Stream: financial
Topic: pre and partially adjudicated claims
Bill Harty (Dec 02 2021 at 22:50):
We have a need to supply pre-adjudicated (and/or partially-adjudicated) claims data within our API. We're debating the use of Claim/ClaimResponse over the EOB resource for this purpose. However, the audience for our API is not claim processors and the use case doesn't really fit into the request/response workflow pattern identified in the FHIR spec. Instead it is more targeted at ACOs who need aggregates, analytics, reporting, etc. Torn between the two options. EOB might be a better fit, but EOB does imply "adjudicated". Claim and CR seem less mature / less implemented. Wondering if anyone has an opinion on this? Does anyone know of a group who is working with Claim and CR as well as EOB. To my knowledge, DaVinci and CARIN mostly focus on EOB. Thanks for any direction.
Lloyd McKenzie (Dec 03 2021 at 01:34):
Da Vinci uses Claim and ClaimResponse in PAS ( for prior authorization submission and response). CRE and DTR use ClaimResponse for unsolicited authorizations.
MaryKay McDaniel (Dec 14 2021 at 17:48):
@Bill Harty Yes, given that you are not looking to respond with adjudication information to the party that submitted the claim, the EOB would be the better choice for providing claim and adjudication information to third parties.
Last updated: Apr 12 2022 at 19:14 UTC
