FHIR Chat · Service Line Claim Adjudication in FHIR Response Resource

Stream: implementers

Topic: Service Line Claim Adjudication in FHIR Response Resource

Aditya Joshi (Aug 24 2016 at 14:52):

Hi All, I am mapping and converting my 835 message to FHIR Claim Response resource. I am bit confused about where to map adjudicated results. There are two elements in Claim Response resource - item and another is addItem. Both providing adjudication elements. addItem also provides way to write service line item code (Procedure code) and original fee for this service. Same is not available in item. Definition of addItem says- Insurer added line items. Not clear what it is. Could someone guide difference in these two elements and which one to chose for writing service line amount adjudication data. thanks. Aditya

Andy Stechishin (Aug 24 2016 at 15:18):

@Aditya Joshi the item on the ClaimResponse points directly to the item on the Claim where there is a one to one correspondence this is where the data should go.

The reason addItem contains the procedure, etc. is that addItems or additional items or replacements items are meant for the situation where the Claim contains a line for 'A' and a line for 'B' but the adjudication has substituted 'X' which replaces 'A' and 'B'

Andy Stechishin (Aug 24 2016 at 15:20):

@Aditya Joshi If you need to show both claim and claim response data, the ExplanationOfBenefit is the resource to use

Aditya Joshi (Aug 24 2016 at 17:14):

@Andy Stechishin thanks a lot. but what if there are multiple service line items with Adjudicated amounts under one claim in 835 message, then how to link each service line to item in FHIR.

Andy Stechishin (Aug 24 2016 at 17:20):

@Aditya Joshi each service line would become an item, you can have multiple items, so I am not sure where your problem lies. FM has not mapped the 835 yet so I can't definitively state

Paul Knapp (Aug 24 2016 at 17:22):

Hi Aditya: Each line (claim.item) on a claim has a sequence number, and each line (claimresponse.line) has sequenceLinkId which will match the sequence number of the line in the original claim.

Paul Knapp (Aug 24 2016 at 17:24):

Actually we have done partial mapping to the 837/835 via mapping to CMS1500, and partial 837/835 review, and mapping to V3 which was mapped to X12 and we also have a xWalk being done now.

Aditya Joshi (Aug 25 2016 at 07:29):

@Paul Knapp thanks a lot. Probably I got my answer. I wanted to link each service line item to claimresponse.item element. Yes, I understand that item in FHIR has sequenceLinkId element, does it map to LX*1 segment sequence number? Can we have below structure for 835-

LX*1~
CLP500001145.545.5*OF1234567~
NM1QC1KINGRONALDMIQMXMB161756~
REFG113579~
SVCHC:99211100045.51~
DTM47212/20/1999 0:00~
CASPR134.52*0315~
LX*2~
CLP500001145.545.5*OF1234567~
NM1QC1KINGRONALD*MIQMXMB161756~
REFG113579~
SVCHC:99211100045.5*1~
DTM47212/20/1999 0:00~
CASPR134.52*0315~

And you want to say that number in LX segment would map to claimresponse.item.sequenceLinkId?

Paul Knapp (Aug 25 2016 at 07:37):

yes, the 1 in LX*1 would be the sequence number (I think from my recollection of X12. I think your example shows 2 services lines (both repprting service HC:99211 for $45.50 - made up data, not actually expected to be for the same service code in real instances).
The Claim would have:
Sequence 1: Service 123, cost 45.50, etc.
Sequence 2: Service 456, cost 65.50, etc.
Sequence 3: Service 789, cost 100.00, etc.

The Claim Response would have:
SequenceLinkId: 1: Eligibile 45.50, Co-pay 0%, Benefit% 100%, Benefit 45.50

SequenceLinkId: 2: Eligibile 60.0, Co-pay 20%, Benefit% 100%, Benefit 48.00

SequenceLinkId: 3: Eligibile 0, Benefit 0.00

Additem 1 SequenceLinkId: 3: Service ABC123 Cost 75.00, Co-pay 10%, Benefit% 100%, Benefit 67.50
Additem 2 SequenceLinkId: 3: Service ABC400 Cost 25.00, Co-pay 0%, Benefit% 50%, Benefit 12.50

Aditya Joshi (Aug 25 2016 at 07:42):

Thanks for quick response. On same data- is it not possible that same service provided at two different times? In such case, service code, amount would be same for both service line, yes date of service can be different. Right now I have made up this example, that is why date is also not coming correctly. All though, I didn't know how to represent time in date inside DTM segment, as all I could understand is that I can write date in CCYYMMDD format (CC is year only). As you look X12 expert, could you please verify that my last structure of 835 is correct or not?

