CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
0.1.7 - STU1

CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®), published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 0.1.7). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Behavior: Capability Statements

The following artifacts define the specific capabilities that different types of systems are expected to have in order to comply with this implementation guide. Systems complying with the implementation guide are expected to declare conformance to one or more of the following capability statements.

C4BB CapabilityStatement

This Section describes the expected capabilities of the C4BB Server actor which is responsible for providing responses to the queries submitted by the C4BB Requestors.

Behavior: Search Parameters

These define the properties by which a RESTful server can be searched. They can also be used for sorting and including related resources.

Coverage_Payor

The identity of the insurer or party paying for services

ExplanationOfBenefit_Careteam

Member of the CareTeam

ExplanationOfBenefit_Coverage

The plan under which the claim was adjudicated

ExplanationOfBenefit_Identifier

The business/claim identifier of the Explanation of Benefit

ExplanationOfBenefit_Insurer

The party responsible for the claim

ExplanationOfBenefit_Patient

The reference to the patient

ExplanationOfBenefit_Provider

The reference to the provider

ExplanationOfBenefit_ServiceDate

Date of the service for the EOB

ExplanationOfBenefit_Type

The type of the ExplanationOfBenefit

ExplanationOfBenefit_Organization

The identity of the organization the practitioner represents / acts on behalf of

ExplanationOfBenefit_Practitioner

Practitioner that is able to provide the defined services for the organization

Structures: Abstract Profiles

These are profiles on resources or data types that describe patterns used by other profiles, but cannot be instantiated directly. I.e. instances can conform to profiles based on these abstract profiles, but do not declare conformance to the abstract profiles themselves.

C4BB Explanation Of Benefit

Abstract parent profile that includes constraints that are common to the four specific ExplanationOfBenefit (EOB) profiles defined in this Implementation Guide. All EOB instances should be from one of the four non-abstract EOB profiles defined in this Implementation Guide: Inpatient, Outpatient, Pharmacy, and Professional/NonClinician

Structures: Resource Profiles

These define constraints on FHIR resources that need to be complied with by conformant implementations

C4BB Coverage

Data that reflect a payer’s coverage that was effective as of the date of service or the date of admission of the claim.

C4BB ExplanationOfBenefit Inpatient Institutional

The profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for inpatient services, which may include the use of equipment and supplies, laboratory services, radiology services and other charges. Inpatient claims are submitted for services rendered at an institution as part of an overnight stay. The claims data is based on the institutional claim format UB-04, submission standards adopted by the Department of Health and Human Services.

C4BB ExplanationOfBenefit Outpatient Institutional

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for outpatient services, which may include including the use of equipment and supplies, laboratory services, radiology services and other charges. Outpatient claims are submitted for services rendered at a Institutional that are not part of an overnight stay. The claims data is based on the institutional claim form UB-04, submission standards adopted by the Department of Health and Human Services.

C4BB ExplanationOfBenefit Pharmacy

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by retail pharmacies. The claims data is based on submission standards adopted by the Department of Health and Human Services defined by NCPDP (National Council for Prescription Drug Program)

C4BB ExplanationOfBenefit Professional NonClinician

This profile is used for Explanation of Benefits (EOBs) based on claims submitted by physicians, suppliers and other non-institutional providers for professional services. These services may be rendered in inpatient or outpatient, including office locations. The claims data is based on the professional claim form 1500, submission standards adopted by the Department of Health and Human Services as form CMS-1500.

C4BB Organization

This profile builds upon the US Core Organization profile. It is used to convey a payer, provider, payee or service facility organization.

C4BB Patient

This profile builds upon the US Core Organization profile. It is used to convey information about the patient who received the services described on the claim.

C4BB Practitioner

This profile builds upon the US Core Practitioner profile. It is used to convey information about the practitioner who provided to the patient services described on the claim.

Terminology: Value Sets

These define sets of codes used by systems conforming with this implementation guide

AHA NUBC Patient Discharge Status

UB-04 Patient Discharge Status (FL-17)

AHA NUBC Point of Origin for Admission or Visit.

