Stream: implementers
Topic: secondary claim
Varvara (Sep 04 2019 at 10:02):
@Paul Knapp hello, I am wondering how to create a secondary claim using FHIR, which resource do you use for that - could you point on any example? By secondary claim I mean a claim which was already adjudicated by primary payer and now we have to bill to secondary payer by COB including all adjudication data from primary payer.
Paul Knapp (Sep 04 2019 at 19:46):
@Varvara See the Secondary Claim Example http://hl7.org/fhir/claim-example-vision-glasses-3tier.html. Essentially it looks like the original claim except that the target insurer is the secondary; the primary insurance now contains an .insurance.claimResponse and the secondary .insurance is now .focal=true.
Varvara (Sep 04 2019 at 19:54):
wow, thank you, @Paul Knapp ! I've mentioned you also included claim.insurance.identifier in stu4, description says 'Pre-assigned Claim number' - could you give me a hint what is this for/any use case description? It feels as it's something I need)
Andy Stechishin (Sep 04 2019 at 20:28):
@Varvara it is a common business practice that the recipient of a claim may provide a claim number to be used for identification of the claim when submitted. The communication may occur via phone call where an agent will 'open a file' and then provide a pre-assigned number to be used. Note that this is a different concept from a pre-authorization reference number (also possibly provided by phone)
Varvara (Sep 04 2019 at 20:33):
so this would be payer-assigned claim id, right? Which is also often returned in remits
Andy Stechishin (Sep 04 2019 at 20:50):
That is what the documentation was referring to, yes.
Paul Knapp (Sep 05 2019 at 19:39):
@Varvara @Andy Stechishin While that could be the source of the claim ID, the intention of the element is to handle the situation where a payor handles COB rather than the provider. If the provider always handles COB then they can issue claim IDs (or use the one(s) given to them) as needed as the claim proceeds down the COB path. However, if the payor handles COB either by adjudication for each of the plans they process (e.g. Blue on Blue) or by exchange with the other plan adjudicators, then the responses to all but the first claim are to claims whose ID are not known. Therefore this provides a mechanism for the provider to provide the claim numbers for all potential claims upfront so that all answers have identifiable questions.
Last updated: Apr 12 2022 at 19:14 UTC
