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  1. FHIR Specification Feedback
  2. FHIR-34758

Combine coinsurance and copay qualifier code systems into one code system

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    • Icon: Change Request Change Request
    • Resolution: Persuasive
    • Icon: Highest Highest
    • US Da Vinci Drug Formulary (FHIR)
    • current
    • Pharmacy
    • Payer Insurance Plan
    • Hide

      Merge the two Code Systems usdf-CoinsuranceOptionCS and usdf-CopayOptionCS in to a new Code System usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE 

      Name: CostShareOptionCS
      ID: usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE
      Title: Codes qualifying the type of cost share amount
      Definition: Codes qualifying the type of cost share amount

      Including the following codes:

      Code Display Definition
      after-deductible After Deductible The consumer first pays the deductible, and after the deductible is met, the consumer is responsible only for the cost-share amount (this indicates that this benefit is subject to the deductible).
      before-deductible Before Deductible The consumer first pays the cost share amount, and any net remaining allowed charges accrue to the deductible (this indicates that this benefit is subject to the deductible).
      no-charge No Charge No cost sharing is charged (this indicates that this benefit is not subject to the deductible).
      no-charge-after-deductible No Charge After Deductible The consumer first pays the deductible, and after the deductible is met, no cost share amount is charged (this indicates that this benefit is subject to the deductible).
      charge Charge The consumer always pays just the cost share amount and the issuer pays the remainder of allowed charges (this indicates that this benefit is not subject to the deductible).
      coinsurance-not-applicable Coinsurance Not Applicable The consumer pays only a copay. Note: When using Not Applicable for coinsurance, Not Applicable cannot also be used for copay (unless the drug tier type is Medical Service Drugs).
      copay-not-applicable Copay Not Applicable Deductible is not applicable: Zero-deductible cost sharing represented by a co-pay value of 'Not applicable' and co-insurance value of 'No charge'.
      deductible-waived Deductible Waived The consumer pays the cost share amount with deductible requirement waived.

      Change the CopayOptionVS to the following codes from CostShareOptionCS

      • after-deductible
      • before-deductible
      • no-charge
      • no-charge-after-deductible
      • charge
      • copay-not-applicable
      • deductible-waived

      Change the CoinsuranceOptionVS to the following codes from CostShareOptionCS

      • after-deductible
      • no-charge
      • no-charge-after-deductible
      • charge
      • coinsurance-not-applicable
      • deductible-waived

      Change the following examples to use the  CostShareOptionCS Code System

      • PayerInsurancePlanA1002
      • PayerInsurancePlanA3001
      • PayerInsurancePlanA3002
      • PayerInsurancePlanA3004t
      Show
      Merge the two Code Systems usdf-CoinsuranceOptionCS and usdf-CopayOptionCS in to a new Code System usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE  Name: CostShareOptionCS ID: usdf-CostShareOptionCS-TEMPORARY-TRIAL-USE Title: Codes qualifying the type of cost share amount Definition: Codes qualifying the type of cost share amount Including the following codes: Code Display Definition after-deductible After Deductible The consumer first pays the deductible, and after the deductible is met, the consumer is responsible only for the cost-share amount (this indicates that this benefit is subject to the deductible). before-deductible Before Deductible The consumer first pays the cost share amount, and any net remaining allowed charges accrue to the deductible (this indicates that this benefit is subject to the deductible). no-charge No Charge No cost sharing is charged (this indicates that this benefit is not subject to the deductible). no-charge-after-deductible No Charge After Deductible The consumer first pays the deductible, and after the deductible is met, no cost share amount is charged (this indicates that this benefit is subject to the deductible). charge Charge The consumer always pays just the cost share amount and the issuer pays the remainder of allowed charges (this indicates that this benefit is not subject to the deductible). coinsurance-not-applicable Coinsurance Not Applicable The consumer pays only a copay. Note: When using Not Applicable for coinsurance, Not Applicable cannot also be used for copay (unless the drug tier type is Medical Service Drugs). copay-not-applicable Copay Not Applicable Deductible is not applicable: Zero-deductible cost sharing represented by a co-pay value of 'Not applicable' and co-insurance value of 'No charge'. deductible-waived Deductible Waived The consumer pays the cost share amount with deductible requirement waived. Change the CopayOptionVS to the following codes from CostShareOptionCS after-deductible before-deductible no-charge no-charge-after-deductible charge copay-not-applicable deductible-waived Change the CoinsuranceOptionVS to the following codes from CostShareOptionCS after-deductible no-charge no-charge-after-deductible charge coinsurance-not-applicable deductible-waived Change the following examples to use the  CostShareOptionCS Code System PayerInsurancePlanA1002 PayerInsurancePlanA3001 PayerInsurancePlanA3002 PayerInsurancePlanA3004t
    • Scott Robertson / Corey Spears: 14-0-1
    • Correction
    • Non-compatible

    Description

      The profile reasonably represents copay and coinsurance as distinct, but the codes for the two different copay and coinsurance-specific code systems use essentially the same mnemonic codes from two distinct code systems that differ in definition only by substituting the two context-aligned words "copay" or "coinsurance." this will lead to confusion and demand that the profile element be kept in mind when reviewing instance information that I suspect will often only be one or the other. Please merge the two code systems into one and change the overlapping code definitions to say "copy or coinsurance" where one or the other word appears. For example, the code after-deductible would be used for either copay and coinsurance by making the definition say "The consumer first pays the deductible, and after the deductible is met, the consumer is responsible only for the copay or coinsurance (this indicates that this benefit is subject to the deductible)."

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            Rob_McClure Rob McClure
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              Updated:
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