Electronic Long-Term Services and Supports (eLTSS) Release 1 - US Realm
2.0.0 - STU2 United States of America flag

Electronic Long-Term Services and Supports (eLTSS) Release 1 - US Realm, published by HL7 International / Human and Social Services. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/eLTSS/ and changes regularly. See the Directory of published versions

Resource Profile: eLTSS Claim Profile

Official URL: http://hl7.org/fhir/us/eltss/StructureDefinition/Claim-eltss Version: 2.0.0
Standards status: Trial-use Maturity Level: 2 Computable Name: Claim_eltss

Claim Resource profile for eLTSS

Requesting and Recording payment for Task, Procedure or ServiceRequest

An important step in eLTSS is payment for services. The following highlights basic CORE FHIR associations that can be used, should business requirements request it.

A Claim FHIR Resource provides costing information, this can be a “claim” or “preauthorization” or “predetermination” (indicated with Claim.use). The claim should be connected to the ServiceRequest with the Claim.referral referencing the ServiceRequest instance. As mentioned, the Procedure Resource can be used to communicate work performed if the business requirements need it. The Procedure can be connected to a Claim using Claim.procedure.procedureReference. Any Task records can be included by referencing using Claim.supportingInfo.

If business rules require it, the FHIR ClaimResponse Resource can be used “to provide the results of the adjudication and/or authorization of a set of healthcare-related products and services for a patient against the patient’s insurance coverages, or to respond with what the adjudication would be for a supplied set of products or services should they be actually supplied to the patient.” see FHIR R4 ClaimResponse Resource In other words, the ClaimResponse Resource is used to respond to a FHIR Claim data instance. The ClaimResponse would detail the actual monies that could or would be paid.

A final consideration is the use of ClaimResponse.net and Claim.net. They both detail the total cost. Using the total cost and the FHIR ServiceRequest (or FHIR Procedure) frequency and quantity information a system could theoretically calculate the hourly rate for a service requested or approved. This might be less ambiguous and more convenient than requesting entry of the cost per unit.

Implementer mapping guidance

The following aids in finding the location of eLTSS data elements. See R4 FHIR Mapping page for complete guidance, here we are providing a subset of fields for convenience.

eLTSS Grouping eLTSS Data Element Name Data Element Definition (includes examples, expected list of values and usage note where applicable) FHIR R4 Resource Element(s) FHIR R4 Resource Element Cardinality (with US Core Constraints) Additional Mapping Details
Service Information Service Rate per Unit The rate of one unit for a service. CarePlan → activity
→ reference(ServiceRequest)

ServiceRequest → supportingInfo(Claim)

Claim → item → unitPrice		 CarePlan
...activity 0..*
......reference(ServiceRequest) 0..1
.........supportingInfo(Claim) 0..*
............item 0..*
...............unitPrice 0..1		 1) Will use CarePlan → activity → reference to reference a ServiceRequest, and supportingInfo to reference a Claim.
2) item maps to a service.
3) unitPrice contains the charge or cost per point, which maps to the cost per one unit of the service.
4) unitPrice is of type Money, which is a descendant of the Quantity complex type and inherits value, unit, system, code, and comparator.
5) Workgroup in charge of ServiceRequest wants to work with the Claim workgroup to determine best approach. One potential approach is to update the scope of ClaimResponse since that reflects what has been approved rather than what is being asked for.
Service Information Total Cost of Service The total cost of a service for the plan. CarePlan → activity
→ reference(ServiceRequest)

ServiceRequest → supportingInfo(Claim)

