Stream: CARIN IG for Blue Button®
Topic: CARIN BB - Related Claim (Must Support)
Joel Hansen (Aetna) (Aug 10 2020 at 16:49):
Hi All,
I'm seeking some feedback as to how other implementers are using the explainationOfBenefit.related (claim) field. We have identified a field that is available "external claim ID" that comes from the provider who submitted the claim. The issue is that since the "external claim ID"is sent in from third-party, it may or may not be a claim in our system. In the later case, the claim would not be able to be referenced. Also, if it's coming in from a third-party we may not know what the claim relationship value is i.e.: prior or replaced. The relationship is a mandatory field, so not sure what to do here.
The description is:
ExplanationOfBenefit.related
Definition
Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.
Thanks,
Joel
Joel Hansen (Aetna) (Aug 13 2020 at 17:33):
Joel Hansen (Aetna) said:
Hi All,
I'm seeking some feedback as to how other implementers are using the explainationOfBenefit.related (claim) field. We have identified a field that is available "external claim ID" that comes from the provider who submitted the claim. The issue is that since the "external claim ID"is sent in from third-party, it may or may not be a claim in our system. In the later case, the claim would not be able to be referenced. Also, if it's coming in from a third-party we may not know what the claim relationship value is i.e.: prior or replaced. The relationship is a mandatory field, so not sure what to do here.
The description is:
ExplanationOfBenefit.related
Definition
Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.Thanks,
Joel
@Pat Taylor Hi Pat, Just wanted to try and get your input on this one as well.
Thanks
Joel
Michele Mottini (Aug 13 2020 at 17:54):
That's a reference to Claim, that would require implementing the Claim resource ... but there is nothing about said about that anywhere else?
Michele Mottini (Aug 13 2020 at 17:57):
..and the profile says that you have to populate relationship 'How the reference claim is related' - but not the reference itself, that makes little sense?
Michele Mottini (Aug 13 2020 at 17:58):
(we are _not_ populating ExplanationOfBenefit.related nor using it when acting as a client)
Pat Taylor (Aug 13 2020 at 19:40):
Hi Joel, The CPCDS data elements are the Claim adjusted from identifier and the Claim adjusted to identifier. They're not intended to capture a claim number that a provider assigns; i.e., an "external claim ID". Instead, they are intended to capture a payer's claim numbers when an adjustment is made to a claim and the payer changes the claim number. @Amol Vyas @Mark Roberts @Ryan Howells @Michele Mottini
Michele Mottini (Aug 13 2020 at 19:51):
...so where does this claim number goes? In ExplanationOfBenefit.related.claim.identifier.value ?
Pat Taylor (Aug 13 2020 at 19:59):
EOB.related.reference and EOB.related.relationship. We're asking HL7 to expand the values of Related Claim Relationship Codes to include 'replaced by or merged' in addition to the current values of prior | replaced by.
Michele Mottini (Aug 13 2020 at 20:04):
Got it, thanks. This mean that
is wrong, correct? It should specify that reference is must support and 1..1
Pat Taylor (Aug 13 2020 at 20:40):
EOB.related.reference should also be must support. However, the cardinality would be 0..1 as it's only used when the claim is related to one that has been adjusted.
Michele Mottini (Aug 13 2020 at 21:13):
So you always have to specify relationship but you can omit reference? That seems strange?
Josh Lamb (Aug 14 2020 at 18:08):
I interpret this as eob.related is optional (0..1) but if you include it then relationship is required (1..1). This aligns with Pat's explanation as well.
Michele Mottini (Aug 14 2020 at 18:21):
Yes, but if you include relationship you have to specify reference as well, shouldn't you? Otherwise what does `relationship' by itself applies to ?
Josh Lamb (Aug 14 2020 at 18:36):
I agree. It seems that eob.related.reference should be Must Support 1..1.
Michele Mottini (Aug 14 2020 at 18:53):
I created https://jira.hl7.org/browse/FHIR-28253
Pat Taylor (Aug 31 2020 at 17:33):
I saw the JIRA ticket Michele. I agree with Josh and you. The resolution is Persuasive.
Last updated: Apr 12 2022 at 19:14 UTC
