Program API

Overview

The Program API is used to communicate between HICAPS and a Program (or scheme or fund) for the purpose of determining the funding result for claims submitted by billers. To facilitate this communication, the Program API comprises a set of webhooks and RESTful API resources for consumption.

Philosophy

The Program API is event-driven. The philosophy behind this approach are based on three principles:

1. Flexible decision making process by program.
2. Visibility/clarity during decision making process for provider. Providers will have access to the most real-time status of their claims.
3. Empower provider to determine how long they want to wait for decisions. An example is that the provider is able to request an invoice cancellation while the invoice is still pending.

Definitions

Programs

The program, or fund, or scheme, is the entity adjudicating and funding the claims on the invoice.

The programs that HICAPS is connected to is defined below. Note this list is continually being updated.

Program Codes

Program Code	Program Name	Program Website	HICAPS Terminal Required?
medicare-bulkbill	Medicare - Bulk Bill	Medicare Bulk Bill	No
medicare-dva	Medicare - Dept. Veteran Affairs (DVA) / Dept. Veteran Affairs - Allied (VAA)	Medicare DVA	No
medicare-pci	Medicare - Patient Claiming Interactive	Medicare Claims Online	No
medicare-easyclaim-pc	Medicare - Easyclaim - Patient Claims (Electronic)	Medicare Easyclaim - Patient Claims	Yes
medicare-easyclaim-bulkbill	Medicare - Easyclaim - Bulkbill	Medicare Easyclaim - Bulkbill	Yes
ndis-agency	National Disability Insurance Scheme API	www.ndis.gov.au	No
tac	Transport Accident Commission	www.tac.vic.gov.au	No
wsv	WorkSafe Victoria	www.worksafe.vic.gov.au	No
mpl	Medibank Private Limited	www.medibank.com.au	No
nib	nib Health Fund	www.nib.com.au	No
wcq	WorkCover Queensland	WorkCover QLD	No
icwa	Insurance Commission of Western Australia	www.icwa.wa.gov.au	No
icare-ni	Insurance and Care NSW - Nominal Insurer	www.icare.nsw.gov.au	No

Billers and Providers

A biller is the entity making the claim and receiving payment. The biller applies for access to a Program and is authorised and identified by the Program.

The program cannot edit the biller’s details (the biller updates their own details using the HICAPS interface). However, the program can read the Billers details and change the biller’s status with the program.

A provider is the entity providing the service to the patient.

Programs can have different requirements in relation to Providers:

1. Program requires the provider information to be submitted with each claim.
2. Program does not require any provider information, in which case the provider information is optional with the claim.

Members and Patients

A member is a person that has membership with a program. A patient is the person receiving the product or service from a provider. Ususally these are the same person but sometimes they may be different.

For example a parent may be a member of a health fund and their child may be listed on their membership but is not a member in their own right. If the child is receiving treatment, then in this case the member would be the parent and the patient is the child.

A member is defined at the invoice level, as defined in the Member Paramters section.

A patient is defined at the claim level (i.e. line item), as defined in the Patient Parameters section.

Invoices and Claims

An Invoice is a holistic representation of the data submitted to the Program. An Invoice contains a collection of Claims, which represent line items on the Invoice. It is recommended that a program responds to all the claims on an invoice in one response.

Predeterminations

Predeterminations are similar in concept to a quote as a point-in-time “what if” assessment of the claim data submitted to the program if the member requests it. Predeterminations are not binding nor guaranteed and no payments are made from a predetermination - even if approved.

A program may store a record of the predetermination against a member’s profile for reference or visibility in a member app and so a predetermination should only be sent if the member requests a quote or estimate of the costs/coverage associated with the product or service that will be claimed.

The program will respond to the predetermination with their adjudication response to give the user an indication of what the program would respond with if that same data was submitted as an invoice.

See Predeterminations in the API Resources section for more technical information.

States, Statuses & Actions

States, statuses and actions are about providing as much context and information to the biller as possible as a claim progresses through the journey of adjudication and payment. They help facilitate a digital conversation between the biller and the program that occurs in real time via the API.

