FHIR Chat · Pharmacy EOB mapping · CARIN BB ExplanationOfBenefit

Stream: CARIN BB ExplanationOfBenefit

Topic: Pharmacy EOB mapping

view this post on Zulip Paul Chayka (Feb 12 2021 at 10:19):

Hello!
I have a couple of questions about "Pharmacy Claim" -> "Pharmacy EOB" mapping.

  1. Do we need to process and save Pharmacy EOBs based on denied and reversal Pharmacy claims?
    What status field in the Pharmacy EOB entity should we use to save the claim's status (Approved, Rejected, Reversal, Denied)?
    Should we also save financial and medication information if a claim was rejected or reversed?

  2. Currently we have only one medication per one pharmacy claim. Do we need to create EOB.item elements in the Pharmacy EOBs?

  3. In our Pharmacy claims we have information about prescribers. Do we need to put these practitioners in the EOB.enterer or the EOB.careTeam?

Thanks for your help!

view this post on Zulip Corey Spears (Feb 12 2021 at 19:25):

Hi. I have some thoughts on your first two numbered questions, but will confer with the CARIN team before providing a response if someone does not already do so here beforehand.
Regarding number 3: the place to put the prescriber is the EOB.careTeam. Be sure to specify the careTeam.role as prescribing where appropriate.

view this post on Zulip Paul Chayka (Feb 17 2021 at 16:08):

Did you have a chance to check this info?

view this post on Zulip Corey Spears (Feb 18 2021 at 01:52):

I have referred this to some of the CARIN BB team, but have not heard back yet. I will touch base again and bring it up in a call.

view this post on Zulip Pat Taylor (Feb 18 2021 at 13:08):

@Paul Chayka
Do we need to process and save Pharmacy EOBs based on denied and reversal Pharmacy claims? As retail pharmacy claims are denied when the pharmacy contacts the PBM, the subscriber does not receive an EOB from the payer. In the same vein, an EOB would not be provided via the Patient Access API.
What status field in the Pharmacy EOB entity should we use to save the claim's status (Approved, Rejected, Reversal, Denied)? Values are active | cancelled
Should we also save financial and medication information if a claim was rejected or reversed? As a retail pharmacy POS transaction, reversal EOBs are rarely provided by the payer to the member; however, if the payer currently provides an EOB in this situation, a transaction should be provided via the Patient Access API

Currently we have only one medication per one pharmacy claim. Do we need to create EOB.item elements in the Pharmacy EOBs? Yes, FHIR maps some of the required data elements, such as NPI, to .item data elements.

In our Pharmacy claims we have information about prescribers. Do we need to put these practitioners in the EOB.enterer or the EOB.careTeam? EOB.careTeam. Valid pharmacy EOB.careTeam roles are performing, PCP and prescribing. @Corey Spears @Amol Vyas

view this post on Zulip Pat Taylor (Feb 18 2021 at 13:08):

@Mark Roberts

view this post on Zulip Paul Chayka (Mar 12 2021 at 16:03):

Thank you for your awesome answers!
I have another small question.
As I can see if we have related EOBs we should use the "EOB.related" field. But why this field contains a reference to a Claim entity?
Is it possible to use a reference to the related EOB entity itself in this field, if we don't create a Claim entity for each OEB?

view this post on Zulip Corey Spears (Mar 12 2021 at 19:43):

Thanks for the question. I was imprecise in my post in the EOB related.reference thread: https://chat.fhir.org/#narrow/stream/204607-CARIN-IG.20for.20Blue.20Button.C2.AE/topic/Base.20EoB.20related.20claim.20reference
@Paul Chayka , you are right, this is not a relation to a claim specifically, but rather to an EOB.

Last updated: Apr 12 2022 at 19:14 UTC


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