Paul Knapp (Aug 25 2016 at 07:59):

Oh, I'm not an X12 expert, but I'll see if can pass your example to someone who is. Yes, theoretically you could have the same service listed twice, but only in special circumstances - for example is code 12331 was for 1 unit of service and 12332 was for 5 units of service then if a patient received 7 units of service you may have to bill for 1 x 12332 and 2 x 12331. Otherwise generally a service to the same body pat will only occur once or you will need to provide an override code - patient breaks arm and has a cast applied, walks out of hospital and falls down breaking cast, re-enters hospital and has a cast applied.

Aditya Joshi (Aug 25 2016 at 08:01):

Thanks for all your inputs. I am also bit new to X12 and difficulty is that X12 specs are not free like HL7 standards :)

Paul Knapp (Aug 25 2016 at 08:03):

I have passed you sample snippet on, but they are in the US where it is just after midnight so I don't expect an answer back for about 10 hours - but I'll post here when I get something. BTW what country are you in?

Aditya Joshi (Aug 25 2016 at 08:05):

Thanks a lot. I live in India.

Paul Knapp (Aug 25 2016 at 08:06):

Thats what I thought. I'm in Saudi Arabia currently which explains why we are both working.

Aditya Joshi (Aug 25 2016 at 08:07):

True :) Its just an afternoon for both of us

MaryKay McDaniel (Aug 25 2016 at 17:37):

Hi all,

MaryKay McDaniel (Aug 25 2016 at 17:37):

I'm not sure what you were trying to do with the 835, but is it close

MaryKay McDaniel (Aug 25 2016 at 17:37):

OK, so every transaction tells a story. Without insight into the story you are trying to tell – or what the claim looked like…
it wouldn't pass validation ...

What you have created are 2 claims, with the same claim number (1234567), each with 1 claim line.

LX*1~
CLP*500001*1*1000*45.5**OF*1234567~
Total Billed: 1000
Total Paid: 45.5
NM1*QC*1*KING*RONALD****MI*QMXMB161756~
REF*G1*13579~
SVC*HC:99211*1000*45.5**1~
DTM*472*CCYYMMDD~
CAS*PR*1*940.5*3*15~
Each claim has to balance. So if the billed amount was 1000, then there has to be an offset.

LX*2~
CLP*500001*1*1000*45.5**OF*1234567~
NM1*QC*1*KING*RONALD****MI*QMXMB161756~
REF*G1*13579~
SVC*HC:99211*1000*45.5**1~
DTM*472*CCYYMMDD~
CAS*PR*1*940.5*3*15~
CO=contractual obligations,
PR=Patient Responsibility
1 = Deductible
3 = Co-Pay

Aditya Joshi (Aug 26 2016 at 16:00):

this is an example, I wanted to understand how to repeat things in 835 message. Should I repeat like I did in my sample- repeating Claim segment and related service and adjudication segment (CAS). Or there is another way where for one claim we can repeat SVC and CAS. "Don't know how to create 835 for same claim but multiple service line adjudications."

Paul Knapp (Aug 27 2016 at 09:46):

<item>

</item>
<item>

</item>

Paul Knapp (Aug 27 2016 at 09:46):

The above example shows teh adjudication for 2 service lines.

Aditya Joshi (Aug 28 2016 at 09:54):

thanks Paul, I understand FHIR part, not clear about 835 part.

Paul Knapp (Aug 28 2016 at 13:08):

I'll check with Mary Kay and get back to you.

Last updated: Apr 12 2022 at 19:14 UTC

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FHIR Chat · Service Line Claim Adjudication in FHIR Response Resource · implementers

Stream: implementers

Topic: Service Line Claim Adjudication in FHIR Response Resource

Aditya Joshi (Aug 24 2016 at 14:52):

Andy Stechishin (Aug 24 2016 at 15:18):

Andy Stechishin (Aug 24 2016 at 15:20):

Aditya Joshi (Aug 24 2016 at 17:14):

Andy Stechishin (Aug 24 2016 at 17:20):

Paul Knapp (Aug 24 2016 at 17:22):

Paul Knapp (Aug 24 2016 at 17:24):

Aditya Joshi (Aug 25 2016 at 07:29):

Paul Knapp (Aug 25 2016 at 07:37):

Aditya Joshi (Aug 25 2016 at 07:42):

Paul Knapp (Aug 25 2016 at 07:59):

Aditya Joshi (Aug 25 2016 at 08:01):

Paul Knapp (Aug 25 2016 at 08:03):

Aditya Joshi (Aug 25 2016 at 08:05):

Paul Knapp (Aug 25 2016 at 08:06):

Aditya Joshi (Aug 25 2016 at 08:07):

MaryKay McDaniel (Aug 25 2016 at 17:37):

MaryKay McDaniel (Aug 25 2016 at 17:37):

MaryKay McDaniel (Aug 25 2016 at 17:37):

Aditya Joshi (Aug 26 2016 at 16:00):

Paul Knapp (Aug 27 2016 at 09:46):

Paul Knapp (Aug 27 2016 at 09:46):

Aditya Joshi (Aug 28 2016 at 09:54):

Paul Knapp (Aug 28 2016 at 13:08):