UB-04 Point of Origin for Admission or Visit (FL-15)

AHA NUBC Present On Admission

UB-04 Present on Admission (FL-67)

AHA NUBC Priority Type Of Admission Or Visit

AHA NUBC Priority Type Of Admission Or Visit

AHA NUBC Revenue Codes

NUBC Revenue codes are used to convey specific accomodation, ancillary service or unique billing calculations or arrangements. They are listed within the UB-04 Data Specifications Manual and maintained by the National Uniform Billing Committee (NUBC) UB-04 Revenue Code (FL-42)

AHA NUBC Type of Bill

UB-04 Type of Bill (FL-4)

AMA CPT CMS HCPCS Modifiers

The Value Set is a combination of two Code Systems: CPT (HCPCS I) and HCPCS II procedure code modifiers. Modifiers help further describe a procedure code without changing its definition.
CPT codes are available by subscription from the AMA at http://www.ama-assn.org/go/cpt. HCPCS codes are available at http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets. The link takes one to a list of files. The target set for this Code System is the procedure code modifiers from this file.

MODIFIER CODES ONLY

AMA CPT CMS HCPCS Procedure Codes

The Value Set is a combination of two Code Systems: CPT (HCPCS I) and HCPCS II procedure codes. They are submitted by providers to payers to convey the specific procedure performed. AMA CPT CMS HCPCS Procedure Codes leverage US Core Procedure Codes composition.
CPT codes are available by subscription from the AMA at http://www.ama-assn.org/go/cpt. HCPCS codes are available at http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets. The link takes one to a list of files. The target set for this Code System is the procedure codes from this file.

PROCEDURE CODES ONLY

C4BB Adjudication

Describes the various amount fields used when payers receive and adjudicate a claim. It includes the values defined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the C4BB Adjudication CodeSystem.

C4BB Claim Identifier Type

Indicates that the claim identifier is that assigned by a payer for a claim received from a provider or subscriber

C4BB Claim Inpatient Institutional Diagnosis Type

Indicates if the inpatient institutional diagnosis is admitting, principal, other or an external cause of injury.

C4BB Claim Institutional Care Team Role

Describes functional roles of the care team members.

C4BB Claim Outpatient Institutional Diagnosis Type

Indicates if the outpatient institutional diagnosis is principal, other, an external cause of injury or a patient reason for visit.

C4BB Claim Pharmacy CareTeam Roles

Describes functional roles of the care team members

C4BB Claim Procedure Type

Indicates if the inpatient institutional procedure (ICD-PCS) is the principal procedure or another procedure

C4BB Claim Professional And Non Clinician Care Team Role

Describes functional roles of the care team members

C4BB Claim Professional And Non Clinician Diagnosis Type

Indicates if the professional and non-clinician diagnosis is principal or secondary

C4BB Organization Identifier Type

Identifies the type of identifiers for organizations

C4BB Patient Identifier Type

Identifies the type of identifier payers and providers assign to patients

C4BB Payee Type

Identifies the type of recipient of the adjudication amount; i.e., provider, subscriber, beneficiary or another recipient.

C4BB Payer Benefit Payment Status

Indicates the in network or out of network payment status of the claim.

C4BB Payer Claim Payment Status Code

Indicates whether the claim / item was paid or denied.

C4BB Payer Provider Contracting Status

Indicates that the Provider has a contract with the Payer as of the effective date of service or admission.

C4BB Practitioner Identifier Type

Identifies the type of identifiers for practitioners

C4BB Related Claim Relationship Codes

Identifies if the current claim represents a claim that has been adjusted and was given a prior claim number or if the current claim has been adjusted; i.e., replaced by or merged to another claim number.

C4BB SupportingInfo Type

Used as the discriminator for the types of supporting information for the CARIN IG for Blue Button� Implementation Guide.

CDC ICD-9-10-CM Diagnosis Codes

The ICD-CM (International Classification of Diseases, Clinical Modification) is a system used by physicians and other healthcare providers to classify and code all diagnoses and symptoms recorded in conjunction with hospital care in the United States.