Claim → item → net		 CarePlan
...activity 0..*
......reference(ServiceRequest) 0..1
.........supportingInfo(Claim) 0..*
............item 0..*
...............net 0..1		 1) Will use CarePlan → activity → reference to reference a ServiceRequest, and supportingInfo to reference a Claim.
2) item maps to a service.
3) net is the total cost of an item, which in this case is the total cost for the service.
4) net is of type Money, which is a descendant of the Quantity complex type and inherits value, unit, system, code, and comparator.
5) See above.
Data Requirements Not Specific to eLTSS Dataset Data Elements
This section documents data elements that are mandatory per FHIR XML schemas or US Core requirements, but that do not align with individual eLTSS Dataset data elements.
FHIR Data Element Name
Requirement Source		 Data Element Definition FHIR R4 Resource Element(s) FHIR R4 Resource Element Cardinality (with US Core Constraints) Additional Mapping Details
Claim Created
FHIR		 The date this resource was created. Claim → created Claim
...created 1		 1) created is required by FHIR. Could use date signers signed or agency authorized. Suggest using date/time that signers signed.
Claim Insurance
FHIR		 Financial instruments for reimbursement for the health care products and services specified on the claim. Claim → insurance Claim
...insurance 1		 1) insurance is required by FHIR.
Claim Insurance Sequence
FHIR		 A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order. Claim → insurance → sequence Claim
...insurance 1
......sequence 1		 1) sequence is required by FHIR and is a positiveInt. Suggest using "1".
Claim Insurance Focal
FHIR		 A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. Claim → insurance → focal Claim
...insurance 1
......focal 1		 1) focal is required by FHIR and is a boolean. Suggest using "true".
Claim Insurance Coverage
FHIR		 Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system. Claim → insurance → coverage Claim
...insurance 1
......coverage 1		 1) coverage is required by FHIR and references Coverage.
Claim Item ProductOrService
FHIR		 When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Claim → item → productOrService Claim
...item 0..*
......productOrService 1		 1) productOrService is required by FHIR and must use the USCLS Codes value set (http://hl7.org/fhir/valueset-service-uscls.html). Suggest using the value "99555" for expense.
Claim Patient
FHIR		 The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought. Claim → patient Claim
...patient 1		 1) patient is required by FHIR and references Patient.
Claim Priority
FHIR		 The provider-required urgency of processing the request. Claim → priority Claim
...priority 1		 1) priority is required by FHIR and must use the Process Priority Codes value set (http://hl7.org/fhir/valueset-process-priority.html). Possible values are: stat, normal, deferred. Suggest using "normal".
Claim Provider
FHIR		 The provider which is responsible for the claim, predetermination or preauthorization. Claim → provider Claim
...provider 1		 1) provider is required by FHIR and references Practitioner, PractitionerRole, Organization. Suggest using Practitioner or Organization.
Claim Status
FHIR		 The status of the resource instance. Claim → status Claim
...status 1		 1) status is required by FHIR, and must use the Financial Resource Status Codes value set (http://hl7.org/fhir/valueset-fm-status.html). Possible values are: active, cancelled, draft, entered-in-error. Suggest using "active".
Claim Type
FHIR		 The category of claim, e.g. oral, pharmacy, vision, institutional, professional. Claim → type Claim
...type 1		 1) type is required by FHIR, and contains the extensible Claim Type Codes value set (http://hl7.org/fhir/valueset-claim-type.html). Possible values are: institutional, oral, pharmacy, professional, vision. Could use "professional", could extend code list, or could use text data element that is part of codeable concept.
Claim Use
FHIR		 A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future. Claim → use Claim
...use 1		 1) use is required by FHIR, and must use the Use value set (http://hl7.org/fhir/valueset-claim-use.html). Possible values are: claim, preauthorization, predetermination. Suggest using "preauthorization"
Claim Item Sequence
FHIR		 A number to uniquely identify item entries Claim → item → sequence Claim
...item 0..*
......sequence 1		 1) sequence is required by FHIR, and is a positive integer.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Claim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..* Claim Claim, Pre-determination or Pre-authorization
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... resource-pertainsToGoal S 0..* Reference(Goal) The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... patient 1..1 Reference(Patient_eltss) The recipient of the products and services
... enterer 0..1 Reference(Practitioner_eltss | eLTSS PractitionerRole Profile) Author of the claim
... related
.... claim 0..1 Reference(Claim_eltss) Reference to the related claim
... payee
.... party 0..1 Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile | Patient_eltss | eLTSS RelatedPerson Profile) Recipient reference
... referral 0..1 Reference(ServiceRequest_eltss) Treatment referral
... facility 0..1 Reference(Location_eltss) Servicing facility
... careTeam
.... provider 1..1 Reference(Practitioner_eltss | eLTSS PractitionerRole Profile | US Core Organization Profile) Practitioner or organization
... diagnosis
.... Slices for diagnosis[x] 1..1 CodeableConcept, Reference(Condition) Nature of illness or problem
Slice: Unordered, Open by type:$this
..... diagnosis[x]:diagnosisReference 0..1 Reference(Condition_eltss) Nature of illness or problem
... accident
.... Slices for location[x] 0..1 Address, Reference(Location) Where the event occurred
Slice: Unordered, Open by type:$this
..... location[x]:locationReference 0..1 Reference(Location_eltss) Where the event occurred
... item S 0..* BackboneElement Product or service provided
.... unitPrice S 0..1 Money Service Rate per Unit name
.... net S 0..1 Money Total Cost of Service

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron