Billing and Accounts

Billing and account configuration defines how laboratory orders are financially processed and which entities are responsible for payment.

Lab Network uses the FHIR Account, Coverage, and related resources to represent billing context for each order. Billing configuration must align with laboratory-specific requirements to pass validation and ensure successful order routing.

Overview

Each laboratory order includes billing information that determines:

• Who is financially responsible for the order
• Which insurance policies apply
• Whether additional billing identifiers are required
• How the order is validated by the performing laboratory

Billing requirements vary by laboratory. Some laboratories require provider or practice account numbers, while others rely solely on patient or insurance information.

Account Resource

The Account resource defines billing preferences for an order. Each order must include an Account resource referenced from RequestGroup using the requestgroup-account extension.

{
  "url": "https://www.healthgorilla.com/fhir/StructureDefinition/requestgroup-account",
  "valueReference": {
    "reference": "#account1"
  }
}

Example Account

{
  "resourceType": "Account",
  "id": "account1",
  "type": {
    "coding": [
      {
        "system": "https://www.healthgorilla.com/order-billto",
        "code": "patient"
      }
    ]
  }
}

Bill-To Types

The Account.type field defines who is responsible for payment.

Example Patient Billing

{
  "resourceType": "Account",
  "type": {
    "coding": [
      { "code": "patient" }
    ]
  },
  "guarantor": [
    {
      "party": {
        "reference": "Patient/12345"
      }
    }
  ]
}

Coverage and Insurance

The Coverage resource represents insurance policies used for billing. Each Account.coverage entry references a Coverage resource.

{
  "resourceType": "Coverage",
  "id": "coverage1",
  "status": "active",
  "subscriber": {
    "reference": "RelatedPerson/guarantor1"
  },
  "beneficiary": {
    "reference": "Patient/12345"
  },
  "payor": [
    {
      "reference": "Organization/payer1"
    }
  ]
}

Up to three coverage entries may be included. When multiple coverages are present, priority must be set.

Guarantor

When billing to a guarantor, a RelatedPerson resource defines the responsible individual.

{
  "resourceType": "RelatedPerson",
  "id": "guarantor1",
  "patient": {
    "reference": "Patient/12345"
  },
  "relationship": {
    "coding": [
      {
        "code": "parent"
      }
    ]
  }
}

Worker Compensation

Worker’s compensation is represented using an extension on the Account resource.

{
  "extension": [
    {
      "url": "https://www.healthgorilla.com/fhir/StructureDefinition/account-wc",
      "valueBoolean": true
    }
  ]
}

Account and Laboratory Relationship

Billing configuration is dependent on both:

• Ordering location
• Performing laboratory

Account selection is determined by the combination of location and laboratory. A single location may have different account numbers for different laboratories. Incorrect account selection may result in validation errors or rejected orders.

Requester and Account Numbers

Some laboratories require provider or practice account numbers to be included in the order. These are represented using the requestgroup-requester extension.

Example Standard Reference

{
  "url": "https://www.healthgorilla.com/fhir/StructureDefinition/requestgroup-requester",
  "extension": [
    {
      "url": "agent",
      "valueReference": {
        "reference": "Practitioner/123"
      }
    },
    {
      "url": "onBehalfOf",
      "valueReference": {
        "reference": "Organization/456"
      }
    }
  ]
}

Example Embedded

{
  "resourceType": "Practitioner",
  "id": "1",
  "identifier": [
    {
      "system": "http://hl7.org/fhir/sid/us-npi",
      "value": "1234567893"
    },
    {
      "type": {
        "coding": [
          { "code": "AN" }
        ]
      },
      "value": "04843980"
    }
  ]
}

If account numbers are required, Practitioner and Organization must be embedded with identifiers. Otherwise, standard references may be used.

Whether account numbers are required depends on the performing laboratory and can be determined using the requisition settings endpoint. If doctorAccountRequired or practiceAccountRequired is true, the corresponding identifiers must be included in the order.

Requisition Settings

Laboratory-specific billing requirements can be retrieved using the requisition settings endpoint.

GET /fhir/R4/Organization/{id}/$requisition-settings

Example Response

{
  "resourceType": "Parameters",
  "parameter": [
    { "name": "orderingEnabled", "valueBoolean": true },
    { "name": "doctorAccountRequired", "valueBoolean": true },
    { "name": "practiceAccountRequired", "valueBoolean": false },
    { "name": "compendiumUrl", "valueId": "ValueSet/abc123" },
    { "name": "electronicOrdering", "valueBoolean": true }
  ]
}

These settings determine:

• Whether ordering is allowed
• Whether account numbers are required
• Which compendium to use

Validation

Billing configuration is validated as part of order submission.

Validation ensures:

• Required account information is present
• Coverage and guarantor requirements are met
• Account configuration matches the selected laboratory

Failures result in an OperationOutcome:

{
  "resourceType": "OperationOutcome",
  "issue": [
    {
      "severity": "error",
      "diagnostics": "Practice account number required"
    }
  ]
}

Common Issues

Common billing-related failures include:

• Missing or incorrect account numbers
• Incorrect bill-to type
• Missing insurance information
• Mismatch between location and laboratory account

Workflow Considerations

To ensure successful billing configuration:

• Select the laboratory before assigning account details
• Use account numbers associated with the laboratory
• Include all required identifiers when applicable
• Validate requisition settings before submission
• Test billing scenarios in sandbox before production

Summary

Billing and account configuration determines how laboratory orders are processed and validated. Use the Account, Coverage, and related resources to define billing context and ensure alignment with laboratory requirements. Accurate billing configuration is required for successful order submission, routing, and fulfillment.