Stream: Da Vinci PAS
Topic: Denied claim items/services
Katerina Nikolova (Jun 02 2021 at 12:57):
Hello!
I have a couple of questions regarding denied/reversed item or services on ClaimResponse resources
Is there a way to indicate (at a line item level) whether an item or service was denied and the reason behind that decision - different processing policies, etc.
The claim itself can be an original but different line items can be denied.
I am thinking of two options:
Creating ClaimResponse for each line item and using outcome and disposition elements to indicate the status of the item
Creating a ClaimResponse for all of the items and using the item.adjudication.reasonCode to indicate why that particular item/service was denied.
Thank you!
Lloyd McKenzie (Jun 02 2021 at 13:29):
Typically there'd be one ClaimResponse for each Claim (though you might receive updates if some items were deferred). item.adjudication.amount and value convey the 'decision' and adjudication.reasonCode conveys why.
Katerina Nikolova (Jun 02 2021 at 13:51):
Thank you for the answer! What if there are multiple reasons? On item level for adjudication you could have only one adjudication.reasonCode.
Lloyd McKenzie (Jun 02 2021 at 17:34):
At the moment, I guess you'd need to use an extension, but I'd encourage you to submit a change request asking for adjudication.reasonCode to be allowed to repeat in the future.
Jean Duteau (Jun 02 2021 at 17:47):
we have an extension on item - item.reviewAction that allows us to send back the review action code as well as multiple review reason codes. that is where we have mapped the X12 HCR data segment
John Silva (Jun 02 2021 at 18:16):
Would it be possible to use repeats of item.adjudication to capture the multiple .reasonCodes (maybe not what is desired though)?
item[0].adjudication[0].reasonCode = <reason1>
item[0].adjudication[1].reasonCode = <reason2>
Lloyd McKenzie (Jun 02 2021 at 21:30):
@Paul Knapp What is the meaning of multiple adjudication repetitions on a single item? What would it mean if they had different amounts?
Jean Duteau (Jun 02 2021 at 22:13):
it's possible to have multiple adjudications as there are different categories. The question would still apply in a different light - what is the meaning of multiple repetitions with the same category?
Last updated: Apr 12 2022 at 19:14 UTC