States

A claim can only be in one of the states defined by HICAPS. For example, a claim will move through states: submitted → pending → approved or rejected. If a claim is in the approved state then the biller can expect the next action is for a payment to be made and a payment notification triggered for that claim.

The program controls the state that a claim is in, and HICAPS stores a cache of the last known version of the state. Once the program changes the state of a claim (e.g. pending → approved) they notify HICAPS and we immediately notify the biller.

See Claiming Process for more information on the claim submission flow.

Statuses

Status fields are available as part of the claim adjudication responses to add more information or context to the claim. These statuses are provided by the program and can be used to “overwrite” the claim state with a more specific/customised state that is displayed in a UI to the biller.

For example, a claim may be set to the pending claim state but this doesn’t tell the biller why the claim is pending. So, using statuses, the program may choose to indicate why the claim is in a pending state and to do this the program may pass back the below:

• claimStatuses.statusTitle = Pending Review
• claimStatuses.statusDescription = This claim is under review by a case manager and will be updated soon

This is a better and more specific representation of the state of the claim which, if provided, can be displayed to the biller instead of, or in addition to, the standard pending claim state.

Actions

Actions are a feature that allows the program to advise the provider that they are required to submit additional information, or take some other step(s), before an invoice can be processed. Similar to Statuses, this allows the program to provide extra context and information to the provider so they can perform the requried action(s).

For example, a program may require a treatment plan to be submitted for a member before they will adjudicate on the claim. To do this, the program may pass back the below:

• actions.title = Submit Plan
• actions.description = Please click here to submit a treatment plan for this member
• actions.href = https://www.example.com/link/to/treatment/plan

Note: Actions are defined at the invoice level, not the claim level, because an action pending on any one claim could impact the adjudication of the whole invoice.

Claiming Process

The claiming process is generally broken down into two steps, explained in further detail in the sections below:

1. Adjudication of a Claim - the program decides whether they will approve or reject a claim and how much they will pay, if anything
2. Payment of a Claim - the biller is paid by the program

Adjudication of a Claim

As shown in the diagram below, the user submits a predetermination or an invoice for a program to HICAPS. HICAPS then sends all claims to the program for adjudication. Once the program has adjudicated on the claim they send an update back to HICAPS. HICAPS then notifies the user through a webhook with the updated status on the claims. This end to end process generally takes less than a second or two.

Note: A program may provide multiple status updates for any given invoice. For example they may respond with a pending status for the claim and then respond again later with an approved status for the claim.

Claim States

On submission to the program, the State of each claim becomes pending. The claim flows through various states throughout its lifecycle. The state of the claim sets the user’s expectations around the timing and result of the claim payment. The program is the ‘source of truth’ for the state of the claim. As shown in the diagram below, most state transitions are initiated by the program performing API actions on HICAPS.

Claim State Definitions

Adjudication Claim States

Claim states relating to normal adjudication flow.

Cancellation Claim States

Claim states relating to cancellation flow.

Payment Claim States

Claim states relating to payment flow.

Payment of a Claim

This section describes the HICAPS payment process. Generally speaking HICAPS manages the payment process on behalf of the program, but this may not be the case for every program - see below.

1. The “direct debit model” - HICAPS debits all programs the total amount of all their approved invoices for that day. HICAPS then credits each provider a single amount which covers all approved invoices for all programs on the direct debit model. This is the preferred and “default” payment model that most programs use.
2. The “bureau model” - HICAPS disburses funds directly from the program’s bank account to the biller’s bank account. This means the biller will receive a single payment per program, per day. Only a small number of programs are on this model and this is no longer offered.
3. The program pays the biller directly and HICAPS is not involved. Currently, only the NDIS, Medicare and Workcover QLD are on this model.

For HICAPS managed payments, #1 and #2 above, HICAPS will notify both the program, and the biller, about these payments so that finance systems can be kept reconciled. See the payments section for more detail.

Technical Overview

API Connection

All connections to HICAPS APIs must be using TLS v1.2 or higher.

API Message Headers

Certain HTTP headers must be provided when posting messages to the Program API, as shown below:

• Content Type (Content-Type) - must be application/json
• Content Length (Content-Length)
• Host (Host)
• Authentication (see below)

API Authentication

HICAPS’s Program API supports OAuth 2.0 authentication.

