachmentID

VetEnvoy identifier for uploaded document

ContentLength

document.other/size

ContentType

document.other/mimeType

Description

act.patientDocument*/description

InsuranceCompanySpecificDetails

not supported

PetPlan

not supported

ClaimForDentalTreatment

not supported

FullDentalHistory

not supported

ClaimForUrinaryProblem

not supported

DietFoodCostIncluded

not supported

    Name

not supported

    Amount

not supported

CrystalsPresent

not supported

    Type

not supported

UrineTests

not supported

    Date

not supported

BRAVNo

not supported

PetProtect

not supported

TotalCostPrescriptionDietFoodExVAT

not supported

 

Archetype Changes

party.supplierInsurerVetEnvoy

The party.supplierInsurerVetEnvoy archetype is a new archetype for insurers that indicates that claims to the insurer are submitted via VetEnvoy. It has the same fields as party.supplierInsurer, but includes:

  • RecipientId - indicates the unique identifier for the Insurer

entity.VetEnvoyConnectionType

This is a new archetype that contains connection information for VetEnvoy. It contains a:

  • VetEnvoy service URL
  • UserId
  • UserPassword
  • VendorPassword
  • a link to the practice or practice location that this connection applies to

security.user

This needs to be updated to include firstName and lastName fields. The name field will need to be derived from these, and existing users migrated.

entity.jobVetEnvoy

A job used to poll the VetEnvoy web service for claim updates.

This contains:

  • a link to the entity.VetEnvoyConnectionType with the connection details
  • scheduling information
  • the VetEnvoy Poll Reference, to be submitted with the next poll request

Exclusions

  • The initial implementation will not support claim queries. These are free-form text messages sent by the insurer to query some aspect of a claim.
  • This version will not support insurance company specific details. E.g. 1.10 of the VetXML InsuranceClaim supports :
    • PetPlan - this includes additional fields for dental and urinary problem claims
    • PetProtect - this includes an additional field for the total cost of prescription diet food.
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