Kenya eClaims FHIR Implementation Guide
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Use Cases

Use Cases

This page describes the primary business use cases supported by the Kenya eClaims FHIR Implementation Guide. Each use case identifies the actors, preconditions, data flow, and the FHIR resources involved.

UC-01: Outpatient Claims Submission

Summary: A health facility submits a claim for outpatient services rendered to an insured patient.

Actors: Healthcare Provider (EMR), Kenya HIE, SHA Adjudication Engine

Preconditions:

  • Patient is registered in the national MPI with a valid SHA number.
  • Patient has active coverage verified prior to or at time of service.
  • Provider is contracted and credentialed with SHA.

Flow:

  1. Clinician records the patient encounter, diagnosis (ICD-11 code), and services rendered in the facility EMR.
  2. EMR generates a FHIR Bundle containing Claim, Patient, Coverage, Encounter, Condition, and Organization resources.
  3. EMR or middleware submits the Bundle to the Kenya HIE via a secured FHIR REST API endpoint (POST /fhir/Bundle).
  4. HIE validates conformance against this IG's profiles and returns validation errors if any.
  5. HIE forwards the conformant Bundle to SHA's adjudication engine.
  6. SHA processes the claim, applies benefits rules and the SHA Interventions Catalogue, and returns a ClaimResponse.
  7. Provider receives the ClaimResponse indicating complete, partial, or error adjudication outcome.

Key Resources:

Resource Profile Role
Claim KenyaClaimBase The submitted claim
Patient EClaimsPatient Insured patient
Coverage EclaimsCoverage Insurance coverage details
Encounter EClaimsEncounter The service encounter
Condition EClaimsCondition Diagnosis at encounter
Organization EClaimsOrganization Provider and insurer
ClaimResponse EClaimsClaimResponse Adjudication result

UC-02: Preauthorization Request (Surgical / High-Cost Procedure)

Summary: A provider requests preauthorization from SHA before performing a high-cost surgical, oncological, renal, or imaging procedure.

Actors: Healthcare Provider (EMR), SHA Authorization System

Preconditions:

  • Patient is enrolled in SHA with active, verified coverage.
  • The requested procedure is in a category requiring prior authorization per SHA clinical guidelines.

Flow:

  1. Clinician identifies a patient requiring a procedure that mandates prior authorization (e.g., renal dialysis, oncology chemotherapy, major surgery, optical services, or advanced imaging).
  2. EMR creates a FHIR Claim resource with use = #preauthorization, containing the planned procedure code, clinical indication (diagnosis), and relevant clinical documentation as supportingInfo attachments.
  3. EMR submits the preauthorization Bundle to the SHA authorization endpoint.
  4. SHA evaluates the request against clinical criteria and coverage policy.
  5. SHA returns a ClaimResponse with an authorization token (preAuthRef) if approved, or with detailed denial reasons if rejected.
  6. The authorization token is stored and referenced in the subsequent Claim submission (UC-01) via Claim.extension[preauthToken].

Key Resources:

Resource Profile Role
Claim (use=preauthorization) KenyaClaimBase Preauth request
Claim (surgical) KenyaSurgicalPreauth Surgical preauth
Claim (oncology) KenyaOncologyPreauth Oncology preauth
Claim (renal) KenyaRenalPreauth Renal preauth
Claim (imaging) KenyaImagingPreauth Imaging preauth
Claim (optical) KenyaOpticalPreauth Optical preauth

UC-03: Pharmacy Claims with Medication Dispensing

Summary: A pharmacy submits a claim for medications dispensed to an insured patient against a valid prescription.

Actors: Pharmacy System, SHA Adjudication Engine

Preconditions:

  • Patient has a valid active prescription (MedicationRequest) generated by a licensed prescriber.
  • The prescribed medication is in SHA's approved generic products formulary.
  • Patient has pharmacy benefits coverage.

Flow:

  1. Prescriber creates a MedicationRequest at the point of care, coded using the SHA Generic Products formulary.
  2. Pharmacist verifies patient coverage and dispenses medication, recording a MedicationDispense resource.
  3. Pharmacy system bundles Claim, MedicationDispense, MedicationRequest, Patient, and Coverage into a FHIR Bundle.
  4. Bundle is submitted to SHA via the HIE.
  5. SHA validates the medication against the formulary and returns a ClaimResponse with adjudication details.

Key Resources:

Resource Profile Role
MedicationRequest EClaimsMedicationRequest The prescription
MedicationDispense EClaimsMedicationDispense Dispensing record
MedicationStatement EClaimsMedicationStatement Patient medication history

UC-04: Inpatient Claim with Episode of Care

Summary: A hospital submits a claim for an inpatient admission encompassing multiple encounters, diagnoses, and services over a period of days.

Actors: Hospital EMR, SHA Adjudication Engine

Preconditions:

  • Patient is admitted to a contracted SHA facility.
  • An EpisodeOfCare is opened at admission time.
  • All clinical activities during admission are linked to the episode.

Flow:

  1. At admission, EMR creates an EpisodeOfCare resource grouping all encounters and clinical events for the admission.
  2. Clinical staff record daily Encounter events, Condition diagnoses, DiagnosticReport results, and medication orders.
  3. At discharge, EMR generates a consolidated Claim (type = institutional) referencing the full admission period and all service line items.
  4. Claim is submitted with the discharge summary as a supportingInfo attachment and the episode period as billablePeriod.
  5. SHA adjudicates the inpatient claim, applying DRG (Diagnosis Related Group) or fee-schedule rules as applicable.

Key Resources:

Resource Profile Role
EpisodeOfCare EClaimsEpisodeOfCare Admission grouper
DiagnosticReport EClaimsDiagnosticReport Lab/radiology results
Claim (institutional) KenyaClaimSubmission Final claim submission

UC-05: Claim Status Query and ClaimResponse Processing

Summary: A provider queries the status of a previously submitted claim and processes the response to update their accounts receivable.

Actors: Healthcare Provider (EMR/Billing System), SHA System

Flow:

  1. Provider's billing system queries SHA for claim status using the claim's business identifier.
  2. SHA returns the current ClaimResponse resource with status (queued, partial, complete, error).
  3. If complete, the billing system extracts adjudicated amounts per line item and posts to accounts receivable.
  4. If error, the system extracts ClaimResponse.error.code details and triggers a re-submission workflow.
  5. Provider tracks the ClaimResponse.payment.identifier to reconcile against bank receipts from SHA.

UC-06: Payment Notification and Reconciliation

Summary: SHA notifies a provider that a payment has been issued for a batch of claims.

Actors: SHA Payment System, Healthcare Provider

Flow:

  1. SHA issues a PaymentNotice resource referencing the batch payment and the associated PaymentReconciliation resource.
  2. Provider receives the PaymentNotice and matches it to outstanding ClaimResponse records using PaymentNotice.payment and PaymentNotice.amount.
  3. Provider marks matched claims as paid and flags unmatched claims for follow-up with SHA.

Key Resources:

Resource Profile Role
PaymentNotice EClaimsPaymentNotice Payment notification