Stream: CARIN IG for Blue Button®
Topic: Adjudication Category
Melissa Benzie (Sep 29 2020 at 16:10):
The CarinBB EOB adjudication specification indicates that the category is: 'Type of adjudication information'. image.png
Looking at the adjudication spec for each of the slices, the category usage is not consistent. denialReason and allowedunits bind to a fixed category code and within a value set that indicates the type of the adjudication information (http://build.fhir.org/ig/HL7/carin-bb/CodeSystem-ClaimAdjudicationCategory.html). Both the adjudicationamounttype and inoutnetwork have category bindings to different valuesets that are specific to that slice (http://build.fhir.org/ig/HL7/carin-bb/ValueSet-C4BBAdjudication.html and http://build.fhir.org/ig/HL7/carin-bb/ValueSet-C4BBPayerBenefitPaymentStatus.html).
This is unlike the specification for SupportingInfo which was standard, there was a category that indicated what the supportingInfo data was (like discharge status) and then the value (which could be a code, timing, etc).
This sub profile has all the adjudication slices (for reference): http://build.fhir.org/ig/HL7/carin-bb/StructureDefinition-C4BB-ExplanationOfBenefit-Professional-NonClinician.html
Is this specification correct? There is no consistent category valueset binding for all slices?
Saul Kravitz (Sep 29 2020 at 21:18):
It is true that each slice of supportingInfo is defined by a specific code in the category field.
For adjudication and item.adjudication both individual values, and membership of the category field value in a value set are used to discriminate the slices. I agree that this is a bit more complicated to understand (and more complicated to eyeball an instance and decide which slice is involved), but it is legitimate FHIR practice. The specification is correctly conveying the authors' intent.
Melissa Benzie (Sep 30 2020 at 16:05):
thank you for the clarification.
Last updated: Apr 12 2022 at 19:14 UTC
