flowrise-hms/insurance

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Multi-payer insurance orchestration module for NHIS and private insurers

dev-main 2026-07-13 12:04 UTC

Requires

• php: ^8.4
• flowrise-hms/billing: dev-main
• flowrise-hms/core: dev-main
• flowrise-hms/patient: dev-main

Unknown License

• Flowrise Digital

Published on Packagist.org on 2026-07-20 10:05 UTC

README

In one sentence: The Insurance module handles multi-payer coverage, claims submission, and claims feedback so billing can be reconciled against what insurers approve or reject.

Why this module exists

Hospitals in mixed-payment environments (cash + national insurance + private insurance) need one workflow to:

• manage payer rules and policy links,
• submit claims,
• receive feedback from payers,
• and reconcile claim decisions with billing outcomes.

This module centralizes that lifecycle.

Where Insurance fits in FlowRise

• Connects Patient policies to payer coverage.
• Connects Billing invoice lines to claim lines and adjudication outcomes.
• Uses Core contracts/services for shared pricing resolution interfaces.

flowchart LR
  Core[Core]
  Patient[Patient]
  Billing[Billing]
  Insurance[Insurance]
  Core --> Insurance
  Patient --> Insurance
  Billing --> Insurance

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Current status

Complete for operational claims workflows. Deferred: Phase 2 feedback XML import, NHIS catalog sync implementation, dedicated PatientPolicy/TariffItem Filament resources, and private insurer connector beyond the generic stub.

See module status for the canonical matrix.

What you can do with it

• Manage payers, tariffs, patient policies, and claim records through services and API endpoints.
• Use the Payers Filament resource for payer administration.
• Submit claims through authenticated API endpoints.
• Process payer feedback and reconcile statuses.
• Support both NHIS-specific XML workflows and private insurer connectors.
• NHIS claims workflow: filter encounters → generate batch → review/vet claims → export NHIA v8.6 XML for Claim-It upload.

How it works (simple)

1. A patient policy links a patient to a payer/coverage context.
2. Billing-generated lines are transformed into claim lines.
3. Claims are submitted through connector services (NHIS/private).
4. Feedback is ingested and persisted idempotently.
5. Reconciliation services update decision state and downstream financial expectations.

API endpoints

• POST /api/v1/insurance/catalog/sync (authenticated)
• POST /api/v1/insurance/claims/submit (authenticated)
• POST /api/v1/insurance/claims/feedback

What is inside this folder

Path	Purpose
app/Models/	Payers, policies, claims, claim lines, submissions, feedback.
app/Services/	Submission, reconciliation, connector registry, catalog sync.
app/Services/Connectors/	NHIS and private insurer connector implementations.
app/Jobs/	Async claim submit and feedback polling workflows.
app/Contracts/	Pricing and connector contracts.
app/Http/Controllers/Api/	Claims/catalog API handlers.
app/Providers/	Module registration and relation wiring.

Dependencies

• flowrise-hms/core
• flowrise-hms/patient
• flowrise-hms/billing

See module status for current rollout state.

Further reading

• Admin setup: Insurance Administration
• Billing context: Billing Workflows

For developers

• Namespace: Modules\Insurance\...
• Service provider: Modules\Insurance\Providers\InsuranceServiceProvider
• Provider wiring includes:
  • InsurancePricingResolver -> DefaultInsurancePricingService
  • dynamic relations: Patient::insurancePolicies and InvoiceLine::insuranceClaimLines
• NHIS path uses NhisXmlEncoder, NhisConnector, and NhisFeedbackParser.