CMS ICD-9-10-PCS Procedure Codes

This value set defines a set of codes from ICD-PCS that can be used to indicate the procedure performed

CMS MS 3M AP APR DRG

This value set defines three sets of DRGs, MS-DRGs (Medicare Severity Diagnosis Related Groups) AP-DRGs (All Patient Diagnosis Related Groups) and APR-DRGs (All Patient Refined Diagnosis Related Groups). MS-DRGs are owned by CMS; AP-DRGs and APR-DRGs are owned by 3M. Assignment of a DRG is defined by a particular set of patient attributes, which include principal diagnosis, specific secondary diagnoses, procedures, sex and discharge status. Identifying a DRG code requires a version.

CMS Place of Service Codes (POS)

Place of Service Codes are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided.

FDA NDC or Compound

National Drug Code (NDC). The US Federal Drug Administration (FDA) Data Standards Council assigns the first 5 digits of the 11 digit code. NCPDP field # 407-D7.
Values will be the NDC Codes when the Compound Code value is 0 or 1. When the Compound Code value = 2, the value will be the literal, ‘compound’

FDA National Drug Code (NDC)

National Drug Code (NDC). The US Federal Drug Administration (FDA) Data Standards Council assigns the first 5 digits of the 11 digit code. NCPDP field # 407-D7.

NCPDP Brand Generic Code

Indicates whether the plan adjudicated the claim as a brand or generic drug. NCPDP field # 686.

NCPDP Compound Code

Indicates whether or not the prescription is a compound NCPDP field # 406-D6.

NCPDP Dispensed As Written Or Product Selection Code

Prescriber’s instruction regarding substitution of generic equivalents or order to dispense the specific prescribed medication. NCPDP field # 408-D8.

NCPDP Prescription Origin Code

Indicates whether the prescription was transmitted as an electronic prescription, by phone, by fax, or as a written paper copy. NCPDP field # 419-DJ.

NCPDP Reject Code

The National Council for Prescription Drug Programs, (NCPDP) Reject Code (511-FB) code set contains exception definitions for use when transaction processing cannot be completed.

X12 Claim Adjustment Reason Codes (CARC) - CMS- Remittance Advice Remark Codes (RARC)

The Value Set is a combination of two sets of codes: X12 Claim Adjustment Reason Codes (CARC) and CMS Remittance Advice Remark Codes (RARC). CARC codes describe why a claim or service line was paid differently than it was billed. RARC codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing.
Use of X12 CARC codes require a license. Reference https://x12.org/codes/. RARC codes are available at http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes.

Terminology: Code Systems

These define new code systems used by systems conforming with this implementation guide

AHA NUBC Discharge Status

UB-04 Patient Discharge Status (FL-17)

AHA NUBC Point Of Origin For Admission Or Visit

UB-04 Point of Origin for Admission or Visit (FL-15)

AHA NUBC PresentOn Admission

UB-04 Present on Admission (FL-67).

AHA NUBC Priority Type Of Admission Or Visit

UB-04 Priority (Type) of Admission or Visit (FL-14).

AHA NUBC Revenue Codes

NUBC Revenue codes are used to convey specific accomodation, ancillary service or unique billing calculations or arrangements. They are listed within the UB-04 Data Specifications Manual and maintained by the National Uniform Billing Committee (NUBC) UB-04 Revenue Code (FL-42)

AHA NUBC Type of Bill

UB-04 Type of Bill (FL-4)

AMA CPT Codes

CPT procedure and modifier codes are submitted to payers to convey the specific procedure performed. CPT codes are available by subscription from the AMA at http://www.ama-assn.org/go/cpt.

C4BB Adjudication

Describes the various amount fields used when payers receive and adjudicate a claim. It complements the values defined in http://terminology.hl7.org/CodeSystem/adjudication.

C4BB Adjudication Discriminator

Used as the discriminator for the data elements in adjudication and item.adjudication

C4BB Claim Care Team Role

Describes functional roles of the care team members. Complements http://terminology.hl7.org/CodeSystem/claimcareteamrole

C4BB Claim Diagnosis Type

Indicates if the institutional diagnosis is admitting, principal, secondary, other, an external cause of injury or a patient reason for visit. Complements http://terminology.hl7.org/CodeSystem/ex-diagnosistype.

