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Insurance module

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.

Current status

Complete for operational claims workflows (verified against code 2026-09-20). Built: NHIS claim batch generation with pre-flight report, vetting and NHIA v8.6 XML export, NHIA feedback XML import, NHIA OTAC claim-check-code generation (settings, hourly token refresh, NhisAttendanceService used by Clinical encounters), master-data Filament resources (tariff books with tariff-item relation manager, NHIS medicines, G-DRG/ICD map, members master, provider credentialing), member verification (offline members master; badge on the patient list and Patient Profile), patient insurance fields on the patient form, insurance:import-master-data command. Deferred: NHIS catalog sync implementation (processed: 0 from connector paths), dedicated PatientPolicy Filament resource (the patient record has a read-only Insurance Policies tab via PatientPoliciesRelationManager), private insurer connector beyond the generic stub. HTTP claim submission for the NHIS payer was removed on 2026-09-02; NHIS claims are file-export only.

See module status for the canonical matrix.

What you can do with it

• Work in the Insurance cluster (Finance sidebar group, /insurance-cluster): Claims (claim batches: Generate Claims page, Pre-flight Report, Submit All / Vet, Export XML, Download XML once exported, Claims in Batch tab with Review / Mark Ready), Payers (a second NHIS payer cannot be created; the seeded NHIS payer is system-managed via Payer::isSystem() — type locked, delete refused by policy, model and UI), master data under the Infrastructure sub-group (NHIS medicines, Tariff books with tariff items, Members master, Provider credentialing, G-DRG / ICD map), Import NHIA Feedback (Administration sub-group) and NHIS Settings (Settings sub-group, incl. Test OTAC Connection). The patient record gets a read-only Insurance Policies relation manager (Filament/RelationManagers/PatientPoliciesRelationManager).
• Record NHIS membership on the patient form (Insurance Information: Insurance Payer, Member Number, and Mother Member Number once a payer is chosen; the effective-date fields are defined but hidden) and see the NHIS Member verification badge on the patient list / profile.
• Generate NHIS claim check codes on encounters (auto via OTAC when the encounter is saved with NHIS coverage, or manual entry; the Generate NHIS Claim Code button only renders for NHIS-covered, uncompleted encounters without a code).
• Submit private insurer claims through the authenticated API endpoint and process payer feedback / reconcile statuses (generic connector stub).
• NHIS claims workflow: filter encounters (branch, patient, year, month, service, medication, or all eligible) → generate batch → pre-flight → review / Mark Ready or Submit All / Vet → export NHIA v8.6 XML → upload to Claim-It → import NHIA feedback XML.

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 (Sanctum + api.branch; connector placeholder returns processed: 0)
• POST /api/v1/insurance/claims/submit (Sanctum + api.branch; rejects the NHIS payer with 422 — use the batch XML export)
• POST /api/v1/insurance/claims/feedback (no auth; shared secret NHIS_FEEDBACK_SECRET)

What is inside this folder

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 claims are batch-export-only (v8.6 XML via NhisBatchXmlEncoder for CLAIM-it upload); feedback imports use NhisFeedbackParser.
• Env keys: INSURANCE_MODULE_ENABLED, NHIS_FEEDBACK_SECRET, NHIS_XML_VERSION (8.6), NHIS_OTAC_BASE_URL, NHIS_OTAC_TIMEOUT, INSURANCE_CLAIMS_QUEUE, INSURANCE_CATALOG_QUEUE.
• Permissions: Shield abilities on ClaimBatch, InsuranceClaim, Payer, NhisMedicine, TariffBook, MembersMaster, ProviderCredentialing, GdrgIcdMap plus View InsuranceCluster and page permissions; no custom snake_case permissions.
• Tests: php artisan test --compact Modules/Insurance/tests (32 test files).