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Eligibility and Benefit Checks

Eligibility and benefit checks are part of the Afiax Enterprise reimbursement workflow.

Afiax FHIR manages the canonical request and response state. Country packs execute the payer-specific or authority-specific integrations. Afiax Billing consumes the resulting reimbursement context for invoicing and collections.

Capability overview​

Eligibility and benefit checks provide:

  • active coverage validation
  • plan and benefit confirmation
  • authorization requirement discovery
  • service-level reimbursement context
  • normalized status for downstream billing and claims workflows

Canonical resources​

Afiax FHIR uses:

Request model​

Eligibility requests in Afiax FHIR capture:

  • the patient
  • the coverage being checked
  • the provider or facility context
  • the service or reimbursement category being checked
  • the supporting clinical context for the reimbursement decision

Country packs map that canonical request into the local payer or authority format without changing the core resource model.

Request flow​

The request flow is:

  1. Afiax FHIR records the payer and clinical context.
  2. A billing or country-pack workflow creates a CoverageEligibilityRequest.
  3. The active country pack or payer integration executes the external eligibility check.
  4. The result is normalized and stored as a CoverageEligibilityResponse.
  5. Afiax Billing receives the resulting reimbursement context for invoice and collection workflows.

Receiving a Response​

Eligibility responses in Afiax FHIR capture:

  • whether the request was processed successfully
  • whether the coverage is active for the requested period
  • what benefits or reimbursement rules apply
  • whether authorization is required
  • what exclusions, limits, or supporting requirements apply

The response remains part of the canonical reimbursement record and is available to claims workflows, collections, and reconciliation.

Coordination of Benefits​

Afiax FHIR supports multiple coverages and focal coverage selection through the standard FHIR request and response pattern.

This allows the platform to model:

  • primary and secondary reimbursement
  • public and private coverage combinations
  • employer, sponsor, and scheme overlays

Integration with Afiax Billing​

Afiax Billing receives:

  • active or inactive coverage status
  • benefit and authorization context
  • reimbursement flags needed for invoice and collection workflows

Afiax Billing does not replace the eligibility record stored in Afiax FHIR.