Stream: implementers
Topic: ExplanationOfBenefit - secondary insurance payment info
jassy (May 02 2017 at 21:49):
Beside a primary insurance payment, it is quite common to have a secondary and in rare case a tertiary plan coverage payment (and including similar set of info such as co-insurance, co-payment, deductible, etc., that apply to non-primary payment processing). Is it something we would/could consider for ExplanationOfBenefit (EOB) resource? The data could be in both EOB level and Item level.
Paul Knapp (May 04 2017 at 06:59):
Each insurer could/would issue an EOB. Also, each insurer would issue a ClaimResponse. So if you have a 4th insurer in a Coordination of Benefit chain they would receive a Claim which contains a list of all coverages and includes the ClaimResponses for each of the preceding coverages. The EOB is a statement from an insurer as to what they received and their per item adjudication details, plus optional plan-account balances. The adjudication details could include the total payable by preceding insurers.
Can you give us examples of standards which already support the provision of adjudication information about other insurers in a given insurer's EOB?
jassy (May 05 2017 at 20:38):
I send an example to @paul. The adjudication details under EOB item property can be used for Coordination of Benefit (COB) of a service. However, there is no property under EOB level can apply for total COB. Also, what is intended usages for addItem and could it be applied for COB?
Last updated: Apr 12 2022 at 19:14 UTC
