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

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.

CARIN BlueButton Consumer App CapabilityStatement

The Section describes the expected capabilities of the Consumer-Directed Payer Data Exchange Consumer App which is responsible for creating and initiating the queries for information about an individual patient. The complete list of FHIR profiles, RESTful operations, and search parameters supported by Consumer-Directed Payer Data Exchange Servers are defined in the Conformance Requirements for Server. Consumer-Directed Payer Data Exchange Consumer Apps have the option of choosing from this list to access necessary data based on their local use cases and other contextual requirements.

Consumer-Directed Payer Data Exchange HealthPlan API CapabilityStatement

This Section describes the expected capabilities of the Consumer-Directed Payer Data Exchange Server actor which is responsible for providing responses to the queries submitted by the Consumer-Directed Payer Data Exchange Requestors. The complete list of FHIR profiles, RESTful operations, and search parameters supported by Consumer-Directed Payer Data Exchange Servers are defined.

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.

ExplanationOfBenefit_Identifier

The business/claim identifier of the Explanation of Benefit

ExplanationOfBenefit_Patient

The reference to the patient

ExplanationOfBenefit_ServiceDate

Date of the service for the EOB

ExplanationOfBenefit_Type

The type of the ExplanationOfBenefit

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.

CARIN BB 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

CARIN BB Coverage

CARIN Blue Button Coverage Profile.

CARIN BB ExplanationOfBenefit Inpatient Facility

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 a facility 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 as form CMS-1450.

CARIN BB ExplanationOfBenefit Outpatient Facility

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 facility 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 as form CMS-1450.

CARIN BB 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)

CARIN BB 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.

CARIN BB Location

CARIN Blue Button Location Profile.

CARIN BB Organization

CARIN Blue Button Organization Profile.

CARIN BB Patient

CARIN Blue Button Patient Profile.

CARIN BB Practitioner

CARIN Blue Button Practitioner Profile.

CARIN BB PractitionerRole

CARIN Blue Button PractitionerRole Profile.

Structures: Extension Definitions

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

Adjudication Type

An extension to provide a human-readable description of an organization.

Terminology: Value Sets

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

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 Category

Benefit Payment Status Category

Benefit Payment Status

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

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-DRG

CMS-DRG

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.

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

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.

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.

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

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.

Terminology: Code Systems

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

Adjudication Slice Codes

Codes used to discriminate slices of adjudication and item.adjudication

Payer Provider Role

Payer Provider Role

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

Example: Example Instances

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

BBEobPharmacy

BBEoB from Jeff

Coverage1

Coverage Example1

EOBInpatient1

EOB Inpatient Example1

EOBOutpatientFacility1

EOB Outpatient Example1

EOBPharmacy1

EOB PHarmacy Example1

EOBProfessional1

EOB Professional Example1

OrganizationPayer1

Payer1

OrganizationProvider1

Provider 1

Patient1

Patient Example1