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  1. FHIR Specification Feedback
  2. FHIR-31594

Add ExplanationOfBenefit requirement for subType

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    Details

    • Type: Change Request
    • Status: Resolved - change required (View Workflow)
    • Priority: Medium
    • Resolution: Persuasive with Modification
    • Specification:
      US CARIN Blue Button (FHIR)
    • Raised in Version:
      1.0.0
    • Work Group:
      Financial Mgmt
    • Related Artifact(s):
      C4BB ExplanationOfBenefit Inpatient Institutional
      C4BB ExplanationOfBenefit Outpatient Institutional
    • Grouping:
    • Resolution Description:
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      To include Claim.subtype 1..1 in Institutional EOB profiles to convey the inpatient/outpatient designation, and to create a code system and valueset with the values inpatient and outpatient and make that a Required binding for the subtype element, and to set inpatient or outpatient as a fixed value in the profiles respectively.

      The designation of inpatient and outpatient reflects the payor interpretation and may not match what was submitted on the original claim.

      The determination of inpatient and the 'bill type' expressed in the .supportingInfo should not be in conflict.

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      To include Claim.subtype 1..1 in Institutional EOB profiles to convey the inpatient/outpatient designation, and to create a code system and valueset with the values inpatient and outpatient and make that a Required binding for the subtype element, and to set inpatient or outpatient as a fixed value in the profiles respectively. The designation of inpatient and outpatient reflects the payor interpretation and may not match what was submitted on the original claim. The determination of inpatient and the 'bill type' expressed in the .supportingInfo should not be in conflict.
    • Resolution Vote:
      Corey Spears/Pat Taylor: 9-0-3
    • Change Category:
      Enhancement
    • Change Impact:
      Compatible, substantive
    • Applied for Version:
      1.1.0

      Description

      To differentiate between Inpatient Institutional and Outpatient Institutional, define Institutional EoB subtype with cardinality of 1..1 and fixed values for inpatient and outpatient. 

      The FHIR Code System for claim subtype is an example with values of ortho and emergency, neither of which apply to our use case. 

      Define C4BB Institutional Claim Sub Type as a Code System and Value Set with the values defined below:  Bind the Value Set as required to the two Institutional profiles, requiring fixed values of institutionalinpatient / institutionaloutpatient respectively.

      Update the CPCDS data dictionary and the CARIN to FHIR mapping to include Subtype.  

       

      Code Display Definition
      inpatient Inpatient Claims for inpatient institutional admissions. 
      outpatient Outpatient Claims for outpatient institutional admissions. 

       

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            Assignee:
            Unassigned Unassigned
            Reporter:
            corey_spears Corey Spears
            Watchers:
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              Created:
              Updated:
              Resolved:
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