HICAPS provides an Oauth 2.0 Identity Provider endpoint. The API Consumer will be given a Client Id and Client Secret. These can be passed to the OAuth 2.0 endpoint using the client_credentials flow to obtain an access token which can be passed to HICAPS as a bearer token in the Authorization header

Each Program is considered a unique user of the API and will have their own API credentials which should not be shared.

HAL/HATEOAS

The HICAPS API uses HAL (Hypertext Application Language) to support a HATEOAS approach as defined by the REST specification.

In many cases, the URI of the resource will have been obtained from a webhook callback. In other cases, the URI of a resource can be found in the _links block of another resource.

Many HICAPS APIs are asynchronous. HICAPS will respond with 202 Accepted, and then signal via a webhook callback when the operation is completed or when the next step in the workflow is ready to be actioned.

API Response Codes

The HICAPS API may respond with any of the below status codes. This table gives guidance as to what the Program should do for a given status code.

{
    "type": "https://example.net/validation-error",
    "title": "Your request parameters didn't validate.",
    "invalidParams": [
        {
            "name": "claimStatuses[0].state",
            "reason": "'state' must not be empty."
        },
        {
            "name": "claimStatuses[2].benefit",
            "reason": "'benefit' must be a number."
        }
    ]
}

{
   "id": "{uuid}",
   "created": "{unix epoch time}",
   "data": "{data object}",
   "type": "{event type name}",
   "_links": {
      "lp:action": {
         "href": "{uri}"
      }
   }
}

Webhook Authentication

Webhooks must be configured with an authentication mode. Options are:

• Custom HTTP Header: Webhook subscriber can configure a header Name and Value for a custom HTTP Header to be included in each webhook call back, e.g. X-PartnerName-API-Key: cee7ef7d-e6ee-4b83-bc60-3a5d5c5c40fe
• OAuth 2.0 Authorization: Webhook subscriber can configure OAuth details. HICAPS will obtain an access token using the client_credentials flow and include it in the Authorization header as a Bearer token. The configuration options are:
  • OAuth 2.0 Idp Authorize endpoint
  • Client Id
  • Client Secret
  • Scope (optional)

Asynchronous Webhook Handlers

When handling a webhook, the Program webhook handler should handle the request asynchronously.

This means responding very quickly with a success status code (202 Accepted is preferred), and then calling back to the relevant nominated HICAPS URI when the Program is ready to effect the next step in the workflow (e.g. approve a claim).

The style ensures that in the event of processing delays within the program, HICAPS and networking resources are not ‘held open’ for the duration of the delay. It encourages the use of internal queueing mechanisms to ensure robust, reliable & scalable handling of requests even when under load.

Webhook Response Codes

The webhook handler may respond with one of the following HTTP Status Codes. HICAPS actions for each status code are as below.

Webhook Error Handling

If a webhook is delivered to your API handler and you return a 202 Accepted to HICAPS, but then fails to reach your back end handler, you can use the lp:webhook-error link relation on any webhook to automatically initiate HICAPS’s Webhook Retry Policy, explained below. To initiate this retry, send an empty POST (with autentication) to the lp:webhook-error link relation which will trigger the retry policy.

Note: the lp:webhook-error link relation may be null if no retry action is possible.

Retry Policy

If a webhook fails to deliver, the retry policy will trigger as described below. In total there will be 24 attempts to deliver a webhook (the initial attempt + 23 retries) and if all webhooks fail this will trigger an alert to HICAPS support staff for investigation.

All 24 webhook delivery attempts will occur over a ~5.5 minute period, with half the retries delivered within the first ~40 seconds to cover intermittent failures with the receiver. The formula used for each retry is [(number of webhooks already sent)² x 0.08] where 0.08 represents an 80ms delay.

Each retry will have the same value in the webhook id field. Due to the use of retries, it is strongly recommended that the webhook id field is used to prevent duplicate handling, particularly in the case where HICAPS is retrying due to a timeout, but internal program systems have successfully handled the webhook.

API Resources

This section below details out all the Program API endpoints and the various functionality of each.

