Stream: CARIN IG for Blue Button®
Topic: Multiple Medications per claim
Melissa Benzie (Mar 01 2022 at 15:11):
I am looking for guidance on how to implement the ExplanationOfBenefit Pharmacy profile when a claim contains multiple medications. I do not see anything in the IG that explicitly states or requires that the EOB Pharmacy must contain only one medication (item), but the cardinality of the supportingInfo slices (dayssupply, dawcode, and refillNum) implies this is the case.
We receive claims with multiple medications from various sources and do need to map those claims to the ExplanationOfBenefit resource.
What would be the recommended guidence for outputting the supportingInfo slices for each medication (item) on the claim?
Corey Spears (Mar 01 2022 at 19:02):
You can and should put all medications associated with a single claim in the same EoB.
The supportingInfo slice can be linked up with the particular line item. Put a unique id in the EoB.supportingInfo.id and link in the item by placing that id in the EoB.item.informationSequence
Melissa Benzie (Mar 01 2022 at 20:08):
Thanks for the explanation.
Melissa Benzie (Mar 02 2022 at 16:54):
@Corey Spears after reviewing your explanation a bit more I have questions...
Is the recommendation to link the supportingInfo slices to the item via the EOB.supportingInfo.id to the EOB.item.informationSequence documented in the IG? It seems to make sense to have the link be via the EOB.supportingInfo.sequence to the EOB.item.informationSequence. This would align with how the item -> careTeamSequence, diagnosisSequence, and procedureSequence elements link to the careTeam, diagnosis, and procedure. Also, the EOB.supportingInfo.id is a string not a positiveInt which is the datatype for the EOB.item.informationSequence.
I would like to link it as we already link the others (careteam, diagnosis) using the sequence, but if this is required/documented by the IG, I will do linking via the id. Please let me know, thanks.
Corey Spears (Mar 09 2022 at 05:28):
@Melissa Benzie , You are right. Good catch. I will just have to chalk it up to multi-tasking poorly. It should be the ExplanationOfBenefit.supportingInfo.sequence used to match up with ExplanationOfBenefit.item.informationSequence.
Michele Mottini (Mar 09 2022 at 14:34):
The slices cardinality is wrong then, isn't it? There can be multiple dayssupply, dawcode, refillnum
Corey Spears (Mar 09 2022 at 16:11):
Good catch @Michele Mottini, I see this may be an issue in other EoB profiles as well, but most notably for the Pharmacy EoB. I have added a ticket and will take the issue to the CARIN Alliance for discussion.
FHIR-36235 - EoBs do not allow for multiple repetitions of SupportingInfo slice when needed
Michele Mottini (Mar 09 2022 at 16:33):
OK, thanks
Melissa Benzie (Mar 09 2022 at 18:41):
thanks for following up and clarifying @Corey Spears and @Michele Mottini .
Corey Spears (Mar 11 2022 at 03:19):
After discussion today with the CARIN Alliance, we determined that the other IGs are not affected as the supportingInfo slices are indeed at the claim level. However, the Pharmacy EoB prescription specific slices need to be associated with line items. The current decision is to unbound the maximum cardinality for those slices and make item.informationSequence to MS and cardinality 1..* (since the prescription related supportingInfo slices are item specific).
Michele Mottini (Mar 11 2022 at 14:29):
Thanks for aligning the implementation guide with our implementation!
Corey Spears (Mar 15 2022 at 21:49):
The matter of multiple medications in a single claim has been discussed during the FM call today. During that call, we were unable to find instances where there would be multiple medications (one per line) on a single EoB where the daw code, refill number, refills authorized, etc. would be unique to the medication. @Michele Mottini and @Melissa Benzie , can you provide some specifics of the use case and some examples?
Melissa Benzie (Mar 16 2022 at 16:22):
We have examples of claims with multiple medications and the daw code, refill number, and days supply values are unique for each medication. Seeing this on claims from VA Medicaid and NC Medicaid sources.
Corey Spears (Mar 17 2022 at 04:22):
Thanks Melissa. Besides being Medicaid claims, is there anything notable about these medications linking them together? Are they components? Are they part of packs? are they somehow related to a specific therapy regimen?
Are these actually sent in the same claim transaction?
Melissa Benzie (Mar 18 2022 at 18:19):
@Corey Spears
Are these actually sent in the same claim transaction?
For these Medicaid sources, the daw code, days supply, and refill # are all provided to us at the line level (ie once for each medication).
During that call, we were unable to find instances where there would be multiple medications (one per line) on a single EoB where the daw code, refill number, refills authorized, etc. would be unique to the medication.
We have taken a closer look at the medicaid claims which contain multiple medications and do not have the same daw code, refill number and days supply. After examining the claims more carefully, we do not think those claims are valid examples.
We are seeing for all the other claims with multiple medications, they do have the same daw code, refill number, and days supply.
Thank you for your quick response, help and guidance in understanding these types of claims.
Last updated: Apr 12 2022 at 19:14 UTC
