Integration Scenarios

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Scenario 4: SHIF - Outpatient - Fee for Service - Elective Preauth

A patient is scheduled for a planned outpatient procedure that requires prior approval before the visit begins (elective preauthorization). The preauth is created and approved in advance. On the day of the actual visit, an outpatient claim is created using the same patient and intervention - no new consent or authorization step is needed.

Intervention Properties

Property	Value
Fund	SHIF
Access Point	Outpatient (OP)
Payment Mechanism	Fee for Service
Needs Preauth	Yes (needsPreauth: true)
Elective Preauth	Yes (needsManualPreauthApproval: true)
Tariff Type	Overall / KEPH Level

How to identify this scenario: After calling GET /api/v1/patients/benefits/interventions, the intervention has paymentMechanism: "FEE_FOR_SERVICE", needsPreauth: true, needsManualPreauthApproval: true, and accessPoint: "OP".

This scenario is identical to Scenario 3 except the access point is Outpatient - the pre-visit phase is the same, but the day-of-visit phase creates an OUTPATIENT claim and ends with POST /api/v1/claims/submit instead of discharge.

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Complete Flow

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Step-by-Step API Calls

Pre-Visit Phase

Phase 1: General API Flow

#	Action	Service	Endpoint	Key Request Fields	Key Output
1	Get access token	Auth	POST /api/v1/tenants/token	client_id, client_secret	access_token
2	Patient search	Registries	GET /api/v1/patients	identification_number, identification_type	id (beneficiary CR ID) - store as patient_id
3	SHA eligibility check	eClaims	GET /api/v1/patients/eligibility	identification_number, identification_type	Eligibility status of schemes under SHA
4	Sub-benefit coverage	eClaims	GET /api/v1/patients/sub-benefits	patient_id	sub_benefit_code list
5	Intervention coverage	eClaims	GET /api/v1/patients/benefits/interventions	patient_id, sub_benefit_code	intervention_code, needsManualPreauthApproval: true confirmed

Phase 2: Authorization for Preauth

OTP path:

#	Action	Service	Endpoint	Key Request Fields	Key Output
6a	Get patient contacts	Consent	GET /api/v1/patients/contacts	patient_id	Masked contact list with id - confirm contact with patient
7a	Send OTP	Consent	POST /api/v1/claims/otp	patient_id, intervention_codes, beneficiary_contact_id (optional)	OTP sent
8a	Create authorization	Consent	POST /api/v1/claims/authorize	patient_id, otp	Authorization token (status: AUTHORIZED_PENDING_VISIT)

Biometrics path:

#	Action	Service	Endpoint	Key Request Fields	Key Output
6b	Create authorization	Consent	POST /api/v1/claims/authorize	patient_id, biometric fields	Authorization PENDING; guid; token; iframe link
7b	(Patient matches fingerprints via iframe)	-	-	-	Authorization transitions to AUTHORIZED_PENDING_VISIT

Phase 3: Create & Await Preauth

#	Action	Service	Endpoint	Key Request Fields	Key Output
9	Create preauth	eClaims	POST /api/v1/preauths	consent_token (authorization token), intervention_code, preauth form, doctor details, diagnosis, requested amount, attachments	Preauth created (status: PENDING_DOCTOR_APPROVAL)
10	Poll preauth status	eClaims	GET /api/v1/preauths	consent_token	status - repeat until FINALISED

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Day of Actual Visit

Phase 4: Create Claim

OTP path:

#	Action	Service	Endpoint	Key Request Fields	Key Output
11a	Send fresh OTP	Consent	POST /api/v1/claims/otp	patient_id, intervention_codes	OTP sent
12a	Create OP claim	eClaims	POST /api/v1/claims/visit	otp, intervention_code, service_type: "OUTPATIENT"	OP claim created; consent_token returned

Biometrics path:

#	Action	Service	Endpoint	Key Request Fields	Key Output
12b	Create OP claim	eClaims	POST /api/v1/claims/visit	auth_guid (from pre-visit authorization), intervention_code, service_type: "OUTPATIENT"	OP claim created; consent_token returned

Phase 5: Add Combined Billing Details

#	Action	Service	Endpoint	Key Request Fields	Key Output
13	Add combined billing details	eClaims	POST /api/v1/claims/lines	consent_token, intervention_code, unit_price, quantity, diagnoses, attachments	Billing saved; amount validated against tariff

Phase 6: Preview & Submit

#	Action	Service	Endpoint	Key Request Fields	Key Output
14	Preview provider claim	eClaims	POST /api/v1/claims/preview	consent_token	Claim preview
15	Submit outpatient claim	eClaims	POST /api/v1/claims/submit	consent_token	Claim submitted to SHA

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Field Flow Between Steps

Output Field	Step It Comes From	Used In
access_token	Step 1	Authorization header - all requests
patient.id	Step 2	patient_id in all subsequent steps
intervention_code	Step 5	Preauth, claim, billing steps
token (OTP path)	Step 8a	consent_token in POST /api/v1/preauths
token (Biometrics path)	Step 6b	consent_token in POST /api/v1/preauths
guid (Biometrics path)	Step 6b	auth_guid in Day-of-Visit claim creation
consent_token	From claim creation (Step 12)	Billing, preview, submit steps

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Important Notes

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See Also

• Elective Preauth Guide
• Scenario 3: SHIF IP Elective Preauth - Same flow, inpatient variant
• Understanding Preauth Statuses
• Outpatient Claim Dispatch