Base URIs

Unless stated otherwise, all URIs in the sections below are relative to these base URIs:

Root

The root resource is the starting point for all API operations when using HATEAOS hypermedia to navigate the API. The first step is to obtain a OAuth access token. This resource can also be used to ensure the Program API is online.

{
    "_links": {
        "self": {
            "href": "https://api.programs.lanternpay.com"
        },
        "lp:oauth-issuer": {
            "href": "https://www.lanternpay.com/ui/iam/identity/oauth"
        },
        "lp:oauth-token": {
            "href": "https://www.lanternpay.com/ui/iam/identity/oauth/connect/token"
        },
        "curies": {
            "name": "lp",
            "href": "https://docs.lanternpay.com/reference#{rel}",
            "templated": true
        }
    }
}

Invoices

An invoice is a representation of the invoice data submitted by a biller. The invoice contains a collection of claims, which represent the line items on the invoice. When the invoice is submitted by the biller, the onInvoiceSubmitted webhook is sent to the program and includes a link to the unique lp:invoice-status-updated URI to POST the adjudications for the claims.

A single response message can contain the result for multiple claims. That is, the Program may respond to all claims in one response, or over multiple responses.

{
    "id": "8ad735a2-21a0-481a-9174-205817e95110",
    "created": 1565140165,
    "data": {
        "invoiceId": "9a15ad10-dbf0-4ab6-83f1-e42019f188b5",
        "sourceChannel": "app",
        "program": "mpl",
        "responsePriority": "normal",
        "biller": {
            "billerId": "de960e0a-5a3b-47e7-8cde-11f6d3b62b60",
            "name": "My Biller Pty Ltd",
            "abn": "27114508771",
            "address": {
                "lines": [
                    "Some street name",
                    "Second line"
                ],
                "city": "Manly",
                "postalCode": "2095",
                "state": "NSW",
                "country": "Australia"
            }
        },
        "member": {
            "memberNumber": "789456123",
            "program": "mpl",
            "givenName": "Spongebob",
            "familyName": "Squarepants",
            "birthDate": "1990-04-01",
            "gender": "female"
        },
        "created": "2019-11-15T01:09:23.633+10:00",
        "invoiceDate": "2019-11-01",
        "invoiceNumber": "INV-911",
        "claims": [
            {
                "claimId": "7329d4a5-a15d-4db0-a831-da2e6bbba425",
                "provider": {
                    "organization": {
                        "facilityName": "Amcal Bourke Street"
                    },
                    "registrations": {
                        "medibankProviderNumber": "808000"
                    },
                    "contactPoint": {
                        "phone": "097591423"
                    },
                    "discipline": "pharmacy"
                },
                "itemPublisher": "mims",
                "itemCode": "10|1|1",
                "itemCustomFields": {
                    "pharmacy": {
                        "scriptNumber": "123123",
                        "prescribingDoctorName": "Squidward Tentacles",
                        "dispensingPharmacistName": "Patrick Star"
                    }
                },
                "serviceDateTime": "2019-08-07T00:00.000+10:00",
                "quantity": 1,
                "unitPrice": 55.63,
                "taxCode": "GST",
                "description": "LonquexSolution for injection6 mg/0.6 mL [1]"
            }
        ]
    },
    "type": "claiming.invoice.submitted",
    "_links": {
        "lp:invoice-status-updated": {
            "href": "https://lanternpay.com/sample/invoices/9a15ad10-dbf0-4ab6-83f1-e42019f188b5/res"
        },
        "lp:webhook-error": {
            "href": "https://lanternpay.com/sample/webhook/8ad735a2-21a0-481a-9174-205817e95110"
        }
    }
}

{
    "id": "6c58efc3-9658-4e90-9e58-c3b2d7f74920",
    "created": 1565676298,
    "data": {
        "program": "mpl",
        "invoiceId": "e23cb7e3-93c6-4e0b-8229-c95a0d0447c3",
        "programInvoiceId": "IC2342348_90",
        "reason" : "The invoice has been submitted by mistake."
    },
    "type": "claiming.invoice.cancellationRequested",
    "_links": {
        "lp:invoice-status-updated": {
            "href": "https://api.lanternpay.com/sample/invoices/08c9c003-3709-4475-85ce-98b7b318c2da/response"
        },
        "lp:webhook-error": {
            "href": "https://lanternpay.com/sample/webhook/8ad735a2-21a0-481a-9174-205817e95110"
        }
    }
}

