Stream: CARIN IG for Blue Button®
Topic: Claims and Clinical Overlap
Spencer Kathol (Nov 26 2020 at 13:41):
Say a health plan's claims contain information about encounters, procedures and diagnoses. If that information will be accessible/included as EOB properties, is it expected they will also be accessible as Encounter, Procedure, and Condition resources?
Spencer Kathol (Nov 30 2020 at 23:56):
Some documentation for reference:
http://build.fhir.org/ig/HL7/davinci-epdx/index.html#mapping-adjudicated-claims-information-to-clinical-resources
Should we interpret this as the resource types listed "shall" be derived from CPCDS data and made available as clinical data resources?
Michele Mottini (Nov 30 2020 at 23:59):
If you are implementing CARIN BB no, you do not have to map to those clinical resources: they are not part of the implementation guide
Ryan Howells (Dec 01 2020 at 00:41):
Hey @Amol Vyas, what are your thoughts here after talking with @Mark Scrimshire? I don't think Question 8 and CMS' response helps here but just in case it does I'm including it here as reference. https://confluence.hl7.org/display/CAR/CMS+Patient+Access+API+%3A+Industry+Questions+and+CMS+Answers
Spencer Kathol (Dec 01 2020 at 10:36):
@Michele Mottini @Ryan Howells @Amol Vyas We are trying to implement the broader CMS rule, so I think we are looking at a combination of PDex and CARIN BB IGs... Based on the question and response in the confluence link above, it seems this kind of cross-mapping is optional, not required. I just want to make sure this is the correct interpretation.
Ryan Howells (Dec 01 2020 at 13:09):
Correct. CMS has said multiple times mapping clinical claims data to USCDI is an option but it's not required. Keep in mind though, if the payer has USCDI data in any discrete form in their systems that map to an individual (e.g., claims, clinical data feeds, etc.) it should be provided to the member.
Last updated: Apr 12 2022 at 19:14 UTC
