Profile: MII_PR_MTB_Antrag_Kostenuebernahme Parent: Claim Id: mii-pr-mtb-antrag-kostenuebernahme Title: "MII PR MTB Antrag Kostenuebernahme" Description: "Antrag Kostenübernahme" * insert PR_Header * status MS * status = #active (exactly) * status ^short = "Antrag" * status ^definition = "Status der FHIR-Ressource - statisch auf #active gesetzt" * type MS * type from MII_VS_MTB_Antrag_Kostenuebernahme_Type * type ^short = "Kategorie des Antragstellers" * type ^definition = "Kategorie des Antragstellers - z.B. stationär, ambulant, Apotheke" * use MS * use ^short = "Art des Kostenerstattungsantrags (claim, predetermination, preauthorization)" * use ^definition = "folgt den Definitionen wie im amerikanischen Gesundsheitswesen gebräuchlich. claim: Erstattungsantrag nach erfolgter Therapie; predetermination: unverbindliche Anfrage, insb. zu Anteilen der Kostenübernahme; preauthorization: Anfrage nach möglicher Erstattung für zukünftige Therapie" * patient MS //* patient only Reference(Patient) das ist redundant * created MS * created ^short = "Antragsdatum" * created ^definition = "Datum der Antragstellung" * provider MS * provider ^short = "Antragstellende Einrichtung / Klinik / Person" * provider ^definition = "Einrichtung, die den Antrag stellt. In der Regel die Klinik, die den Patienten behandelt" //* provider only Reference(Organization) * priority MS * priority = $process-priority#normal * priority ^short = "Priorität des Antrags" * priority ^definition = "Priorität des Antrags. Pflichtfeld in FHIR, aber nicht in der MII-Logik relevant" // TODO: Überlegen ob prescription die richtige Wahl für Therapieempfehlung ist * prescription MS * prescription ^short = "Therapieempfehlung" * prescription ^definition = "Verweis auf die Therapieempfehlung des MTB, die zu diesem Antrag führt" * prescription only Reference(MedicationRequest) * insurance MS * insurance.sequence MS * insurance.sequence ^short = "Priorität der Versicherung" * insurance.sequence ^definition = "Priorität der Versicherung. In der Regel 1 für die Hauptkrankenversicherung, und fortlaufend für weitere freiwilligge Zusatzversicherungen. Wird vsl. selten relevant sein." * insurance.focal MS * insurance.focal = true * insurance.focal ^short = "Versicherung relevant für diesen Antrag" * insurance.coverage MS * insurance.coverage only Reference(Coverage) * insurance.coverage ^short = "Versicherung relevant für diesen Antrag" * insurance.claimResponse MS * careTeam ^slicing.discriminator.type = #type * careTeam ^slicing.discriminator.path = "sequence" * careTeam ^slicing.rules = #open * careTeam ^slicing.description = "Slice für Antragsstellung ZPM" * careTeam ^slicing.ordered = false * careTeam contains ZPMBeteiligung 1..* MS * careTeam[ZPMBeteiligung] ^short = "Antragstellung ZPM" * careTeam[ZPMBeteiligung] ^definition = "Verweis auf entsprechendes Feld in NGS Bericht und/oder IHC (Verweis auf KDS Molekular-Pathologischer Befundbericht)" * careTeam[ZPMBeteiligung] 1..1 MS * careTeam[ZPMBeteiligung].sequence MS * careTeam[ZPMBeteiligung].sequence = 1 * careTeam[ZPMBeteiligung].sequence ^short = "interne Variable der beteiligten Einrichtung" * careTeam[ZPMBeteiligung].provider MS * careTeam[ZPMBeteiligung].provider only Reference(Organization) * careTeam[ZPMBeteiligung].provider ^short = "Verweis auf ZPM" * careTeam[ZPMBeteiligung].provider ^definition = "Verweis auf Antragstellendes ZPM (z.B. ZPM ID)" * careTeam[ZPMBeteiligung].responsible 1..1 MS * careTeam[ZPMBeteiligung].responsible ^short = "Beteiliung ZPM - Ja/Nein" * careTeam[ZPMBeteiligung].responsible ^definition = "Beteiliung des ZPM - Ja/Nein" * related MS /* related ^slicing.discriminator.type = #value * related ^slicing.discriminator.path = "type" * related ^slicing.rules = #open * related ^slicing.description = "Stadium des Antrags auf Kostenübernahme" */ * related.claim 0..1 MS * related.claim ^short = "bei Folgeantrag/Widerspruch: Verweis auf ursprünglichen Erstantrag" * related.claim ^definition = "Verweis auf ursprünglichen Erstantrag, der zu diesem Folgeantrag oder Widerspruch führt" * related.claim only Reference(MII_PR_MTB_Antrag_Kostenuebernahme) * related.relationship MS * related.relationship.coding 1..