Integration Scenarios

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Scenario 5: SHIF - Outpatient - Fee for Service - Normal/Special Preauth

A patient presents for an outpatient service that requires a non-elective preauthorization raised within the same visit. The claim is created first, then the preauth is created within the visit context. Billing proceeds once the preauth is approved. The claim is submitted at the end of the visit.

Intervention Properties

Property	Value
Fund	SHIF
Access Point	Outpatient (OP)
Payment Mechanism	Fee for Service
Needs Preauth	Yes (needsPreauth: true)
Elective Preauth	No (needsManualPreauthApproval: false)
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: false, and accessPoint: "OP".

This scenario is the outpatient equivalent of Scenario 2 - the preauth flow is the same, but the claim is an outpatient claim and dispatch ends with submit rather than discharge.

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Complete Flow

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Step-by-Step API Calls

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, needsPreauth, needsManualPreauthApproval, preauth type flags

Phase 2: Patient Consent

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 claim with OTP	eClaims	POST /api/v1/claims/visit	otp, intervention_code, service_type: "OUTPATIENT"	OP claim created

Biometrics path:

#	Action	Service	Endpoint	Key Request Fields	Key Output
6b	Create authorization	Consent	POST /api/v1/claims/authorize	patient_id, biometric fields, service_type: "OUTPATIENT"	Authorization PENDING; guid; iframe link
7b	(Patient matches fingerprints via iframe)	-	-	-	Authorization transitions to AUTHORIZED
8b	Create claim with auth_guid	eClaims	POST /api/v1/claims/visit	auth_guid, intervention_code, service_type: "OUTPATIENT"	OP claim created

Phase 3: Create & Await Preauth

#	Action	Service	Endpoint	Key Request Fields	Key Output
9	Create preauth	eClaims	POST /api/v1/preauths	consent_token, intervention_code, preauth form fields (normal or special), doctor details, diagnosis, attachments, requested amount	Preauth created (no doctor approval step)
10	Poll preauth status	eClaims	GET /api/v1/preauths	consent_token	status - repeat until FINALISED

Phase 4: Add Combined Billing Details

#	Action	Service	Endpoint	Key Request Fields	Key Output
11	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 5: Preview & Submit

#	Action	Service	Endpoint	Key Request Fields	Key Output
12	Preview provider claim	eClaims	POST /api/v1/claims/preview	consent_token	Claim preview
13	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 Steps 3-8
sub_benefit_code	Step 4	Step 5
intervention_code	Step 5	Steps 8, 9, 11
OTP (OTP path)	Patient receives via SMS	otp field in POST /api/v1/claims/visit
guid (Biometrics path)	Step 6b authorize	auth_guid in POST /api/v1/claims/visit
consent_token	From claim creation (Step 8)	Steps 9-13

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Choosing the Right Preauth Form

Preauth Type	When to Use	Intervention Flag
Normal Preauth	General services	All special flags = false
Surgical Preauth	Surgical procedures	isSurgicalPreauth: true
Oncology Preauth	Cancer treatments	isOncologyPreauth: true
Renal Preauth	Dialysis and renal care	isRenalPreauth: true
Imaging Preauth	Radiology / imaging	isImagingPreauth: true
Optical Preauth	Eye care	isOpticalPreauth: true

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Important Notes

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See Also

• Scenario 2: SHIF IP FFS Normal Preauth - Same flow, inpatient variant
• Normal Preauth
• Preauth Doctor Consent
• Understanding Preauth Statuses
• Outpatient Claim Dispatch