Stream: implementers
Topic: Use of ExplanationOfBenefit information and adjudication
Susan Crawford (Apr 13 2017 at 03:37):
What type of claims detail should go into ExplanationOfBenefit.information? Can it be used to capture details about a claim where separate placeholders are not available? Would 'information' include data that comes in on the claim from the provider? Would 'adjudication' be data that does not come in on the claim and occurs during the adjudication process?
Andy Stechishin (Apr 13 2017 at 03:55):
@Susan Crawford the adjudication section of the Items and AdditionalItems is exactly as you described, the information generation by performing the adjudication is recorded in this section (item might be a prescription cost of $10, adjudication is Insurer pays 80% amount $8). The information section is identical to the information section on the Claim and records the various other item of information that are found on every Claim form. The information section would likely be a little more transparent if the CMS1500 mapping on the Claim were available but they appear to have disappeared once again
Last updated: Apr 12 2022 at 19:14 UTC
