Systems
Insurance / TPA / Claims
Pre-auth and claims out; adjudication and settlement back.
What this class of system is
These are the payer, TPA, and claims endpoints a hospital settles against.
orophin speaks FHIR R4 (NHCX), HL7 DFT, and API or CSV. Out: pre-auth and claims; in: adjudication and settlement. Vault packages the claim; Raven carries the status.
Everything above rides one path. The on-prem orophin agent speaks the protocol on the hospital's own network and opens a single outbound mutually authenticated link to the Pensieve backend. Your network team approves egress.
On the wire
What it emits, and what carries it
The traffic
A pre-authorisation leaves with the clinical justification attached and returns with an approval, a query or a refusal. A claim leaves with the bill, the discharge summary and the documents the payer’s checklist names. NHCX carries this as FHIR R4 Claim and ClaimResponse resources. Every other counterparty carries it as its own portal, its own checklist and its own tariff sheet.
What breaks here
Adjudication is rarely binary. The routine loss is a line-item deduction on an approved claim, and a deduction has to be traceable to the charge it removed and appealable against the evidence that supports it. Vault models the claim as lines against the encounter that produced them, so a deduction lands on a charge with an order and a clinician behind it rather than on a total.
Protocols
The standards this class speaks
Each one is described in full on the standards register, at the anchor named here.
- HL7 v2The dominant hospital messaging standard. orophin sends and receives ADT, ORM / OMG, ORU, DFT, MDM, and SIU. India’s EHR Standards name v2.8.2.
- FHIR R4Modern REST / JSON resources: Patient, Encounter, Observation, ServiceRequest, DiagnosticReport, Claim, Coverage. Pensieve speaks FHIR R4 for record exchange, ABDM linkage, and NHCX claims.
- MLLP transportThe TCP framing HL7 v2 rides on. A start block, the message, an end block and a carriage return, over a socket. orophin’s MLLP adapter is the transport under every HL7 v2 connection.
- CSV / flat fileThe fallback for a system with no live interface. orophin watches a drop folder for scheduled exports and reads each file once.
- mTLS WebSocket bridgeThe single outbound, mutually authenticated link orophin opens to the Pensieve backend. Both ends verify a certificate, nothing listens on the hospital side, and every row in this register rides it.
- OIDC SSOOpenID Connect sign-in for a hospital identity provider.
- ABDM (ABHA / HIE-CM)India’s national health-data rails: FHIR-R4 ABHA linkage and consent-driven sharing through the Health Information Exchange and Consent Manager.
- NHCX claimsThe FHIR-based National Health Claims Exchange, built jointly by the National Health Authority and IRDAI. Vault packages pre-auth and claims to it.
Members
Systems in this class
8 entries on the register, each at its own anchor.
- NHCXFHIR R4 (NHCX). Out: pre-auth and claims. In: adjudication and settlement.
- PMJAY / Ayushman BharatFHIR R4 / REST (PMJAY). Out: scheme claims. In: eligibility and approval.
- Generic TPA via HL7HL7 v2 (DFT) over MLLP. Out: charges and claims. In: status.
- Generic TPA via APIREST / FHIR R4, OIDC SSO. Out: pre-auth and claims. In: status.
- IRDAI e-claimFHIR R4 / REST API. Out: standardised claim submission.
- ECHSREST API / CSV. Out: scheme claims. In: approval.
- CGHSREST API / CSV. Out: scheme claims. In: approval.
- Corporate cashless portalREST / FHIR R4, OIDC SSO. Out: pre-auth and claims. In: approval.
What a name in this register means
Compatibility only. Pensieve connects to systems in this class over the protocol they speak. Naming a system describes the connection Pensieve is built to make; it implies no partnership, no certification, and no existing deployment.