Insurance Eligibility and Claims
Automated, real-time verification of patient coverage and electronic submission of claims, built on HL7® FHIR® IPS and aligned to Malaysia’s MY-Core profiles.
For technical details, see the SI-LAB FHIR Implementation Guide and MY-Core profiles
Why start with Insurance Eligibility & Claims?
The diagram shows the overview flow of how data will be exchanged between the Healthcare Provider and insurance Payors. Standardised formats will ease data flow, enabling seamless interaction between any Provider and any Payor.
Operational Efficiency
Traditional reliance on phone calls, emails, and non-standard portals for eligibility and pre-authorization leads to long wait times, miscommunication, and administrative burden for both providers and payors.
Financial Clarity
Without real-time, transparent data on coverage and patient responsibility, providers face claim denials and patients receive unexpected bills, eroding trust and satisfaction.
Foundational Data Exchange
The lack of a common data standard prevents the automation of claims adjudication and makes it difficult to aggregate data for analytics, fraud prevention, and cost management.
Alignment with MY-Core: The transactions are implemented using MY-Core resource profiles for local identifiers, code bindings, and must-support elements to ensure national consistency.
REUSABILITY
- Multi-payor
- Payor-neutral spec
TRANSPARENCY
- Real-time
- Eligibility & pre-auth
STANDARDS
- FHIR R4
- SI-LAB profiles
FHIR Resources
Primary resources
- Coverage
- CoverageEligibilityRequest
- CoverageEligibilityResponse
- Claim
- ClaimResponse
- Condition (Comorbid)
Supporting (main)
- Patient
- Organization (Provider & Payor)
- Invoice
- ChargeItem
- ChargeItemDefinition
- PaymentReconciliation
Supporting (as applicable)
- Encounter
- Condition
- ServiceRequest
- DiagnosticReport
- MedicationDispense
- DocumentReference
- Practitioner
- PractitionerRole
Expected outcomes
Automated Eligibility Checks
Providers receive real-time, accurate responses on patient coverage and benefits before service delivery.
Lower Administrative Cost
Reduced manual data entry, unnecessary phone calls, and paper-based processes for both providers and payors
Simplified Claims Adjudication
Standardised digital claims submission leads to fewer rejections and faster payor processing and payment.
Improved Customer Outcomes
Enhanced transparency and faster turnaround translate into higher satisfaction and peace of mind for patients
FAQ
Is this production or a sandbox?
This is a standards interoperability lab (sandbox) used to prove readiness and de-risk go-live.
Which standards are used?
HL7 FHIR R4, IPS Implementation Guide, and MY-Core profiles for local alignment.
Do we need new software to start?
No. Vendors can integrate from existing systems using standard FHIR APIs and our examples.
What do we get at the end?
A validation report, improvement recommendations, and a completion certificate.
CONTACT US
Share your email and any remarks, feedback, a demo request, or a meetup suggestion. We’ll respond with the next steps.
Other ways to reach us
Direct Email
contact@silab.my
pilot@silab.my
Office Hours
Wednesday, 3-4 pm MYT (virtual)
Meeting Location
DHM, Kuala Lumpurpilot@silab.my