Stream: Da Vinci PCT
Topic: PCT Claim Profile(s) for the GFE
Vanessa Candelora (Oct 21 2021 at 22:36):
Looking for Feedback from Payers and Providers: There's been much discussion about the architectural design to have one claim profile defining both Institutional and Professional GFEs. I've laid out some pros and cons from recent discussions below, but putting the call out to gather more pros and cons (please format comments as such) We'll be reviewing the PCT IG and demo'ing the RI on our public call tomorrow at 11am ET if you'd like to join for more context: http://www.hl7.org/concalls/CallDetails.cfm?concall=57052
Pros:
- Technically, there aren't so many differences that it needs two profiles and we can harmonize them into one, then manage with rules/validation
- Others (e.g. PACIO) are reducing number of profiles used to simplify architectural design also (though clinical data based)
Cons:
- This will be confusing for implementers not laid out on the page clearly
- Other standards in the US and other countries have multiple claim profiles
For Quick Reference:
DRAFT IG: https://build.fhir.org/ig/HL7/davinci-pct/
Github: https://github.com/HL7-DaVinci/test-pct-payer
@Larry Decelles @Pat Taylor @Caleb Wan @MaryKay McDaniel @Sam Undine @Michael Gould @Gary Gryan
Sam Undine (Oct 28 2021 at 18:31):
The BCBSA team's current thoughts on the topic are as follows:
The approach to a single Claim profile for both Institutional and Professional GFEs assumes that the data models and sets of required elements for each are largely similar, but these use different sets of data values in each context. We see that the data model and required elements of each claim format as shown in a profile are different in very significant ways. Standards development organizations have on more than one occasion attempted to consolidate institutional and professional claims into one, but repeatedly have been unable to do so as the data elements, codes, value sets, business rules, and validations are extremely complicated due to the variation between the two.
Some examples of the significant variances between the two claim formats are:
- Institutional inpatient claim procedures are at the claim level, only line items for drugs and biologics or HIPPS rate codes are submitted
- Institutional claims use codes that are not allowed on professional claims, i.e. value codes, occurrence and occurrence span codes and while condition codes can be used on professional claims, it is a very limited subset of codes
- Institutional claims have a very different set of providers that are not found on professional claims: Attending Physician, Operating Physician, Other Operating Physician. This becomes even more complex when the claim is a secondary, tertiary, etc. claim
- Institutional claims use Type of Bill to indicate the type of facility whereas professional claims use Place of Service codes.
- Institutional outpatient claims are billed using the institutional claim format and comingling that with professional claims creates complex rules and validations to ensure appropriate values sets and data would be used.
Interested in thoughts from:
@Amol Vyas @Linda Michaelsen @Ranjith Kandur @Tony Benson
Ranjith Kandur (Oct 28 2021 at 19:44):
Agree with you Sam. Just finished listening to the recording from the testing event summary yesterday and looks like it may not have had the full value sets yet in those tests and some missing ICD codes as well - is what I heard, although there was a successful test for an initial request/response. Yes, it will make it challenging to combine professional and institutional under one for sure and account for all variations of value sets/code sets and the associated business rules. It would require lot more testing to account for all scenarios across both in my opinion with single submission model - while nothing is impossible, the implementations will be more streamlined/not complicated to keep them separate resource profiles. That’s why IG guides for X12 837 are separate for Inst/prof as well.
Pat Taylor (Nov 03 2021 at 12:45):
To add to 'Standards development organizations have on more than one occasion attempted to consolidate institutional and professional claims into one', X12 worked closely with the Data Content Committees, i.e. NUBC, NUCC. Additionally, WEDI looked at trying to combine into one and was unsuccessful. NUBC and NUCC also discussed and realized it did not work.
Pat Taylor (Nov 12 2021 at 18:03):
DaVinci team, Attached is feedback for the sections IG Home and PCT Specification. We will next review the Profiles and Value Sets. DaVinci-PCT-IG-feedback-Nov-11.docx
Sam Undine (Nov 18 2021 at 17:12):
Question on updated profiles
In reviewing the PCT Institutional and Professional profiles, what was the thought behind, for those data elements common to the PCT and CARIN IGs, not using the same data mappings as those defined by CARIN? Payers across the nation have implemented the CARIN profiles for the Patient Access API. If PCT were to use the same data element mappings, the commonality would provide efficiencies. They way they’re defined now, payers will need to remap the PCT data elements.
@Amol Vyas @Pat Taylor @Michael Gould @Ranjith Kandur @Tony Benson @Linda
Larry Decelles (Nov 18 2021 at 23:34):
The CARIN BB IG is based on the EOB Resource and the PCT GFE uses the Claim Resource. Although similar they are not the same. Could you please provide an example that we could further explore?
Pat Taylor (Nov 19 2021 at 16:15):
@Larry Decelles The EOB Resource is a super set of the Claim Resource + Claim Response Resource. For those attributes common to EOB and Claim, we advocate the PCT Claim mapping be identical to the EOB mapping, unless there is a use case reason not to do so. An example is Diagnosis Type. In CARIN the types of diagnosis code are mapped to diagnosis.type. In the PCT IG, slices are defined for each type. There are several other examples. Working sessions may be the best way to harmonize the two.
Last updated: Apr 12 2022 at 19:14 UTC
