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  1. FHIR Specification Feedback
  2. FHIR-27002

Replace CARIN Blue Button Adjudication Benefit Payment Status Category Value Set with Payer Benefit Payment Status 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 Benefit Payment Status Category Value Set

      Replace with the following Value Set:

       

      Defining URL: http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus
      Name: C4BBPayerBenefitPaymentStatus
      Title: C4BB Payer Benefit Payment Status
      Definition: Indicates the in network or out of network benefit payment status of the claim
      Copyright: This Value Set is not copyrighted. 
      Logical Definition: This value set includes codes from the following code system:
      ·       Include in-network, out-of-network and other defined in http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus
      Expansion: This value set contains 3 concepts
      Code Display Definition
      innetwork In Network Indicates the claim or claim line was paid in network.  This does not indicate the contracting status of the provider
      outofnetwork Out Of Network Indicates the claim or claim line was paid out of network.  This does not indicate the contracting status of the provider
      other Other Indicates other network status or when a network does not apply 

       

      Bind with binding strength Required to the slice inoutnetwork, data element total in the Inpatient Institutional, Outpatient Institutional and Pharmacy Profiles

      Bind with binding strength Required to the slice inoutnetwork, data element item.adjudication in the Professional and Non-Clinician Profile

       

      Define Code System: 

       

      Defining URL: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus
      Name: C4BBPayerAdjudicationStatus
      Title: C4BB Payer Adjudication Status
      Definition: Describes the various status fields used when payers adjudicate a claim, such as whether the claim was adjudicated in or out of network, if the provider was contracted or non-contracted for the service
      Copyright: This Code System is not copyrighted.  
      Content:
      Code Display Definition
      innetwork In Network Indicates the claim or claim line was paid in network.  This does not indicate the contracting status of the provider
      outofnetwork Out Of Network Indicates the claim or claim line was paid out of network.  This does not indicate the contracting status of the provider
      other Other Indicates other network status or when a network does not apply 
      contracted Contracted Indicates the provider was contracted for the service
      noncontracted Non-Contracted Indicates the provider was not contracted for the service
      paid Paid Indicates if the claim was approved for payment
      denied Denied Indicates if the claim was denied
      partiallypaid Partially paid Indicates that some line items on the claim were denied

       

      Show
      Delete Value Set  CARIN Blue Button Adjudication Benefit Payment Status Category Value Set Replace with the following Value Set:   Defining URL: http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBPayerBenefitPaymentStatus Name: C4BBPayerBenefitPaymentStatus Title: C4BB Payer Benefit Payment Status Definition: Indicates the in network or out of network benefit payment status of the claim Copyright: This Value Set is not copyrighted.  Logical Definition: This value set includes codes from the following code system: ·       Include in-network, out-of-network and other defined in http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus Expansion: This value set contains 3 concepts Code Display Definition innetwork In Network Indicates the claim or claim line was paid in network.  This does not indicate the contracting status of the provider outofnetwork Out Of Network Indicates the claim or claim line was paid out of network.  This does not indicate the contracting status of the provider other Other Indicates other network status or when a network does not apply    Bind with binding strength Required to the slice inoutnetwork, data element total in the Inpatient Institutional, Outpatient Institutional and Pharmacy Profiles Bind with binding strength Required to the slice inoutnetwork, data element item.adjudication in the Professional and Non-Clinician Profile   Define Code System:    Defining URL: http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus Name: C4BBPayerAdjudicationStatus Title: C4BB Payer Adjudication Status Definition: Describes the various status fields used when payers adjudicate a claim, such as whether the claim was adjudicated in or out of network, if the provider was contracted or non-contracted for the service Copyright: This Code System is not copyrighted.   Content: Code Display Definition innetwork In Network Indicates the claim or claim line was paid in network.  This does not indicate the contracting status of the provider outofnetwork Out Of Network Indicates the claim or claim line was paid out of network.  This does not indicate the contracting status of the provider other Other Indicates other network status or when a network does not apply  contracted Contracted Indicates the provider was contracted for the service noncontracted Non-Contracted Indicates the provider was not contracted for the service paid Paid Indicates if the claim was approved for payment denied Denied Indicates if the claim was denied partiallypaid Partially paid Indicates that some line items on the claim were denied  
    • 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 benefits:

      1)  Delete Value Set CARIN Blue Button Adjudication Benefit Payment Status Category Value Set

      2)  Define Value Set PayerBenefitPaymentStatus

      4)  Title:  Payer Benefit Payment Status

      5) Description:  Indicates the in network or out of network payment status of the claim.

      5) Value Set:  http://hl7.org/fhir/us/ValueSet/payer-benefitpaymentstatus  where values include the following codes from the Code System:  in-network | out-of-network | other

      6)  Define a Code System: http://hl7.org/fhir/us/CodeSystem/payer-adjudication-category where values are: in-network | out-of-network | other | contracted | non-contracted |  paid | denied

      7) The Code System is also used to source the following Value Sets: Payer Provider Contracting Status, Claim Payment Status Code

      8)  Bind the ValueSet with binding strength required to the slice inoutnetwork, data element total.category in all EOB profiles.  

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

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

                Dates

                Created:
                Updated:
                Resolved:
                Vote Date: