Stream: CARIN IG for Blue Button®
Topic: item.adjudication:denialreason
jason chow (Nov 05 2020 at 19:06):
for a denialreason element of item.adjudication, the IG indicates the codeableconcept for the reason property should be from the X12 set. If we don't have a reliable mapping from our internal reason codes to X12, can we provide the reason as text without a system URI?
Paul Knapp (Dec 08 2020 at 18:06):
@jason chow @Pat Taylor @Amol Vyas I have added the IG authors to the response for their review. From a Financial Management perspective this CodeableConcept, and most other CodeableConcepts in the administrative space, should not permit .text when a valueset is provided. The provision of payor-specific text breaks interoperability. So the answer to Jason's question would be no.
jason chow (Dec 08 2020 at 18:14):
Thanks @Paul Knapp
Pat Taylor (Dec 10 2020 at 20:28):
@jason chow Do your internal codes communicate to the subscriber or to the provider? The X12 CARCs and CMS RARCS are intended to capture codes returned to providers. Messages to subscribers tend to be codes and descriptions that are payer specific. The CARIN IG maps the text for these messages to process.Note @Paul Knapp @Amol Vyas
jason chow (Dec 10 2020 at 20:34):
@Pat Taylor i recently found out that our denial/rejection codes do in fact map to x12 values.
jason chow (Jan 05 2021 at 15:33):
Question about a validation error on outpatient item.adjudication slice.
I have a denial reason element of code system C4BBAdjudicationDiscriminator, but the validator is flagging it as error.
The validator is telling me:
"adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice [(exists() implies where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists())]"
In our source system, the disallow/adjustment reason codes are associated to a line and not to an individual adjuciation amount.
The actual adjudication amounts are present in the eob item array as their own elements.
How can I represent this correctly within the constraints of the profile?
Offending item.adjudication element below:
{
"category": {
"coding": [
{
"system": "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
"code": "denialreason"
}
]
},
"reason": {
"coding": [
{
"system": "https://x12.org/codes/claim-adjustment-reason-codes",
"code": "22",
"display": "PAYMENT ADJUSTED BECAUSE THIS CARE MAY BE COVERED BY ANOTHER PAYER PER COORDINATION OF BENEFITS."
}
],
"text": "The amounts reflect services covered or denied by Medicare. Please refer to your Medicare statement for responsibility."
}
},
Saul Kravitz (Jan 11 2021 at 17:31):
@Pat Taylor
Pat Taylor (Jan 13 2021 at 21:30):
@jason chow
There is no direct association between a specific adjudicationamount and a specific denialreason. The adjudication amounts are associated to the item. The denialreasons are associated to an item, not an adjudication amount.
- item.adjudication contains:
adjudicationamounttype 0..* MS and /* restricted to 1..* by invariant */
denialreason 0..* MS and
allowedunits 0..1 MS
Each item.adjudication can have:
- multiple adjudicationamounttype slices
- multiple denialreason slices
- up to 1 allowedunits slice
@Saul Kravitz @Corey Spears @Amol Vyas @Suma Addagadde
jason chow (Jan 13 2021 at 21:41):
so when my item adjudication array has multiple amount type elements, and one denial reason element, and the validator reports an error specifically on the denial reason element, is that a false positive?
Saul Kravitz (Jan 13 2021 at 22:16):
@jason chow which profile?
jason chow (Jan 14 2021 at 13:27):
Facility in-patient
Saul Kravitz (Jan 14 2021 at 22:29):
I think think so... What is the precise message? Is that the only problem with the instance?
jason chow (Jan 15 2021 at 21:40):
@Saul Kravitz the precise error message is:
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice [(exists() implies where(category.memberOf('http://hl7.org/fhir/us/carin-bb/ValueSet/C4BBAdjudication')).exists())]
in each instance, i have verified that the item.adjudication array does indeed have other elements of type C4BBAdjudication
Melissa Benzie (Aug 05 2021 at 14:18):
The X12 Claim Adjustment Reason Codes is the required value set for this slice. To obtain the reason codes from X12, there is a subscription fee. We would need to obtain this code set to ensure we are properly outputting the reason codeable. What is the guidence on supporting this when there is a subscription fee involved?
Melissa Benzie (Aug 05 2021 at 14:44):
Ah, I see the guidence here: http://hl7.org/fhir/us/carin-bb/STU1/Terminology_Licensure.html
Last updated: Apr 12 2022 at 19:14 UTC
