Uploaded image for project: 'FHIR Specification Feedback'
  1. FHIR Specification Feedback
  2. FHIR-35217

Updating / Cancelling AEOB Request

    XMLWordPrintableJSON

Details

    • Icon: Change Request Change Request
    • Resolution: Not Persuasive with Modification
    • Icon: Medium Medium
    • US Da Vinci Patient Cost Transparency (PCT) (FHIR)
    • current
    • Financial Mgmt
    • STU
    • GFE Reference
      PCT Advanced EOB
      PCT-GFE-Institutional-1
    • Formal Specification
    • 4.2.1
    • Hide

      Will add guidance to the "Use Cases and Overview" section 2.1 Use Cases, changing the text from:

      The below describes the process of initiating the creation of an AEOB and the process of receiving or retrieving an AEOB. Note: An AEOB includes all GFEs as well as other required information.

      to:

      This guide provides specifications enabling a provider to submit a Good Faith Estimate (GFE) Bundle including one or more Good Faith Estimates (Claim resources of type predetermination) along with supporting data (such as Patient, Coverage, etc.) to a payer. The payer can then use this information to generate an Advanced Explanation of Benefit Bundle including one or more Advanced Explanation of Benefits (ExplanationOfBenefit resources of type predetermination) along with supporting data that the patient, and possibly the GFE Bundle submitting provider, can retrieve to get an estimation of costs.  

      The primary use case for this guide is to enable the patient to have access to AEOBs for potential future medical services or items. Sharing this information with the original submitting provider may also be useful in facilitating conversations between patients and providers about their care and options. If this capability is supported by the implementer, the patient’s AEOB will be provided to the submitting provider using the same profiles in this guide. 

      This guide does not currently specify a means for providers to update or cancel a GFE submission. Rather, if there is new information that may materially affect the estimation, the provider would submit a new GFE Bundle.

      The below describes the process of initiating the creation of an AEOB, through submitting a GFE Bundle, and the process of receiving or retrieving an AEOB. Note: An AEOB includes all GFEs as well as other required information.

       

      Show
      Will add guidance to the "Use Cases and Overview" section 2.1 Use Cases, changing the text from: The below describes the process of initiating the creation of an AEOB and the process of receiving or retrieving an AEOB. Note: An AEOB includes all GFEs as well as other required information. to: This guide provides specifications enabling a provider to submit a Good Faith Estimate (GFE) Bundle including one or more Good Faith Estimates (Claim resources of type predetermination) along with supporting data (such as Patient, Coverage, etc.) to a payer. The payer can then use this information to generate an Advanced Explanation of Benefit Bundle including one or more Advanced Explanation of Benefits (ExplanationOfBenefit resources of type predetermination) along with supporting data that the patient, and possibly the GFE Bundle submitting provider, can retrieve to get an estimation of costs.   The primary use case for this guide is to enable the patient to have access to AEOBs for potential future medical services or items. Sharing this information with the original submitting provider may also be useful in facilitating conversations between patients and providers about their care and options. If this capability is supported by the implementer, the patient’s AEOB will be provided to the submitting provider using the same profiles in this guide.  This guide does not currently specify a means for providers to update or cancel a GFE submission. Rather, if there is new information that may materially affect the estimation, the provider would submit a new GFE Bundle. The below describes the process of initiating the creation of an AEOB, through submitting a GFE Bundle, and the process of receiving or retrieving an AEOB. Note: An AEOB includes all GFEs as well as other required information.  
    • Rachel Foerster/Rick Geimer: 11-0-0
    • Clarification
    • Non-substantive

    Description

      In the implementation guide, AEOB Bundles are given an unique identifier to pull the status and updates to the AEOB bundle. However, this implementation guide does not have anything defined related to updating or cancelling the AEOB request after it has been submitted. 

      In a real-world scenario, there will likely be many changes to the scheduled service throughout the time period leading up to the date of the service. Change in provider, date of service, and location could be enough to invalidate the previous AEOB. There could even be small changes to the service performed or additional services added on. The provider or institution could send this modification to the payers and give transparency of the changes to the patient.

      If there was a way to cancel or modify these requests, then the payer could potentially use the AEOB request to reliably keep track of scheduled services and pre-accumulate benefits across multiple future services. For example, hitting deductibles/MOOPs/insurance maximums across multiple AEOBs could significantly change the patient portion. Keeping track of these limits will give patients significantly more accurate estimates.

      Attachments

        Activity

          People

            Unassigned Unassigned
            terskine Tyler Erskine
            Watchers:
            2 Start watching this issue

            Dates

              Created:
              Updated:
              Resolved: