Stream: implementers
Topic: Provider for Carrier and Part-D Event Claims
Brady Fausett (Oct 07 2021 at 18:05):
I'm wondering how others have handled the mapping for the eob.provider (R4), which is required, for Carrier and Part-D Events (Medication) claim types.
For Carrier claims it's possible that an EoB will have several claim line items, potentially from different providers, so which provider is used to in the eob.provider field for the over-arching EoB that contains/or could contain, multiple claims?
For Medication claims is the eob.provider the prescribing provider or the pharmacy filling the order?
Any thoughts and suggestions are appreciated!
Lloyd McKenzie (Oct 07 2021 at 18:34):
@Paul Knapp
Brady Fausett (Oct 25 2021 at 15:36):
Brady Fausett said:
I'm wondering how others have handled the mapping for the eob.provider (R4), which is required, for Carrier and Part-D Events (Medication) claim types.
For Carrier claims it's possible that an EoB will have several claim line items, potentially from different providers, so which provider is used to in the eob.provider field for the over-arching EoB that contains/or could contain, multiple claims?
For Medication claims is the eob.provider the prescribing provider or the pharmacy filling the order?
Any thoughts and suggestions are appreciated!
Anybody have some thoughts on this that they could share? Thank you!
Lloyd McKenzie (Oct 25 2021 at 18:44):
@Paul Knapp
Paul Knapp (Oct 25 2021 at 20:09):
@Brady Fausett It would be the billing provider. For rendering providers who may have provided the services on different claim lines you would use the Claim.careTeam.provider.
Brady Fausett (Oct 25 2021 at 20:50):
Thank you @Paul Knapp . For PDE, it's pretty easy and straightforward, after doing more digging into the actual data and your answer matches up for that (Part-D Event). For Carrier Claims, it gets more difficult. A carrier claim will have multiple claim lines that end up composing the entire eob structure. Currently I do have all the different providers being listed in the eob.careTeam correctly. However, the eob.provider is required in R4 and it's hard to determine which of the providers to use for this field as there 'may' be different providers per line item that are associated with the single eob. Does that make sense? Thoughts?
MaryKay McDaniel (Oct 25 2021 at 22:56):
@Brady Fausett Just to confirm you are talking about the Medicare Prescription Drug Event (PDE) and the PDE Data Elements that are sent to CMS?
Brady Fausett (Oct 26 2021 at 14:18):
@MaryKay McDaniel Correct PDE = Medicare Part-D Event claim.
MaryKay McDaniel (Oct 26 2021 at 14:40):
Thanks Brady! I've not spent any time with the CMS layout for PDE reporting and it wasn't reviewed when we built out the claim resource. If you have questions, please feel free to pop on one of the Financial Management weekly calls (Tuesday AM at 11am call logistics in the HL7 conference calendar). We're happy to help.
Last updated: Apr 12 2022 at 19:14 UTC
