Details
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Change Request
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Resolution: Persuasive
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Medium
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US Da Vinci PDex (FHIR)
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2.0.0-ballot
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Financial Mgmt
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PdexPriorAuth
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PDex Prior Authorization
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Bob Dieterle / Celine Lefebvre: 21-0-1
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Correction
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Compatible, substantive
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Yes
Description
PDEX defined their own code system to describe adjudication categories, for example:
| noncovered | http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS | Noncovered | The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. |
| priorpayerpaid | http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS | Prior payer paid | The reduction in the payment amount to reflect the carrier as a secondary payor. |
| paidbypatient | http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS | Paid by patient | The amount paid by the patient at the point of service. |
| paidtopatient | http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationCS | Paid to patient | paid to patient |
This looks very similar to an existing code system that describes adjudication categories:
| noncovered | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Noncovered | The portion of the cost of this service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. |
| priorpayerpaid | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Prior payer paid | The reduction in the payment amount to reflect the carrier as a secondary payor. |
| paidbypatient | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Paid by patient | The amount paid by the patient at the point of service. |
| paidtopatient | http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication | Paid to patient | paid to patient |
There should only be one code system (value set) that describes a clinical concept. In this case "adjudication category". Recommend using the existing code systems that define these terms instead of creating a pdex copy of them.
As is, either an implementer codes with pdex and fails carinbb OR codes carinbb and fails pdex OR puts both codes everywhere and becomes bloat.
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