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  1. FHIR Specification Feedback
  2. FHIR-36574

Missing Benefits Determination prior to Coverage Requirements Discovery

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    • Icon: Change Request Change Request
    • Resolution: Not Persuasive
    • Icon: Highest Highest
    • US Da Vinci CRD (FHIR)
    • 1.1.0-ballot [deprecated]
    • Financial Mgmt
    • STU
    • Technical Background
      Use Cases and Overview
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      There is no presumption there are benefits.  CRD can indicate that the service is covered or not, as well as covered but requires prior authorization - see the codes listed here: https://build.fhir.org/ig/HL7/davinci-crd/CodeSystem-coverageGuidance.html

      The example we're agreeing to add in FHIR-36576 should help clarify this.

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      There is no presumption there are benefits.  CRD can indicate that the service is covered or not, as well as covered but requires prior authorization - see the codes listed here:  https://build.fhir.org/ig/HL7/davinci-crd/CodeSystem-coverageGuidance.html The example we're agreeing to add in FHIR-36576 should help clarify this.
    • Bob Dieterle / Chris Cioffi : 12-0-0

    Description

      The workflow described assumes there are benefits for the covered service, especially when prior authorization is not required. To address this, the workflow should start with Benefits Determination as this would be necessary prior to determining what the coverage requirements are. This is the case for some specialty providers services, such as dietitians, depending on the insurance plan, as not all plans offer benefits for nutrition counseling.

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            bgradl Becky Gradl
            Becky Gradl
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              Updated:
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