Stream: implementers
Topic: ExplanationOfBenefit.type for durables
Michele Mottini (Jun 26 2019 at 15:42):
ExplanationOfBenefit.type binds to http://hl7.org/fhir/valueset-claim-type.html - as required in STU3 and extensible in R4. What would be the correct code there for a durable medical equipment claim? (eg insulin pump)
Lloyd McKenzie (Jun 26 2019 at 16:00):
@Paul Knapp @MaryKay McDaniel @Andy Stechishin
Andy Stechishin (Jun 26 2019 at 18:40):
@Michele Mottini for the ExplanationOfBenefit.type the simple answer is you should probably use the same value as is recorded on the related Claim. The answer becomes somewhat more complex when you don't have the original Claim or are also creating the Claim. If the device was provided in or during a hospital stay, this would be an institutional type, from a doctor's office, a professional and finally from a pharmacy, a pharmacy type. The type is indicative of the business practices for that section of the business domain. Hospitals (institutional) want to send everything at once, dozens of items including pharmaceuticals, services and sundry items. Pharmacies usually send claims with single items (visiting a pharmacy to get 3 prescriptions filled will result in 3 separate claims). Hope this helps
Michele Mottini (Jun 26 2019 at 19:06):
Thanks Andy, that's helpful. @Karl M. Davis ^
Andy Stechishin (Jun 26 2019 at 19:11):
I made no assumptions about WHO is allowed to dispense the device as this would vary from jurisdiction to jurisdiction
Karl M. Davis (Jul 04 2019 at 18:09):
Based on my (imperfect!) understanding of CMS' Medicare claims & business practices, this likely won't work for Blue Button: I cannot recall seeing a field that distinguishes what scenario/setting that DME claims are associated with.
Put another way: for Blue Button, DME claims are top-level and standalone. Accordingly, we are not currently mapping EOB.type to a http://hl7.org/fhir/valueset-claim-type.html value for them.
Very open to suggestions and ideas on this!
Andy Stechishin (Jul 04 2019 at 18:38):
I am wondering what @Mark Scrimshire did when he exposed the EOB in the FHIR Blue Button interface? I think he would have encountered this situation
Andy Stechishin (Jul 04 2019 at 18:40):
Is there anything here: https://bluebutton.cms.gov/developers/#core-resources that addresses this?
Andy Stechishin (Jul 04 2019 at 18:45):
@Karl M. Davis there is a profile specifically for the DME claims in Blue Button 2.0: https://bluebutton.cms.gov/assets/ig/StructureDefinition-bluebutton-dme-claim.html but it does not add anything to the discussion on type
Karl M. Davis (Jul 06 2019 at 11:40):
:laughing: I need to up my branding game, I guess -- I work with Mark on Blue Button, and I'm the one who made all those mapping decisions.
And yes, I did encounter this situation, which is why I asked about it.
Paul Knapp (Jul 12 2019 at 17:29):
@Lloyd McKenzie If the durables are supplied within an existing type then use that type, if they are being supplied purely from a supplier of durable goods then I'd use the 'professional' unless there is a compelling need to create an additional type of claim..
Last updated: Apr 12 2022 at 19:14 UTC