* MS * related.relationship.coding ^short = "Antragsstadium" * related.relationship.coding ^definition = "Stadium des Antrags auf Kostenuebernahme - Erstantrag, Widerspruch, Folgeantrag, Unbekannt. Bei Widerspruch oder Folgeantrag ist der Verweis auf den Erstantrag erforderlich" * related.relationship.coding.system = $mii-cs-mtb-antrag-kostenuebernahme-antragsstadium * related.relationship.coding.code 1..1 MS // certainly works, not sure whether this is the best way to do this. moved business logic to related above /* * extension contains MII_EX_MTB_Antrag_Kostenuebernahme_Antragsstadium named Antragsstadium 1..1 MS * extension[Antragsstadium] ^short = "Antragsstadium" * extension[Antragsstadium] ^definition = "Stadium des Antrags auf Kostenübernahme - Erstantrag, Widerspruch, Folgeantrag, Unbekannt" */ /*# Understanding Healthcare Claims Terminology In healthcare insurance systems, particularly in the United States, there are three distinct but related processes that are often confused: claims, pre-determinations, and pre-authorizations. Here's how they differ: ## Healthcare Claims A healthcare claim is a formal request submitted by a healthcare provider (like a hospital or doctor's office) to an insurance company seeking reimbursement for medical services provided to a patient[1]. This document includes: - Patient information - Details of services provided - Associated medical codes - Total cost of treatment[8] Claims are submitted after the medical service has been delivered and contain unique medical codes detailing the care administered, including diagnoses, procedures, medical supplies, devices, pharmaceuticals, and transportation[8]. ## Pre-determination Pre-determination is a process where healthcare providers submit details of a proposed medical or dental procedure to the insurer before treatment[9]. This process: - Helps determine if a specific procedure will be covered under the patient's insurance policy[9] - Confirms what percentage of the treatment is covered[7] - Specifies the approved payment amount and the patient's financial responsibility[9] - Does not guarantee final approval[9] - Is optional but recommended for services that may be considered experimental or investigational[9] Pre-determination essentially gives both the provider and patient advance knowledge about coverage and potential costs, helping to avoid unexpected expenses[10]. It's typically done using a claim form that includes patient details, procedure codes, charges, and provider information[7]. ## Pre-authorization (Prior Authorization) Pre-authorization (also called prior authorization, preauthorization, or prior approval) is a required approval process that must be completed before a patient receives certain treatments or medications[5][9]. This process: - Is mandatory for specific services, unlike pre-determination which is optional[9] - Determines if the patient is eligible for certain procedures, medications, or tests[9] - Assesses whether a service or treatment is medically necessary[9] - Is typically required for expensive medications, treatments, invasive procedures, and imaging scans[9] - Must be obtained before services are provided, or the insurance may not cover the cost[6] Pre-authorization confirms whether patients have the recommended treatment covered by their insurance company, while pre-determination provides more detailed information about coverage percentages and payment specifics[7]. ## Key Differences - **Timing**: Claims are submitted after services are provided; pre-determinations and pre-authorizations happen before treatment. - **Purpose**: Claims request payment; pre-determinations check coverage details; pre-authorizations seek mandatory approval. - **Requirement**: Claims and pre-authorizations are mandatory processes; pre-determinations are optional but recommended. - **Consequence**: Without pre-authorization, insurance may deny coverage completely; pre-determination helps avoid surprises but isn't required[10]. Understanding these distinctions is important for patients to navigate healthcare systems effectively, especially in countries with private insurance models like the United States. Citations: [1] https://thessigroup.com/blog/understanding-the-healthcare-claim-life-cycle-from-patient-registration-to-payment/ [2] https://www.iciciprulife.com/health-insurance/health-insurance-claim.html [3] https://datamatrixmedical.com/insurance-predetermination-vs-prior-authorization/ [4] https://www.rcmmastersacademy.com/blog/what-is-pre-determination-in-medical-billing [5] https://www.priorauthtraining.org/prior-authorization/ [6] https://en.wikipedia.org/wiki/Prior_authorization [7] https://www.caplinedentalservices.com/what-is-the-difference-between-prior-authorization-and-predetermination/ [8] https://www.definitivehc.com/blog/medical-claims-101-what-you-need-to-know [9] https://www.outsourcestrategies.com/blog/predetermination-vs-prior-authorization/ [10] https://www.bradybilling.com/blog/preauthorization-predetermination/ [11] https://primarycareins.com/everything-you-need-to-know-about-the-importance-of-predetermination/ [12] https://www.definitivehc.com/resources/glossary/claim [13] https://www.healthysteps.org/wp-content/uploads/2023/07/Medical-Claims-101-How-to-avoid-common-denial-and-rejection-pitfalls_2022.pdf [14] https://www.ehealthinsurance.com/resources/individual-and-family/what-is-a-health-insurance-claim [15] https://www.healthpartners.com/blog/medical-claim/ [16] https://azzly.com/blog/understanding-encounters-and-claims-in-healthcare/ [17] https://food.ec.europa.eu/food-safety/labelling-and-nutrition/nutrition-and-health-claims/health-claims_en [18] https://en.wikipedia.org/wiki/Health_claim [19] http://plus.telushealth.co/page/eclaims/help/learningcorner/Submitting_a_predetermination.htm [20] https://www.bcbsil.com/PDF/sprint_understanding_predetermination.pdf [21] http://clienthelp.grouphealth.ca/wp-content/uploads/2018/08/20180430_FYB_Predetermination-of-Benefits.pdf [22] https://www.omsp.com/blog/pre-authorization-vs-predetermination/ [23] https://hr.virginia.edu/sites/default/files/IMPACT%20COE/Benefits/Predetermination_Flyer_08122021.pdf [24] https://w.bcbsmt.com/static/mt/provider/pdf/predetermination-general-interactive-request-form-mt.pdf [25] https://www.ama-assn.org/practice-management/prior-authorization/prior-authorization-practice-resources [26] https://www.healthinsurance.org/glossary/prior-authorization/ [27] https://practicesuite.com/preauthorization/ [28] https://www.ama-assn.org/practice-management/prior-authorization/what-doctors-wish-patients-knew-about-prior-authorization [29] https://www.health.harvard.edu/staying-healthy/prior-authorization-what-is-it-when-might-you-need-it-and-how-do-you-get-it [30] https://www.cigna.com/knowledge-center/what-is-prior-authorization [31] https://www.patientadvocate.org/download-view/what-does-an-approved-pre-authorization-mean/ [32] https://pmc.ncbi.nlm.nih.gov/articles/PMC10391030/ [33] https://w.bcbsmt.com/provider/claims-and-eligibility/predetermination-and-preauthorization [34] https://www.dentalclaimsupport.com/blog/dental-predetermination-and-preauthorizations?hs_amp=true [35] https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives [36] https://publicsitestx.hcsc.net/provider/claims/um.html [37] https://www.onsurity.com/blog/how-does-the-health-insurance-claim-process-work/ [38] https://mbamedical.com/blog/what-is-a-medical-claim/ [39] https://www.businessnewsdaily.com/16237-medical-claims-how-to.html [40] https://www.healthinsurance.org/glossary/claim/ [41] https://www.linkedin.com/pulse/understanding-medical-claims-comprehensive-guide-shah-ch4bf [42] https://www.bcbsil.com/provider/claims/claims-eligibility/utilization-management/predetermination [43] https://www.verywellhealth.com/prior-authorization-1738770 [44] https://www.patientadvocate.org/wp-content/uploads/What-does-an-Approved-Pre-Authorization-Mean-1.pdf [45] https://portiva.com/preauthorization-vs-authorization-in-healthcare/ [46] https://annexmed.com/comprehensive-guide-to-pre-authorization/ [47] https://www.adonis.io/resources/what-is-prior-authorization-in-healthcare-all-you-need-to-know [48] https://www.priorauthtraining.org/the-importance-of-prior-authorization-in-healthcare/ [49] https://www.bostonscientific.com/content/dam/bostonscientific/Reimbursement/Neuromodulation/preauth/Pre%20Authorization%20Reference%20Guide.pdf --- Answer from Perplexity: pplx.ai/share*/