PAYERS & REIMBURSEMENT CONNECTORS

Claims & Prior Authorization

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Integrate payer eligibility, claims, reimbursement and reconciliation workflows without turning Mediloop into a payer or payment institution.

ClaimClaimResponseCoveragePrior AuthorizationAttachmentsStatusFHIR

End-to-End Claims Management

Track the claim from care to adjudication.

Prior Authorization Support

Manage authorization requirements before covered services.

Standards Based

Use FHIR resources with payer/national extensions.

Multiple Payers

Adapt to CNS, Assurance Maladie and complementary payer workflows.

Claims Workflow

Care / Service

Consultation, procedure, medication or device supply

Check Coverage

Eligibility and authorization requirement

Prior Authorization

Submit clinical evidence if required

Prepare Claim

Validate claim and supporting documents

Submit to Payer

National/private payer API or secure channel

Track & Follow-up

Acknowledgement, status and requests for information

Adjudication

Receive decision, amounts and explanation

Prior Authorization

Determine requirement from payer/service rules

Reference patient coverage and service/procedure

Attach only necessary clinical evidence

Track submitted, pending-info, approved, denied and expired states

Do not deliver conditional services as authorized until authoritative approval is received

Preserve payer decision and rationale

FHIR Resources

Resource	Use	Notes
Coverage	Patient plan / payer	Referenced by claim/authorization
Claim	Service/claim submission	May require national profiles/extensions
ClaimResponse	Payer adjudication response	Authoritative response
ExplanationOfBenefit	Detailed outcome / benefit explanation	Patient/provider-facing as appropriate
DocumentReference	Supporting documents	Purpose-limited attachments

APIs & Examples

httpCopy

# Illustrative claim submission
POST /v1/payers/claims
Authorization: Bearer <token>
Idempotency-Key: claim-2026-001

{
  "payer":"cns-lu",
  "patientId":"patient_123",
  "coverageId":"cov_456",
  "items":[{"serviceCode":"CONSULT","quantity":1}]
}

Illustrative contract only. Payer-specific profiles, attachments, signatures and submission channels remain adapter-specific.

Error Handling

Issue	Action
Validation failure	Reject before payer submission with field-level errors
Authorization missing	Route to prior-authorization workflow
Payer timeout	Keep pending; retry according to payer policy
Claim rejected	Store response/reason and surface correction/appeal workflow
Duplicate submission	Prevent with idempotency and payer reference

Best Practices

Validate coverage and required authorization before claim creation

Preserve original payer/national codes

Version mapping and claim rules

Use deterministic idempotency keys

Store full ClaimResponse/EOB provenance

Keep clinical evidence access purpose-limited and auditable

Developer Integration Surface

Surface	Operation / resource	Use	Status
FHIR	Claim / ClaimResponse / EOB / Coverage	Standard resource exchange	FHIR where supported
Payer API	authorize / submit / status	National/private payer workflow	Adapter
Documents	DocumentReference / secure attachment channel	Prior-auth and claim evidence	Payer-specific
Events	claim.acknowledged / claim.status.changed	Async processing	Provider-dependent

Next Steps

Implement claim validation

Add prior-authorization decision branch

Connect first payer sandbox

Test rejection/correction/duplicate flows

Add monitoring and adjudication handling