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  1. FHIR Specification Feedback
  2. FHIR-25577

Use of Claim Profile for Use Case 2

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    Details

    • Type: Change Request
    • Status: Resolved - change required (View Workflow)
    • Priority: Medium
    • Resolution: Persuasive with Modification
    • Specification:
      US CARIN Real-time Pharmacy Benefit Check (RTPBC) (FHIR)
    • Work Group:
      Pharmacy
    • Related Artifact(s):
      RTPBC Request Profile (Claim)
    • Grouping:
    • Resolution Description:
      Hide

      Adjust profiles as follows to enable an RTPBC request to reference a Coverage resource (when submitting to an insurer) or populate an identifier representing the pricing source (when submitting to a pricing source):

      • rtpbc-request-bundle (Bundle profile):
        • Adjust the optionality of the entry:coverage slice to 0..1, and the optionality of entry:coverage .resource to 1..1.
        • Add clarification to the Must Support section that a Coverage resource is required when submitting to an insurer but not when submitting to a pricing source
      • rtpbc-request (Claim profile): 
        • Remove the 1..1 constraint on Claim.insurance.coverage.reference (to make it 0..1)
        • Add clarification to the Must Support section that a reference to a coverage resource is required when submitting to an insurer but not when submitting to a pricing source

      Correct the omission of patient information in requests to medication pricing sources:

      • Information content and FHIR resources page: Add the following bullet under "Content when submitting to a medication pricing source / Request content:
        • "basic patient identifying information"

      Note: No change to the MedicationRequest or ClaimResponse resources, as Patient is always required. The Information Content page incorrectly left Patient off of the list of required content when submitting to a pricing source; it will be corrected as indicated above.

      Show
      Adjust profiles as follows to enable an RTPBC request to reference a Coverage resource (when submitting to an insurer) or populate an identifier representing the pricing source (when submitting to a pricing source): rtpbc-request-bundle (Bundle profile): Adjust the optionality of the entry:coverage  slice to 0..1, and the optionality of  entry:coverage  .resource to 1..1. Add clarification to the Must Support section that a Coverage resource is required when submitting to an insurer but not when submitting to a pricing source rtpbc-request (Claim profile):   Remove the 1..1 constraint on Claim.insurance.coverage.reference (to make it 0..1) Add clarification to the Must Support section that a reference to a coverage resource is required when submitting to an insurer but not when submitting to a pricing source Correct the omission of patient information in requests to medication pricing sources: Information content and FHIR resources page: Add the following bullet under "Content when submitting to a medication pricing source / Request content: "basic patient identifying information" Note: No change to the MedicationRequest or ClaimResponse resources, as Patient is always required. The Information Content page incorrectly left Patient off of the list of required content when submitting to a pricing source; it will be corrected as indicated above.
    • Resolution Vote:
      Scott Robertson / Pooja Babbrah : 8-0-0
    • Change Category:
      Enhancement
    • Change Impact:
      Compatible, substantive
    • Applied for Version:
      0.1.0

      Description

      The Claim profile requires that Claim.patient Claim.insurance are populated (1..1) but Use Case 2 on the Use Case page suggests that it doesn't require the patient or insurance information. Is the same Claim profile used for both use cases? If so, please clarify how those elements should be populated for Use Case 2.

       

      The Bundle, ClaimResponse and MedicationRequest profiles would need similar clarification.

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              Assignee:
              Unassigned Unassigned
              Reporter:
              craig.newman Craig Newman
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                Updated:
                Resolved:
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