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  1. FHIR Specification Feedback
  2. FHIR-34955

Network status in advanced EOB profile

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    • Icon: Change Request Change Request
    • Resolution: Persuasive with Modification
    • Icon: Medium Medium
    • US Da Vinci Patient Cost Transparency (PCT) (FHIR)
    • 0.1.0 [deprecated]
    • Financial Mgmt
    • STU
    • PCT Advanced EOB
    • 7.3.1
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      Bind ExplanationOfBenefit.adjudication.category to PCTAdjudictionCategoryVS (extensible)

       

      Bind ExplanationOfBenefit.item.adjudication.category to PCTAdjudictionCategoryVS (extensible)

       

      Make ExplanationOfBenefit.adjudication MS

       

      Create the following slices on Profile davinci-pct-aeob

      Billing Network Status

      • ExplanationOfBenefit.adjudication[billingnetworkstatus] 0..1 MS "Billing Provider Network Status"
        • With reason codes binding to PCTPayerProviderNetworkStatusVS

      Rendering Network Status

      • ExplanationOfBenefit.adjudication[renderingnetworkstatus] 0..1 MS "Rendering Provider Network Status"
        • With reason codes binding to PCTPayerProviderNetworkStatusVS

       

      Benefit Payment Status

      • ExplanationOfBenefit.adjudication[benefitpaymentstatus] 0..1 MS "Benefit Payment Status"
        • With reason codes binding to PCTPayerBenefitPaymentStatusVS

       

      • ExplanationOfBenefit.item.adjudication[benefitpaymentstatus] 0..1 MS "Benefit Payment Status" (Description "Line level benefit payment status associated with professional claim estimates only.")
        • With reason codes binding to PCTPayerBenefitPaymentStatusVS

       

      Adjustment Reason

      • ExplanationOfBenefit.adjudication[adjustmentreason] 0..* MS "Adjustment Reason"
        • With reason codes binding to PCTAdjustmentReasonVS

       

      • ExplanationOfBenefit.item.adjudication[adjustmentreason] 0..* MS "Adjustment Reason"
        • With reason codes binding to PCTAdjustmentReasonVS

       

       

       

      Create the CodeSystem and ValueSet 

      id: PCTAdjudictionCategory(CS/VS) (Renaming the ValueSet PCTGFEItemAdjudicationVS to PCTAdjudicationCategoryVS and PCTAdjudicationCategoryType to PCTAdjudicationCategoryCS)

      Title: PCT Adjudication Category

      Description: Codes indicating the type of adjudication information provided.

      Codes:

      Code Display Definition
      billingnetworkstatus Billing Network Status Indicates the Billing Provider network status in relation to the patient's coverage.
      renderingnetworkstatus Rendering Network Status Indicates the Rendering Provider network status in relation to the patient's coverage.
      benefitpaymentstatus Benefit Payment Status Indicates the in network or out of network payment status of the claim.
      adjustmentreason Adjustment Reason Defines the adjudication slice to identify the adjustment reason

       

      Create the CodeSystem 

      id: PCTNetworkStatusCS

      Title: PCT Network Status

      Description: Indicates the network  status in relation to a patient's coverage.

      Codes:

      Code Display Definition
      innetwork In Network Indicates an in network status in relation to a patient's coverage
      outofnetwork Out Of Network Indicates a not in network status in relation to a patient's coverage
      other Other Indicates other network status or when a network does not apply

       

      Create the ValueSet 

      id: PCTPayerProviderNetworkStatusVS

      Title: PCT Payer Provider Network Status

      Description: Indicates the Provider network status with the Payer as of the effective date of service or admission.

      Codes: (from PCTNetworkStatusCS)

      Code Display Definition
      innetwork In Network Indicates an in network status in relation to a patient's coverage
      outofnetwork Out Of Network Indicates a not in network status in relation to a patient's coverage

       

      Create the ValueSet 

      id: PCTPayerBenefitPaymentStatusVS

      Title: PCT Payer Benefit Payment Status

      Description: Indicates the in network or out of network payment status of the claim or line item.

      Codes:  ** (from PCTNetworkStatusCS)

      Code Display Definition
      innetwork In Network Indicates an in network status in relation to a patient's coverage
      outofnetwork Out Of Network Indicates a not in network status in relation to a patient's coverage
      other Other Indicates other network status or when a network does not apply

       

       

      Create the  ValueSet 

      id: PCTAdjustmentReasonVS

      Title: PCT Adjustment Reason

      Description: Codes indicating reasons why a claim or line item is adjusted.

      Codes:

       

       

      All Code Systems defined by the IG in this ticket will have the id appended to with the string "-TEMPORARY-TRIAL-USE" 

      If CodeSystems and ValueSets are added to THO before approval for publishing, the relevant CodeSystems and ValueSets will be deleted and the binding will be changed appropriately.

