Integration Scenarios

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Scenario 6: UHC - Outpatient - Capitation

A patient presents at a facility for a UHC-covered outpatient service under a capitation payment mechanism. No preauthorization is required. This path also covers PHC (Primary Healthcare Fund) outpatient visits at Level 2, Level 3, and select Level 4 (primarily government-owned) facilities, where attachments are not mandatory.

Intervention Properties

Property	Value
Fund	UHC (or PHC for Level 2/3 and select Level 4 facilities)
Access Point	Outpatient (OP)
Payment Mechanism	Capitation
Needs Preauth	N/A
Elective Preauth	N/A
Tariff Type	N/A

How to identify this scenario: After calling GET /api/v1/patients/benefits/interventions, the intervention has paymentMechanism: "CAPITATION" and fund = UHC.

For PHC claims at Level 2, Level 3, and select Level 4 (primarily government-owned) facilities, the flow is the same but attachments are not required.

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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, paymentMechanism: "CAPITATION" confirmed

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: Add Combined Billing Details

#	Action	Service	Endpoint	Key Request Fields	Key Output
9	Add combined billing details	eClaims	POST /api/v1/claims/lines	consent_token, intervention_code, unit_price, quantity, diagnoses (ICD-11 array), attachments (optional for PHC)	Billing saved

Phase 4: Preview & Submit

#	Action	Service	Endpoint	Key Request Fields	Key Output
10	Preview provider claim	eClaims	POST /api/v1/claims/preview	consent_token	Claim preview
11	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, 10
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 9-11

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Important Notes

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See Also

• Start Visit Consent Process
• Outpatient Claim Dispatch
• Billing Process Overview
• Understanding Benefits and Intervention Codes