{
    "programInvoiceId" : "CLM-123213",
    "claimStatuses": [
        {
            "claimId": "ef5bc5d2-943e-473c-bfc4-dab2e252a000",
            "programClaimId":"AA-1231231",
            "benefit": 690,
			"adjudications": [
                {
                    "reason": "Policy limit for Physiotherapy reached",
                    "amount": 590
                },
                {
                    "reason": "Client is eligible to receive a Bonus to cover the claim amount",
                    "amount": 100
                }
            ],
            "state": "approved"
        },
        {
            "claimId": "ac2a7251-149e-4e5a-b526-bbc9e256723b",
            "programClaimId":"AA-3453434",
            "benefit": 0,
            "state": "rejected",
			"statusTitle": "InvCombo",
            "statusDescription": "ItemCode 12345 is not allowed in combination with itemCode 4567"
        },
        {
            "claimId": "68e1a679-a455-4726-b52d-d467c7f2d1f5",
            "programClaimId":"AA-897978",
            "benefit": 0,
            "state": "rejected",
			"statusTitle": "Invalid",
            "invalidParams": [
                {
                    "name": "itemCode",
                    "reason": "Item 123456 is unknown"
                },
                {
                    "name": "location",
                    "reason": "A location is required for this claim"
                }
            ]
        }
    ]
}

Predeterminations

The Predetermination process is used to request an expected funding result for an Invoice. The Predetermination may not be subsequently honoured by the Program - the result of the Submit is the final and true result. It is expected that the rules applied by a Program for calculating the result of a Predetermination are the same as those which will apply on the Submit. The Predetermination is used for information purposes only, and does not change the State of the claim.

The Predetermination is sent as an Invoice (containing a collection of Claims), but the result for each Claim is processed and returned independently. The Predetermination process may be run several times before a Submit, the most recently received Predetermination response will be displayed to the Biller.

If Predetermination is not supported by a Program it may be configured to be bypassed, in which case the Biller will not be given any indication of the expected result prior to submission.

The data structure for a Predetermination is the same as an Invoice.

{
    "id": "8ad735a2-21a0-481a-9174-205817e95110",
    "created": 1565140165,
    "data": {
        "invoiceId": "9a15ad10-dbf0-4ab6-83f1-e42019f188b5",
        "sourceChannel": "app",
        "program": "mpl",
        "responsePriority": "normal",
        "biller": {
            "billerId": "de960e0a-5a3b-47e7-8cde-11f6d3b62b60"
        },
        "member": {
            "memberNumber": "789456123",
            "program": "mpl",
            "givenName": "Spongebob",
            "familyName": "Squarepants",
            "birthDate": "1990-04-01",
            "gender": "female"
        },
        "created": "2019-11-15T01:09:23.633+10:00",
        "invoiceDate": "2019-11-01",
        "invoiceNumber": "INV-911",
        "claims": [
            {
                "claimId": "7329d4a5-a15d-4db0-a831-da2e6bbba425",
                "provider": {
                    "organization": {
                        "facilityName": "Amcal Bourke Street"
                    },
                    "registrations": {
                        "medibankProviderNumber": "808000"
                    },
                    "contactPoint": {
                        "phone": "097591423"
                    },
                    "discipline": "pharmacy"
                },
                "itemPublisher": "mims",
                "itemCode": "10|1|1",
                "itemCustomFields": {
                    "pharmacy": {
                        "scriptNumber": "123123",
                        "prescribingDoctorName": "Squidward Tentacles",
                        "dispensingPharmacistName": "Patrick Star"
                    }
                },
                "serviceDateTime": "2019-08-07T00:00.000+10:00",
                "quantity": 1,
                "unitPrice": 55.63,
                "taxCode": "GST",
                "description": "LonquexSolution for injection6 mg/0.6 mL [1]"
            }
        ]
    },
    "type": "claiming.predetermination.submitted",
    "_links": {
        "lp:predetermination-status-updated": {
            "href": "https://lanternpay.com/sample/invoices/9a15ad10-dbf0-4ab6-83f1-e42019f188b5/predet"
        },
        "lp:webhook-error": {
            "href": "https://lanternpay.com/sample/webhook/8ad735a2-21a0-481a-9174-205817e95110"
        }
    }
}