C4BB Claim Procedure Type

Indicates if the inpatient institutional procedure (ICD-PCS) is the principal procedure or another procedure

C4BB Compound Literal

CodeSystem for a Literal ‘compound’ value

C4BB Identifier Type

Identifier Type codes that extend those defined in http://terminology.hl7.org/CodeSystem/v2-0203 to define the type of identifier payers and providers assign to claims and patients

C4BB Payee Type

Indicates that a payee type may be a beneficiary.

C4BB Payer Adjudication Status

Describes the various status fields used when payers adjudicate a claim, such as whether the claim was adjudicated in or out of network, if the provider was contracted or non-contracted for the service

C4BB Related Claim Relationship Codes

Identifies if the current claim represents a claim that has been adjusted and was given a prior claim number or if the current claim has been adjusted; i.e., replaced by or merged to another claim number.

C4BB Supporting Info Type

Claim Information Category - Used as the discriminator for supportingInfo

CMS HCPCS Codes

HCPCS procedure codes and modifiers are submitted by providers to payers to convey the specific procedure performed. HCPCS codes are available at http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets.

CMS MS DRG

MS-DRGs (Medicare Severity Diagnosis Related Groups). MS-DRGs are owned by CMS. Assignment of a DRG is defined by a particular set of patient attributes, which include principal diagnosis, specific secondary diagnoses, procedures, sex and discharge status. Identifying a DRG code requires a version.

CMS Place of Service Codes (POS)

Place of Service Codes are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided.

CMS- Remittance Advice Remark Codes (RARC)

RARC codes provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or convey information about remittance processing.
RARC codes are available at http://www.wpc-edi.com/reference/codelists/healthcare/remittance-advice-remark-codes.

NCPDP Brand Generic Code

Indicates whether the plan adjudicated the claim as a brand or generic drug. NCPDP field # 686.

NCPDP Compound Code

Indicates whether or not the prescription is a compound NCPDP field # 406-D6.

NCPDP Dispensed As Written Or Product Selection Code

Prescriber’s instruction regarding substitution of generic equivalents or order to dispense the specific prescribed medication. NCPDP field # 408-D8.

NCPDP Prescription Origin Code

Indicates whether the prescription was transmitted as an electronic prescription, by phone, by fax, or as a written paper copy. NCPDP field # 419-DJ.

NCPDP Reject Code

Contains exception definitions for use when transaction processing cannot be completed. NCPDP field # 511-FB (Reject Code)

3M AP DRG

AP-DRGs (All Patient Diagnosis Related Groups). AP-DRGs are owned by 3M. Assignment of a DRG is defined by a particular set of patient attributes, which include principal diagnosis, specific secondary diagnoses, procedures, sex and discharge status. Identifying a DRG code requires a version.

3M APR DRG

APR-DRGs (All Patient Refined Diagnosis Related Groups). APR-DRGs are owned by 3M. Assignment of a DRG is defined by a particular set of patient attributes, which include principal diagnosis, specific secondary diagnoses, procedures, sex and discharge status. Identifying a DRG code requires a version.

X12 Claim Adjustment Reason Codes (CARC)

CARC codes describe why a claim or service line was paid differently than it was billed. Use of X12 CARC codes require a license. Reference https://x12.org/codes/.

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like

Coverage1

Coverage Example1

EOBInpatient1

EOB Inpatient Example1

EOBOutpatientInstitutional1

EOB Outpatient Example1

EOBPharmacy1

EOB PHarmacy Example1

EOBProfessional1a

EOB Professional Example1

OrganizationProvider1

Provider 1

Patient1

Patient Example1

OrganizationPayer1

Payer1

CoverageEx1
CoverageEx2
EOBInpatientInstitutionalEx1
EOBOutpatientInstitutionalEx1
EOBProfessionalEx1
PayerOrgEx1
ProviderOrganizationEx1
ProviderOrganizationEx2
ProviderOrganizationEx3
ProviderOrganizationEx4
ProviderOrganizationEx5
ProviderOrganizationEx6
PatientEx1
PractitionerEx1
PractitionerEx2
PractitionerEx3