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  1. FHIR Specification Feedback
  2. FHIR-26992

Replace CARIN Blue Button Adjudication Amount Category Value Set with Adjudication CARINBB Value Set

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    Details

    • Type: Change Request
    • Status: Published (View Workflow)
    • Priority: Highest
    • Resolution: Persuasive with Modification
    • Specification:
      US CARIN Blue Button (FHIR)
    • Raised in Version:
      0.1
    • Work Group:
      Financial Mgmt
    • Related Page(s):
      (NA)
    • Related Section(s):
      Terminology
    • Grouping:
    • Resolution Description:
      Hide

      Delete Value Set CARIN Blue Button Adjudication Amount Category Value Set

      Delete Value Set CARIN Blue Button Claim Adjudication Category Value Set

      Delete Value Set CARIN Blue Button Claim Information Category Value Set

      Delete CARIN Blue Button Claim Information Category Code System

       

      Replace with Value Set:
       

      Defining URL: http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication
      Name: C4BBAdjudication
      Title: C4BB Adjudication
      Definition: Describes the various amount fields used when payers receive and adjudicate a claim
      Copyright: This Value Set is not copyrighted. 
      Logical Definition: This value set includes codes from the following code systems:
      ·       Include submitted, copay, eligible, deductible and benefit defined in http://terminology.hl7.org/CodeSystem/adjudication
      ·       Include all codes defined in http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
      Expansion: This value set contains 14 concepts
      Code Display Definition
      submitted Submitted Amount The total submitted amount for the claim or group or line item.
      copay CoPay Patient Co-Payment
      eligible Eligible Amount Amount of the change which is considered for adjudication.
      deductible Deductible Amount deducted from the eligible amount prior to adjudication.
      benefit Benefit Amount Amount payable under the coverage
      coinsurance Co-insurance The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%.
      noncovered Noncovered The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.
      priorpayerpaid Prior payer paid The reduction in the payment amount to reflect the carrier as a secondary payor.
      paidbypatient Paid by patient The amount paid by the patient at the point of service.
      paidtoprovider Paid to provider The amount paid to the provider.
      paidtopatient Paid to patient The amount paid to the patient.
      memberliability Member liability The amount of the member's liability.
      discount Discount The amount of the discount
      drugcost Drug cost Price paid for the drug excluding mfr or other discounts.  It typically is the sum of the following components: ingredient cost, dispensing fee, sales tax, and vaccine administration

       
      Bind with binding strength Required to the the slice adjudicationamounttype, data element item.adjudication.category, adjudication.category and total.category in the Inpatient Institutional and Outpatient Institutional Profiles
      Bind with binding strength Required to the slice adjudicationamounttype, data element item.adjudication.category and total.category in the Professional and Non-Clinician Profile
      Bind with binding strength Required to the slice adjudicationamounttype, data element total.category in the Pharmacy Profile
      Delete Code System CARIN-BB-Adjudication-Category
      Replace with Code System:  (This assumes that HL7 does not include the values in http://terminology.hl7.org/CodeSystem/adjudication as proposed in the attached harmonization of RTPBC and C4BB.)
       

