CARIN Consumer Directed Payer Data Exchange
0.3.1 - STU1

CARIN Consumer Directed Payer Data Exchange, published by HL7 Financial Management Working Group. This is not an authorized publication; it is the continuous build for version 0.3.1). This version is based on the current content of https://github.com/HL7/carin-bb/ and changes regularly. See the Directory of published versions

Terminology

Code Systems Requiring Licenses

Access to Licensed Code Systems

This HL7 specification contains and references intellectual property owned by third parties ("Third Party IP"). Implementers and testers of this specification SHALL abide by the license requirements for each terminology content artifact utilized within a functioning implementation. Terminology licenses SHALL be obtained from the Third Party IP owner for each code system and/or other specified artifact used. It is the sole responsibility of each organization deploying or testing this specification to ensure their implementations comply with licensing requirements of each Third Party IP.

Licensed Industry Standard Code Systems

This IG includes value set bindings to code systems that reference industry standard codes which require implementers to purchase a license before the coded concepts can be used. The following information summarizes the set of licensed Code Systems required by this IG and provides links to the information about where to go to obtain a license.
  • AMA CPT: The CPT procedure and modifier codes are owned by the American Medical Association.
  • X12: CARC (Claim Adjustment Reason Codes are owned by X12.</a>.
  • NUBC: The NUBC secretariat is the American Hospital Association..
  • NUCC: National Uniform Claim Committee (NUCC) is presently maintaining the Taxonomy code set. The codes are free and publically available for download and use. If the use however is “For commercial use, including sales or licensing, a license must be obtained”. It would be appropriate for an app developer to file the license form just like they would for any other code set; however, there is no fee.
  • NCPDP: Retail Pharmacy data standards are defined by the NCPDP. .

Code Systems Not Requiring Licenses

This IG includes value set bindings to code systems that are industry standard codes available for use without licenses. The following information summarizes the set of Code Systems required by this IG that are available for use:
  • ICD-CM Diagnosis Codes (ICD-10-CM): International Statistical Classification of Diseases and Related Health Problems (ICD). This IG will use version 10. The ICD-10-CM code set is maintained by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC) for use in the United States. It is based on ICD-10, which was developed by the World Health Organization (WHO) and is used internationally a medical classification.
  • ICD-Procedure Codes (ICD-PCS): The ICD-10-PCS code set is owned by CMS..
  • DRGs.:All versions of the DRG (MS-DRG, AP-DRG, etc.) are owned by CMS. MS-DRGs are used for the Medicare population.
  • HCPCS Level II Procedure and Modifier Codes: Primarily include non-physician products, supplies, and procedures not included in CPT. They are owned by CMS and are available for use.
  • NDC (National Drug Codes): The US Federal Drug Administration (FDA) Data Standards Council assigns the first 5 digits of the 11 digit code..
  • RARCCodes: The RARC codes are owned by CMS..

Value Sets defined as part of this Implementation Guide.

Name Definition
AMA CPT and CMS HCPCS Modifier Codes AMA CPT and CMS HCPCS Modifier Codes
AMA CPT and CMS HCPCS Procedure Codes AMA CPT and CMS HCPCS Procedure Codes
Adjudication CARINBB Value Codes As per Jira FHIR-26992... HL7 Requested to fix HL7 Adjudication codesystem
Adjudication Denial Reason Reason codes used to interpret the adjudication denial reason. X12 CARC + CMS RARC
Adjudication Slice Codes Codes used to discriminate slices of adjudication and item.adjudication
Benefit Payment Status Indicates the in network or out of network payment status of the claim.
Benefit Payment Status Category Benefit Payment Status Category
CARINBB Institutional Claim Care Team Roles Indicates the role of the provider providing the care.
CARINBB Pharmacy CareTeam Roles Indicates the role of the provider providing the care.
CARINBB Professional and Non-Clinician CareTeam Roles Indicates the role of the provider providing the care.
CMS Place of Service https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html . The link takes one to the Place of Service list as an html document; it is not a file to which an IG can be bound. The code set is owned by CMS and is available for use.
CMS-DRG CMS-DRG
Claim Adjudication Category Values for EOB.item.adjudication.category, as per Igor
Claim Information Category Claim Information Category - Used as the discriminator for supportingInfo
Claim Payment Status Code Indicates whether the claim / item was paid or denied.
Diagnosis Type -- Inpatient Facility Payer Inpatient Facility Diagnosis Type
Diagnosis Type -- Outpatient Facility Payer Outpatient Facility Diagnosis Type
Diagnosis Type -- Professional and Non-Clinician Payer Professional and Non-Clinician Diagnosis Type
FDA NDC NCPDP Compound Code NCPDP field # 407-D7 (National Drug Code (NDC)) or NCPDP field # 406-D6 (Compound Code)
FDA National Drug Code (NDC) FDA National Drug Code (NDC)
ICD-10-CM Diagnosis Codes ICD-10-CM Diagnosis Codes. ***We need ALL Codes, inactive and inactive. Current binding is to active codes only***
ICD-10-PCS ICD-10-PCS
NCPDP Brand Generic Code http://www.ncpdp.org/brand-generic-code
NCPDP Dispensed As Written (DAW) http://www.ncpdp.org/dispensed-as-written-or-product-selection-code
NCPDP Prescription Origin Code http://www.ncpdp.org/prescription-origin-code
NCPDP Reject Code http://www.ncpdp.org/reject-code
NUBC Patient Discharge Status NUBC Patient Discharge Status
NUBC Present On Admission NUBC Present On Admission
NUBC Priority of Admission NUBC Priority of Admission
Patient Identifier Type Patient Identifier Type
Payer Adjudication Amount Category This describes the various amount fields used when payers receive and adjudicate a claim.
Provider Provider Contracting Status Indicates that the Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission.

Code Systems defined as part of this Implementation Guide.

Name Definition
Adjudication Slice Codes Codes used to discriminate slices of adjudication and item.adjudication
Claim Adjudication Category Values for EOB.item.adjudication.category and total.category
Claim Information Category Claim Information Category - Used as the discriminator for supportingInfo
Identifier Type Identifier Type
Payer Adjudication Category Payer Adjudication Category
Payer Diagnosis Type Payer Diagnosis Type
Payer Provider Role Payer Provider Role