Stream: implementers
Topic: FHIR Insurance Model
Aditya Joshi (Sep 05 2018 at 23:28):
Insurance policy data mapping in FHIR.
I understand that EligibilityResponse resource can provide details on benefits of a insurance plan. insurance.benefitBalance can map to various benefits of a plan.
Q1: Is insurance.benefitBalance is per category? definition states it is "Benefits by Category".
Q2.Then if subCategory element is populated along with category then would benefits still are for category or it is for sub category?
In other words, what is the way to represent benefits specific to sub categories.
Taking a insurance use case-
a. Benefit Category= MATERNITY
b. benefits per use case= benefits for Inpatient and Outpatient (like limit for each of them)
c. benefits for sub services like= limit for Miscarriage/Legal Abortion, normal delivery etc.
Plan mentions all above 3 things separately. I can easily map a. to insurance.benefitBalance.category and associated limit, copay etc. under insurance.benefitBalance.financial
But how to map or handle b. and c. scenarios in FHIR?
Any thoughts or help would be great. Thanks.
Lloyd McKenzie (Sep 05 2018 at 23:31):
@Paul Knapp
Aditya Joshi (Sep 24 2018 at 15:48):
Hi @Paul Knapp could you please see my request for this question. Would be great to hear your thoughts.
Paul Knapp (Sep 24 2018 at 16:08):
@Aditya Joshi Please see the R4 version of CoverageEligibilityResponse including examples where the subcategory has been removed.
Q1: It is by category where the category may contain multiple level of granularity as appropriate for the jurisdiction, e.g. medical or maternity or normal delivery/Caesarian.
Q2 The above covers cases A and C, we would need to consider handling via different category codes, maternity inpatient vs maternity outpatient, or adding a 'setting code 'inpatient|outpatient|other' or an inpatient flag.
If you are using R3 I suggest adding an inpatient Boolean extension, we will discuss in Baltimore next week, are you attending the WGM?
Aditya Joshi (Sep 29 2018 at 18:36):
Thanks a lot for your response @Paul Knapp . So, your suggestion is to my own code for insurance.benefitBalance.category in EligibilityResponse to define "MATERNITY-Normal Deliver", or "MATERNITY-Legal Abortion", so each specific type would be represented with its own code. Is that correct?
I am not clear on R4 changes, I checked "https://hl7.org/fhir/2018Jan/eligibilityresponse.html" and it still has subCategory element under benefitBalance. Also, there is an example with subCategory- https://hl7.org/fhir/2018Jan/eligibilityresponse-example-benefits.json.html
I am in India, so not possible to attend WGM.
Thanks.
Aditya Joshi (Sep 29 2018 at 18:50):
Hi @Paul Knapp Questions related to Claim Resource
1. item.serviceDate : can it be a future date when claim.use=proposed but definition says "The date or dates when the enclosed suite of services were performed or completed."
Then where to define future date when service would be provided (like in case of planned surgeris while sending pre-auth type of claim).
2. Observations in Claim Resource Click to join video call : How to mention vitals, cheif complaint, investigations, radiology report or any other kind of Observation (except Diagnosis and Procedure, as these have discrete elements available) in Claim resource?
Is claim.information.valueReference is the way?
Paul Knapp (Oct 08 2018 at 12:43):
1) .item.serviceDate can be left out or in the future for preauthorizations and predeterminations.
2) Yes, .information is the right place for additional information.
Aditya Joshi (Oct 15 2018 at 18:04):
Thanks @Paul Knapp . but in case provider or hospital sending fix future date when they have planned service, is it fine to map those dates to serviceDate.
Aditya Joshi (Oct 15 2018 at 18:05):
Hi @Paul Knapp
Which resource to use for ApprovalInquiry (to check pre auth status)?
Context: Provider send Approval request (claim type of "proposal") for pre authorization of some services. Insurance company send back ApprovalResponse (may be with status- Pending).
After couple of days, Provider wants to check what happened with is their ApprovalRequest.
Is it Task resource or can we use Claim only with reference to previous Claim (using related.claim reference element)?
Aditya Joshi (Oct 21 2018 at 15:45):
Hi @Paul Knapp awaiting for your kind response.
Is it ProcessRequest and ProcessResponse I should look for this use case?
Paul Knapp (Oct 22 2018 at 10:16):
@Aditya Joshi It is/was ProcessRequest with an action=status, we are changing it to a Task with code=status. CHanges should be in place by Nov 5.