{
    "claimStatuses": [
        {
            "claimId": "ef5bc5d2-943e-473c-bfc4-dab2e252a000",
            "benefit": 690,
            "adjudications": [
                {
                    "reason": "Policy limit for Physiotherapy reached",
                    "amount": 690
                }
            ],
            "state": "rejected",
            "statusDescription": "ItemCode 12345 is unknown. A location is required for this claim.",
            "invalidParams": [
                {
                    "name": "itemCode",
                    "reason": "Item 123456 is unknown"
                },
                {
                    "name": "location",
                    "reason": "A location is required for this claim"
                }
                ]
        },
        {
            "claimId": "ef5bc5d2-943e-473c-bfc4-dab2e252a123",
            "benefit": 90.05,
            "state": "approved"
        }
    ]
}

Members

A Member is also known as the “client” or “participant” in the Program. Programs have different requirements for identifying a member, which is further covered under Member Validation.

Example code here

Example code here

Payments

HICAPS will trigger webhooks to inform the program of certain payment related events, defined below.

NOTE: this payments section is currently being updated to support direct debit payment notifications. Please speak with an integration resource regarding this for the latest information.

{
    "id": "d76eac52-6b7f-4303-8c70-91ae2f4313f9",
    "created": "2020-10-30T09:10:11.2321413+11:00",
    "data": {
        "remitter": "tac",
        "paymentDate": "2020-04-04",
        "billerId": "d5e6e8f7-bc9c-4a5b-8c60-8e8ffd665e26",
        "paymentId": "55435069-4217-4c8b-8d17-7c7edec69796",
        "paymentReference": "YHL233432424ref",
        "amount": 2322.23,
        "billerBankAccount": {
            "bsb": "123123",
            "accountNumber": "123456789",
            "accountName": "ABC Care"
        }
    },
    "type": "settlement.payment.scheduled",
    "_links": {
        "lp:payment-invoices": {
            "href": "https://api.payments.sandbox.lanternpay.com/payments/55435069-4217-4c8b-8d17-7c7edec69796/invoices"
        },
        "lp_webhook-error": {
            "href": "https://lanternpay.com/sample/webhook/url/8ad735a2-21a0-481a-9174-205817e95110"
        }
    }
}

{
    "id": "d76eac52-6b7f-4303-8c70-91ae2f4313f9",
    "created": "2020-10-30T09:10:11.2321413+11:00",
    "data": {
        "remitter": "tac",
        "paymentDate": "2020-04-04",
        "billerId": "d5e6e8f7-bc9c-4a5b-8c60-8e8ffd665e26",
        "paymentId": "55435069-4217-4c8b-8d17-7c7edec69796",
        "paymentReference": "YHL233432424ref",
        "amount": 2322.23,
        "billerBankAccount": {
            "bsb": "123123",
            "accountNumber": "123456789",
            "accountName": "ABC Care"
        }
    },
    "type": "settlement.payment.failed",
    "_links": {
        "lp:payment-invoices": {
            "href": "https://api.payments.sandbox.lanternpay.com/payments/55435069-4217-4c8b-8d17-7c7edec69796/invoices"
        },
        "lp_webhook-error": {
            "href": "https://lanternpay.com/sample/webhook/url/8ad735a2-21a0-481a-9174-205817e95110"
        }
    }
}

{
    "invoices": [
        {
            "invoiceId": "614f61e1-c62c-4d42-b0cf-3bf972030c21",
            "programInvoiceId": "47d6538e-de2b-4877-80cf-f293fbb36d30",
            "claimTransactions": [
                {
                    "claimId": "ea070557-757d-4127-8be6-690cb05b948a",
                    "amount": 234.23
                },
                {
                    "claimId": "54eadf24-aaba-4dbd-8d3b-f15f01c0ad3f",
                    "amount": 34.12
                }
            ]
        },
        {
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