Payer Integration Workflow

1. Onboarding: Payers complete the HCX onboarding process to receive and respond to claim-related requests from providers.

2. Eligibility Check Response:

• Payers receive eligibility check requests from providers through the Coverage Eligibility Callback API (/coverageeligibility/on_check).

• Payers review the request and respond to the provider using the same API to confirm or deny the patient's coverage for the requested service(s).

1. Pre-authorization Response:

• Payers receive pre-authorization requests from providers through the Pre-authorization Callback API (/preauth/on_submit).

• Payers review the request and respond using the same API to approve or deny the pre-authorization request, based on established criteria.

1. Claim Processing:

• Payers receive claim submissions from providers through the Claim API (/claim/on_submit).

• Payers process the claim, verifying details and ensuring adherence to policies and regulations.

• Payers communicate the claim status (approved, denied, or pending) back to the provider through the same API.

1. Payment Notification:

• Upon claim approval and settlement, payers initiate a payment notification to the provider through the Payment Notification API (/paymentnotice/request).

• Payers receive an acknowledgement from the provider through the Payment Notification Callback API (/paymentnotice/on_request) confirming receipt of the notification.