Aditya Joshi (Oct 22 2018 at 12:10):
Thanks @Paul Knapp . Will these changes going to be available in STU3 or only in R4 version of FHIR?
Paul Knapp (Oct 22 2018 at 12:12):
@Aditya Joshi Changes only in R4 - R3 is frozen other than technical corrections.
Aditya Joshi (Oct 22 2018 at 12:19):
So for R3 (STU3), ProcessRequest and Response are the resources to go for this purpose?
Paul Knapp (Oct 22 2018 at 16:18):
Yes
Aditya Joshi (Oct 22 2018 at 17:25):
Thanks
Aditya Joshi (Nov 22 2018 at 15:03):
Hi @Paul Knapp
What is the difference or usage of ClaimResponse.item v/s ClaimResponse.addItem.
item does not have service code element to define adjudication is related to which service. addItem does have service element. I can think of writing adjudication of a particular service mentioned in Claim resource using ClaimResponse.additem but confused on what is the purpose of ClaimResponse.item element. Thanks for your help and time.
As ClaimResponse.item does not have service element to define service code, "sequenceLinkId" is the key to link each claim item (each service in Claim resource)?
So, ClaimResponse.=sequenceLinkId=Claim.sequence ??
is that a way to link specific service mentioned in Claim resource to its response (adjudication of this service)?
ClaimResponse.addItem: is this used to provide further details by Insurers. For example, Claim is for some surgery which involves multiple small procedures. Provider sent a Claim with one service instance mentioning surgery. Insurer in response can provide adjudication of this surgery service under ClaimResponse.item, and, if they break down surgery to multiple small procedures and want to respond how much they are paying for each small part of that surgery then they can use ClaimResponse.addItem? Is that right?
Can anyone help in understanding this? @Grahame Grieve , @Paul Knapp , @Lloyd McKenzie . Thanks.
Paul Knapp (Nov 25 2018 at 06:26):
Hi @Aditya Joshi: ClaimResponse.item contain the adjudication details for the matching item in the Claim (where Claim.item.sequence=ClaimResponse.item.itemSequence (or .sequenceLinkId - the element name has evolved).
Sometimes a provider submits a code for a package of services which the insurer adjudicates individually. In that case the insurer would adjudicate the Claim.item to $0.00 and add in one or more .addItem elements which both refer to the original Claim.item.sequence and provide the product or service billing code and adjudication details.
For example, the claim may have item sequence=1, billing code=ABC123, net=$100.00 where the insurer adjudicates to $0.00 and provides 2 additems: additem.itemSequence=1, billing code=ABC101, net=$65.00 and additem.itemSequence=1, billing code=ABC202, net=$35.00, each with their adjudication details.
See the "A ClaimResponse demonstrating Payor service code substitutions" example in the current build (or any R4 builds) for a full example.
Aditya Joshi (Nov 26 2018 at 11:22):
Thanks a lot @Paul Knapp Understood the concept. It is good to see that there are now 4 examples for ClaimResponse in R4 version. In STU3, there is only one example.
Just a thought- Also, it would be good to have ClaimResponse example related to any Claim example, that would give real understanding on how Claim is adjudicated and represented in ClaimResponse in FHIR.
Aditya Joshi (Nov 26 2018 at 11:27):
Hi @Paul Knapp
Could not find how ClaimResponse would handle approval timeline (duration for which pre-auth approval is valid)?
Scenario- Provider submits a pre-auth Claim. Insurer responded with approval but that approval is valid for another 15 days. I guess this is real world use case also, approval cannot be of lifetime. How this 15 days of time period for approval (on pre-auth request) would be shown in ClaimResponse resource?
Thanks.
Paul Knapp (Nov 26 2018 at 12:29):
@Aditya Joshi The example I mentioned ( "A ClaimResponse demonstrating Payor service code substitutions" ) is a response to the "Claim Oral Average" example. Often this is documented in the .text element at the top of the resource.
ClaimResponse.PreAuthPeriod is the validity period for the preauthorization.
Aditya Joshi (Nov 26 2018 at 12:39):
Thanks @Paul Knapp
Ah! my bad, Got it, it is in the current build- https://build.fhir.org/claimresponse.html.
Earlier, I was looking at R4 Jan 2018 version. So, PreAuthPeriod is newly added and would be available from R4 release. If I am not wrong, it is not available in STU3.
Good to see R4 coming up with these elements, this will help to reduce extension elements used in STU3. Thanks.
Last updated: Apr 12 2022 at 19:14 UTC
