Stream: implementers
Topic: FHIR Claim Response - Item VS Add_Item
Varvara (Dec 11 2017 at 17:03):
Does anyone have an experience on a usage of ClaimResponse resource for remittance advice from healthcare insurance companies? We are trying to map it with x12 electronic remittance advice, but we are not sure about the usage of ClaimResponse.item VS ClaimResponse. add_item objects, can you give some explanations or examples on this topic?
Lloyd McKenzie (Dec 11 2017 at 17:04):
@Paul Knapp
Paul Knapp (Dec 11 2017 at 17:41):
@Varvara The ClaimResponse.items are the adjudications of the Claim.items. In some cases, for example if a Claim.item represents a group of services, an insurer will adjudicate the Claim.item at $0 and replace it with several new items representing the individual items in the group and provide both the new items and their adjudications in the ClaimResponse.addItem element. Note that each additem contains references back to the line item or detail which it is replacing.
nicola (RIO/SS) (Dec 11 2017 at 19:13):
@Paul Knapp is anybody working on X12 => ClaimResponse and Claim => X12? Potentially we (@Varvara ) could share our results with community. I think, it can be placed at "Mapping" tab of Claim[Response] resources.
nicola (RIO/SS) (Dec 11 2017 at 19:16):
Why ClaimResp.item does not have .service element as addItem does? As i understand, this is a right place for CPT code?
Paul Knapp (Dec 11 2017 at 21:21):
@nicola (RIO/SS) The Financial Management Work Group has reached out to X12 and the senior levels of both X12 and HL7 are trying to connect to allow such a mapping to proceed in a manner which respects both organizations, their IP etc. We would not post such a mapping on an open forum as that would violate X12 IP.
If you check the existing mappings to UB04 and CMS1500 you will find that the representation required to provide a complete mapping is more than can be effectively represented in a FHIR mapping column so we provided a spreadsheet multi-column representation on the HL7 wiki with links provided on the claim.html page.
ClaimResponse.item does not have .service because it is already specified on the referred to Claim.item, but additems.item does need to specify the new .service. For example, if Claim.item.sequence=1, .service=1500 is for a package of services including an exam and an xray, the insurer may adjudicate this as benefit=$0.00 and create two addItems:
addItem.sequence=1, .itemSequence=1, .service=1100 (exam), benefit=$50.00, and
addItem.sequence=2, .itemSequence=1, .service=5401 (xray), benefit=$125.50.
Bettina Lieske (Mar 16 2018 at 10:57):
@Paul Knapp Thanks for mentioning the the spreadsheet with the mapping to FHIR on the HL7 wiki. Could you please provide the link to it? Thanks a lot.
Paul Knapp (Mar 16 2018 at 13:31):
@Bettina Lieske Mappings are currently maintained by the Financial Management Work Group to UB04 and CMS1500 and are available at http://wiki.hl7.org/index.php?title=Financial_Management_FHIR_Resource_Development .
Bettina Lieske (Mar 16 2018 at 14:30):
Thanks a lot!
Varvara (Sep 14 2018 at 12:46):
Hi, @Paul Knapp , could you please advise where to put subsequent payer information in ClaimResponse in case when claim was adjudicated by the first payer and then forwarded to another payer ?
Paul Knapp (Sep 14 2018 at 13:12):
Hi @Varvara in ClaimResponse.insurance.claimResponse for the 2nd instance which refers to the other coverage and for which focal=false.
Last updated: Apr 12 2022 at 19:14 UTC
