FHIR Chat · Receiving insurance billing code data in a ClaimResponse · implementers

Stream: implementers

Topic: Receiving insurance billing code data in a ClaimResponse

Jim Cain (May 17 2018 at 15:43):

I have a pre-auth integration partner who has a need to send some insurance data in ClaimResponses when those responses indicate authorization. These data include billing frequency and period for the applicable CPT codes (S0353 and S0354, for those who are interested). Am I better off adding an extension to ClaimResponse to accommodate these, or using something like ChargeItem for them?

Thanks for any insights.

Lloyd McKenzie (May 17 2018 at 19:03):

@Paul Knapp ?

Kevin Olbrich (May 17 2018 at 19:19):

@Paul Knapp This is the same problem I was talking to you about at the WGM.

Paul Knapp (May 17 2018 at 21:11):

@Jim Cain @Kevin Olbrich and I discussed this today and the thinking is to add the normally-missing item elements such as quantity and to allow the period to be an extension.

Jim Cain (May 18 2018 at 15:13):

Here is a first attempt at adding an extension to addItem. The period and authorizationDate apply to both S0353 and S0354 codes, so in this example I include it in just one of them, rather than having an extra extension to ClaimResponse itself.

{
  "resourceType": "ClaimResponse",
  "addItem": [
    {
      "revenue": {
        "system": "http://www.ama-assn.org/go/cpt",
        "code": "S0353"
      },
      "extension": [
        {
          "url": "https://myUrlHere",
          "extension": [
            {
              "url": "frequency",
              "valuePositiveInt": 1
            },
            {
              "url": "period",
              "valuePeriod": {
                "start": "2018-06-01",
                "end": "2018-09-30"
              }
            },
            {
              "url": "authorizationDate",
              "valueDate": "2018-05-31"
            }
          ]
        }
      ]
    },
    {
      "revenue": {
        "system": "http://www.ama-assn.org/go/cpt",
        "code": "S0354"
      },
      "extension": [
        {
          "url": "https://myUrlHere",
          "extension": [
            {
              "url": "frequency",
              "valuePositiveInt": 4
            }
          ]
        }
      ]
    }
  ]
}

Does this look reasonable at all?

Kevin Olbrich (May 18 2018 at 16:03):

@Jim Cain I'd suggest using 'quantity' instead of 'frequency'

Jim Cain (Jun 14 2018 at 13:38):

@Paul Knapp Has there been any movement on adding the relevant attributes to ClaimResponse?

Paul Knapp (Jul 05 2018 at 11:26):

@Jim Cain This is a topic for next weeks FM conference call. I highlighted it on this weeks call.

Jim Cain (Jul 05 2018 at 13:59):

@Jim Cain This is a topic for next weeks FM conference call. I highlighted it on this weeks call.

@Paul Knapp Are you referring to the conference calls referenced on this page? http://wiki.hl7.org/index.php?title=Financial_Management

Paul Knapp (Jul 11 2018 at 11:29):

@Jim Cain Hi Jim: Was hoping to be on the FM call yesterday but other events intervened. I will try to progress this before next weeks FM call and we can review this then if you can attend.

Jim Cain (Jul 12 2018 at 13:17):

Ok thanks @Paul Knapp. I have next week's call on my calendar too.

Paul Knapp (Jul 12 2018 at 13:41):

@Jim Cain Great. I am working on those changes but the FHIR terminology service is down so I can't get a full check of the build, but once its up and I have I'll commit the changes and you can inspect. I have added elements in ClaimResponse.additem and add .additem.detail which provides a second tier to the line structure. Is 2 tiers sufficient or do you think we need 3 like in the claim?

Paul Knapp (Jul 16 2018 at 13:29):

@Jim Cain @MaryKay McDaniel I have committed to the FHIR current build changes so that now the ClaimResponse.additem contains more of the expected line elements and there is now a 3-tier structure matching the Claim 3-tier structure. Please review if you can in advance of Tuesday's FM call at 11AM eastern. Also the same structure changes have been applied to the ExplanationOfBenefit resource to keep it all in sync.

Jim Cain (Jul 17 2018 at 17:54):

@Paul Knapp I've looked at the new elements inside ClaimResponse.addItem and it looks useful to us. The only question I have is what CodeableConcept element would be appropriate for specifying a CPT code? Thanks!

Paul Knapp (Jul 17 2018 at 17:58):

@Jim Cain additem.service and .service in any other component

Last updated: Apr 12 2022 at 19:14 UTC