      Defining URL: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication
      Name: C4BBAdjudication
      Title: C4BB Adjudication
      Definition: Describes the various amount fields used when payers receive and adjudicate a claim.  It complements he values defined in http://terminology.hl7.org/CodeSystem/adjudication
      Copyright: This Code System is not copyrighted.  
      Content:
      Code Display Definition
      coinsurance Co-insurance The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%.
      noncovered Noncovered The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.
      priorpayerpaid Prior payer paid The reduction in the payment amount to reflect the carrier as a secondary payor.
      paidbypatient Paid by patient The amount paid by the patient at the point of service.
      paidtoprovider Paid to provider The amount paid to the provider.
      Paidtopatient Paid to patient The amount paid to the patient.
      memberliability Member liability The amount of the member's liability.
      discount Discount The amount of the discount
      drugcost Drug cost Price paid for the drug excluding mfr or other discounts.  It typically is the sum of the following components: ingredient cost, dispensing fee, sales tax, and vaccine administration
      Show
      Delete Value Set  CARIN Blue Button Adjudication Amount Category Value Set Delete Value Set CARIN Blue Button Claim Adjudication Category Value Set Delete Value Set CARIN Blue Button Claim Information Category Value Set Delete CARIN Blue Button Claim Information Category Code System   Replace with Value Set:   Defining URL: http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication Name: C4BBAdjudication Title: C4BB Adjudication Definition: Describes the various amount fields used when payers receive and adjudicate a claim Copyright: This Value Set is not copyrighted.  Logical Definition: This value set includes codes from the following code systems: ·       Include submitted, copay, eligible, deductible and benefit defined in http://terminology.hl7.org/CodeSystem/adjudication ·       Include all codes defined in http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication Expansion: This value set contains 14 concepts Code Display Definition submitted Submitted Amount The total submitted amount for the claim or group or line item. copay CoPay Patient Co-Payment eligible Eligible Amount Amount of the change which is considered for adjudication. deductible Deductible Amount deducted from the eligible amount prior to adjudication. benefit Benefit Amount Amount payable under the coverage coinsurance Co-insurance The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%. noncovered Noncovered The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. priorpayerpaid Prior payer paid The reduction in the payment amount to reflect the carrier as a secondary payor. paidbypatient Paid by patient The amount paid by the patient at the point of service. paidtoprovider Paid to provider The amount paid to the provider. paidtopatient Paid to patient The amount paid to the patient. memberliability Member liability The amount of the member's liability. discount Discount The amount of the discount drugcost Drug cost Price paid for the drug excluding mfr or other discounts.  It typically is the sum of the following components: ingredient cost, dispensing fee, sales tax, and vaccine administration   Bind with binding strength Required to the the slice adjudicationamounttype, data element item.adjudication.category, adjudication.category and total.category in the Inpatient Institutional and Outpatient Institutional Profiles Bind with binding strength Required to the slice adjudicationamounttype, data element item.adjudication.category and total.category in the Professional and Non-Clinician Profile Bind with binding strength Required to the slice adjudicationamounttype, data element total.category in the Pharmacy Profile Delete Code System  CARIN-BB-Adjudication-Category Replace with Code System:  (This assumes that HL7 does not include the values in http://terminology.hl7.org/CodeSystem/adjudication as proposed in the attached harmonization of RTPBC and C4BB.)   Defining URL: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication Name: C4BBAdjudication Title: C4BB Adjudication Definition: Describes the various amount fields used when payers receive and adjudicate a claim.  It complements he values defined in http://terminology.hl7.org/CodeSystem/adjudication .  Copyright: This Code System is not copyrighted.   Content: Code Display Definition coinsurance Co-insurance The amount the insured individual pays, as a set percentage of the cost of covered medical services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%. noncovered Noncovered The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. priorpayerpaid Prior payer paid The reduction in the payment amount to reflect the carrier as a secondary payor. paidbypatient Paid by patient The amount paid by the patient at the point of service. paidtoprovider Paid to provider The amount paid to the provider. Paidtopatient Paid to patient The amount paid to the patient. memberliability Member liability The amount of the member's liability. discount Discount The amount of the discount drugcost Drug cost Price paid for the drug excluding mfr or other discounts.  It typically is the sum of the following components: ingredient cost, dispensing fee, sales tax, and vaccine administration
    • Resolution Vote:
      Pat Taylor/Mark Roberts: 24-0-2
    • Change Category:
      Correction
    • Change Impact:
      Compatible, substantive

      Description

      Ballot feedback was that the Terminology Section of the IG requires a major overall, renaming the Value Sets and Code Systems and updating links.  Following is a recommended resolution for the categories of adjudication amounts:

      1)  Delete Value Set CARIN Blue Button Adjudication Amount Category Value Set

      2)  Delete Code System CARIN-BB-Adjudication-Category

      3)  Define Value Set AdjudicationCarinBBValueCodes

      4)  Title:  Adjudication CARINBB Value Codes

      5) Description:  Describes the various amount fields used when payers receive and adjudicate a claim

      6) http://hl7.org/fhir/us/ValueSet/adjudication-carinbb-value-codes where values include the following codes from the Code System https://www.hl7.org/fhir/codesystem-adjudication.html: submitted | eligible | deductible |coinsurance | copay | noncovered | priorpayerpaid | benefit | paidbypatient | paidtoprovider | paidtopatient | memberliability | discount | drugcost

      7)  Using this Code System assumes that values have been added as harmonized with CARIN RTPBC

      8)  Bind the ValueSet with binding strength required to the the slice adjudicationamounttype, data element item.adjudication.category, adjudication.category and total.category in the Inpatient Facility and Outpatient Institutional Profiles

      9)  Bind the ValueSet with binding strength required to the slice adjudicationamounttype, data element item.adjudication.category and total.category in the Professional and Non-Clinician Profile

      10)  Bind the ValueSet with binding strength required to the slice adjudicationamounttype, data element total.category in the Pharmacy Profile

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              Assignee:
              Unassigned Unassigned
              Reporter:
              taylorpatriciab Patricia Taylor
              Request in-person:
              Patricia Taylor
              Watchers:
              1 Start watching this issue

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                Updated:
                Resolved:
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