      Show
      Bind ExplanationOfBenefit.adjudication.category to PCTAdjudictionCategoryVS (extensible)   Bind ExplanationOfBenefit.item.adjudication.category to PCTAdjudictionCategoryVS (extensible)   Make ExplanationOfBenefit.adjudication MS   Create the following slices on Profile davinci-pct-aeob Billing Network Status ExplanationOfBenefit.adjudication [billingnetworkstatus] 0..1 MS "Billing Provider Network Status" With reason codes binding to PCTPayerProviderNetworkStatusVS Rendering Network Status ExplanationOfBenefit.adjudication [renderingnetworkstatus] 0..1 MS "Rendering Provider Network Status" With reason codes binding to PCTPayerProviderNetworkStatusVS   Benefit Payment Status ExplanationOfBenefit.adjudication [benefitpaymentstatus] 0..1 MS "Benefit Payment Status" With reason codes binding to PCTPayerBenefitPaymentStatusVS   ExplanationOfBenefit.item.adjudication [benefitpaymentstatus] 0..1 MS "Benefit Payment Status" (Description "Line level benefit payment status associated with professional claim estimates only.") With reason codes binding to PCTPayerBenefitPaymentStatusVS   Adjustment Reason ExplanationOfBenefit.adjudication [adjustmentreason] 0..* MS "Adjustment Reason" With reason codes binding to PCTAdjustmentReasonVS   ExplanationOfBenefit.item.adjudication [adjustmentreason] 0..* MS "Adjustment Reason" With reason codes binding to PCTAdjustmentReasonVS       Create the CodeSystem and ValueSet   id: PCTAdjudictionCategory(CS/VS) (Renaming the ValueSet PCTGFEItemAdjudicationVS to PCTAdjudicationCategoryVS and PCTAdjudicationCategoryType to PCTAdjudicationCategoryCS) Title: PCT Adjudication Category Description: Codes indicating the type of adjudication information provided. Codes: Code Display Definition billingnetworkstatus Billing Network Status Indicates the Billing Provider network status in relation to the patient's coverage. renderingnetworkstatus Rendering Network Status Indicates the Rendering Provider network status in relation to the patient's coverage. benefitpaymentstatus Benefit Payment Status Indicates the in network or out of network payment status of the claim. adjustmentreason Adjustment Reason Defines the adjudication slice to identify the adjustment reason   Create the CodeSystem   id: PCTNetworkStatusCS Title: PCT Network Status Description: Indicates the network  status in relation to a patient's coverage. Codes: Code Display Definition innetwork In Network Indicates an in network status in relation to a patient's coverage outofnetwork Out Of Network Indicates a not in network status in relation to a patient's coverage other Other Indicates other network status or when a network does not apply   Create the ValueSet   id: PCTPayerProviderNetworkStatusVS Title: PCT Payer Provider Network Status Description: Indicates the Provider network status with the Payer as of the effective date of service or admission. Codes: (from PCTNetworkStatusCS) Code Display Definition innetwork In Network Indicates an in network status in relation to a patient's coverage outofnetwork Out Of Network Indicates a not in network status in relation to a patient's coverage   Create the ValueSet   id: PCTPayerBenefitPaymentStatusVS Title: PCT Payer Benefit Payment Status Description: Indicates the in network or out of network payment status of the claim or line item. Codes:   ** (from PCTNetworkStatusCS) Code Display Definition innetwork In Network Indicates an in network status in relation to a patient's coverage outofnetwork Out Of Network Indicates a not in network status in relation to a patient's coverage other Other Indicates other network status or when a network does not apply     Create the  ValueSet   id: PCTAdjustmentReasonVS Title: PCT Adjustment Reason Description: Codes indicating reasons why a claim or line item is adjusted. Codes: Include all codes defined in  https://x12.org/codes/claim-adjustment-reason-codes Include all codes defined in  https://x12.org/codes/remittance-advice-remark-codes     All Code Systems defined by the IG in this ticket will have the id appended to with the string "-TEMPORARY-TRIAL-USE"  If CodeSystems and ValueSets are added to THO before approval for publishing, the relevant CodeSystems and ValueSets will be deleted and the binding will be changed appropriately.
    • Corey Spears / Paul Knapp : 8-0-1
    • Correction
    • Non-compatible

    Description

      1. The in network or out of network payment status for the claim (institutional / professional) or service line (professional) is not included. Define as supportingInfo simiar to CARIN. Bind as required to C4BB Payer Benefit Payment Status
      2. Payers may reject the entire claim from a provider or specific non-covered items. This needs to be reflected in the data structure. Use CARC / RARC and .notes like that now done by the CARIN IG.

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            deroode David DeRoode
            sundine Sam Undine (Inactive)
            Patricia Taylor, Sam Undine (Inactive)
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            Dates

              Created:
              Updated:
              Resolved: