CARIN Blue Button Framework and Common Payer Consumer Data Set - PowerPoint Presentation

1. CARIN Blue Button Framework and Common Payer Consumer Data SetEmpowering consumers with their health plan data

2. Our Template : The Argonaut ProjectBackground: The Argonaut Project was formed in December 2014 as an implementation community comprising leading technology vendors and provider organizations to accelerate the use of FHIR and OAuth in health care information exchange. The Argonaut project is private-sector initiated and funded and works collaboratively with other FHIR initiatives to create open industry Implementation Guides in high priority use cases of importance to patients, providers and the industry as a whole. Deliverables: Focused on the ONC’s 2015 Edition Common Clinical Data Set (CCDS) to co-develop the SMART App Application Guide using the OAuth 2.0 profile for authorizing apps to access FHIR data and the Argonaut Data Query Implementation Guide (FHIR DSTU2). Timeline: As of October 2018:IG Publication – Mid 2016 (1 ½ years) 82% of all Hospitals using FHIR DSTU2Full Implementation – 2016 to 2019 (3 years) 64% of all Physicians using FHIR DSTU2

3. Why do we need more ‘Argonaut-like’ efforts?Standards development process, by design, values comprehensiveness over speed-to market Market input is needed to make standards relevant and usable Identification of priority use cases to meet market needs Development of well-packaged implementation guides Facilitation of testing and implementation community Coupling with other standards or protocols needed for implementation (e.g., security) Implementers need to have greater input (i.e., deeper, earlier) into standards development Need to get as much collaboration as early as possible in the cycle to head off problems of heterogeneous implementations down the roadConsumer platform companies have the ability to scale standards August 2018 – Amazon, Google, IBM, Microsoft, IBM, Oracle, Salesforce pledged to promote open standards in health care*Largely taken from March 2018 Argonaut Project presentation at HL7

4. CARIN Blue Button FrameworkLeverage the Argonaut Project as a best practice approachCommon Payer Consumer Data Set (CPCDS)Includes key health data that should be accessible and available for exchange.Data must conform with specified vocabulary standards and code sets.CPCDS data elements can be stored and queried as profiled FHIR resources.Data Query ProfilesBased on CPCDS, define the minimum mandatory elements, extensions and terminology requirements that must be present in the FHIR resource.Data Query Implementation GuideCollection of security specifications, profile definitions and supporting documentation.The guide satisfies use cases for member access to health plan data, ensuring the CPCDS elements are included and modeled in a standard format.Flat File Format Specification Representing CPCDS Data ElementsMapping From Flat File Format To FHIR Resource Profiles

5. Argonaut & CARIN Blue Button FrameworkArgonaut ProjectCARIN Blue Button FrameworkLogical Data SpecificationCommon Clinical Data Set (CCDS)Common Payer Consumer Data Set (CPCDS)Physical Data Specification Using FHIR (Data Query)FHIR Resource Profiles Representing CCDS Data ElementsFHIR Resource Profiles Representing CPCDS Data ElementsPhysical Data Specification Using Flat FileNoneFlat File Format Specification Representing CPCDS Data ElementsDocument QueryDocumentReference Profile Exposing Patient’s Existing Clinical DocumentNoneFlat File to FHIR TranslationNot ApplicableMapping From Flat File Format To FHIR Resource ProfilesAuthorizationSMART on FHIRSMART on FHIR/OAuth2

6. BB 2.0 API Using CARIN Blue Button FrameworkHow can Plans leverage the CARIN Blue Button Framework?Map directly to FHIR ProfilesCreate a direct mapping from the Claims SOR to FHIR Profiles.Map to FHIR Profiles using Flat File as a bridgeGenerate Flat File extracts from the Claims SOR using existing ETL tools and processes.Leverage CARIN Framework’s common mapping from Flat File format to FHIR Profiles.Sharing and reuse of direct mappings from some Claims SORs in option 1 may be limited due to license restrictions or varying versions, configurations or hosting implementations.Option 2’s bridge mapping introduces additional step & governance.Option 2’s bridge mapping may be easier to manage than option 1’s when using mature, enterprise grade ETL tools and processes.

7. CARIN Blue Button FrameworkFHIR ServerKeyHealth Plan AHealth Plan BFHIR ProfilesFlat File FormatCARIN Blue Button Framework with CPCDSMedicareHealth Plan Covered Entities/BAsApp AApp BCPCDS – Common Payer Consumer Data Set (Claims, Eligibility, Benefits)CMS BB 2.0 HIPAA IndividualRight of Access APIConsumer AppsApp ZCCW RIFFHIRHealth Plan CClaims SOR2Facets v4Claims SOR1CPCDSFHIR Extensions, Profiles & Implementation GuidesMappings & TerminologiesHealth Plan DFacets v3Claims SOR3SOR – System of RecordMappingCustom CSVCovered Entity/BAData Hub AMulti-plan Data WarehouseHealth Plan ZClaims SOR4

8. DeliverablesDefine how to meet CMS Blue Button 2.0Define the logical data set (similar to ONC 2015 Edition Common Clinical Data Set) that meets CMS Blue Button 2.0 API content – Common Payer Consumer Data Set (CPCDS) version 1.0Define the FHIR Resource Profiles that map to CPCDS version 1.0 data elementsDefine next versions that exceed CMS Blue Button 2.0Define Flat File BridgeDefine Flat File format specification representing logical CPCDS data elementsDefine mapping from Flat File format to FHIR Resource ProfilesDefine the checklist for launching the CARIN Blue Button FrameworkImplementation Guide & ProfilesFlat File specification & mappingTest harnessReference implementations

9. ExceedsCommon Payer Consumer Data Set (CPCDS) v1.0MeetsCPCDS v1.0CMS Medicare Blue Button 2.0 APIHealth Plan #2Health Plan #1HCCIIn March 2018, CMS launched Blue Button 2.0, which provides secure beneficiary-directed data transport in a structured Fast Healthcare Interoperability Resources (FHIR) format that is developer-friendly. This will enable beneficiaries to connect their data to applications, services, and research programs they trust. Blue Button 2.0 uses open source code that is available for all plans at https://bluebutton.cms.gov/developers/.In February 2019, CMS issued the Interoperability and Patient Access Proposed Rule. Under this proposal, the scope and volume of the information to be provided or made accessible through the open API would include: adjudicated claims (including cost); encounters with capitated providers; provider remittances; enrollee cost-sharing; and clinical data, including laboratory results (where available)Data Element Consensus

10. Two Implementation Paths To Blue Button 2.0 API (FHIR Profiles)

11. Proposed Common Payer Consumer Data Set (CPCDS) v1.0 – Draft

12. Claim#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]1Claim service start dateCLM_FROM_DT[CLM_FST_DT]2Claim service end dateCLM_THRU_DT[LST_DT]3Claim paid datePD_DT[PAID_DT]4Claim received dateNCH_WKLY_PROC_DT5Member admission dateCLM_ADMSN_DTThe date corresponding with the onset of services. Inpatient only. [FST_ADMTDT]6Member discharge dateNCH_BENE_DSCHRG_DT Inpatient only. [LAST_DISCHDT]7Patient account numberProvider submitted information that can be included on the claim8Medical record number9Claim unique identifierCLM_ID[Z_CLMID]10Claim adjusted from identifierTBD: Merged claims11Claim adjusted to identifier12Claim diagnosis related groupCLM_DRG_CD Inpatient only. [DRG]#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]13Claim inpatient source admission codeCLM_SRC_IP_ADMSN_CD Inpatient only. [ADMIT_TYPE]14Claim inpatient admission type codeCLM_IP_ADMSN_TYPE_CD Inpatient only. [ADMIT_SRC]15Claim bill facility type codeCLM_FAC_TYPE_CDType of bill code structure – Type of facility [TOB (1st character)]16Claim service classification type codeCLM_SRVC_CLSFCTN_TYPE_CDType of bill code structure – Type of care [TOB (2nd character)]17Claim frequency codeCLM_FREQ_CDType of bill code structure – Sequence in this episode of care [TOB (3rd character)]18Claim status codedenied,completed..etc19Claim type codeNCH_CLM_TYPE_CDMedical, vision, dental20Claim sub type codeNCH_NEAR_LINE_REC_IDENT_CD21Patient discharge status codePTNT_DSCHRG_STUS_CDFacility only. [DSTATUS]22Claim payment denial codeCARR_CLM_PMT_DNL_CD / CLM_MDCR_NON_PMT_RSN_CDCARC/RARC, excd disallowed code

13. Claim#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]23Claim primary payer codeNCH_PRMRY_PYR_CDType of carrier [PRIMARY_COV_IND]24Claim payee type codeRecipient of benefits payable25Claim payee Recipient reference

14. Claim#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]13Claim other physician network status14Claim rendering physician NPIRNDRNG_PHYSN_NPI15Claim rendering physician network status16Claim service location NPISRVC_LOC_NPI_NUM17Claim PCP[PCP]Claim prescriber NPI#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]Provider1Claim billing provider NPICARR_CLM_BLG_NPI_NUM [HNPI_BE]2Claim billing provider network status3Claim attending physician NPIAT_PHYSN_NPI[HNPI]4Claim attending physician network status5Claim site of service NPICARR_CLM_SOS_NPI_NUM6Claim referring provider NPICARR_CLM_RFRNG_PIN_NUM7Claim referring provider network status8Claim performing provider NPIPRF_PHYSN_NPI[HNPI]9Claim performing provider network status10Claim operating physician NPIOP_PHYSN_NPI11Claim operating physician network status12Claim other physician NPI OT_PHYSN_NPI

15. Claim#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]Amounts1Claim total submitted amountCLM_TOT_CHRG_AMTSubmitted charge amount* [CHARGE]2Claim total allowed amountNCH_CARR_CLM_ALOWD_AMT* [CALC_ALLWD]3Amount paid by patientPTNT_PAY_AMTPDE* [TOT_MEM_CS]4Claim amount paid to providerCARR_CLM_PRMRY_PYR_PD_AMT* [AMT_NET_PAID]5Member reimbursementNCH_CLM_BENE_PMT_AMT6Claim payment amountCLM_PMT_AMTBy Payer* [AMT_NET_PAID]7Claim disallowed amountNCH_IP_NCVRD_CHRG_AMT*8Member paid deductibleNCH_BENE_IP_DDCTBL_AMT* [DEDUCT]9Co-insurance liability amountNCH_BENE_PTA_COINSRNC_LBLTY_AMT* [COINS]10Copay amount[COPAY]11Member liabilityE.g. Non-contracted provider*12Claim primary payer paid amountNCH_PRMRY_PYR_CLM_PD_AMT** = Situational

16. Claim (Pharmacy)#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]Drug1Days supplyDAYS_SUPLY_NUMNumber of days' supply of medication dispensed by the pharmacy [DAYS_SUP]2RX service reference numberRX_SRVC_RFRNC_NUMAssigned by the pharmacy at the time the prescription is filled3DAW product selection codeDAW_PROD_SLCTN_CDPrescriber's instruction regarding substitution of generic equivalents or order to dispense the specific prescribed medication [DAW]4Refill numberFILL_NUMThe number fill of the current dispensed supply (0, 1, 2, etc) [FST_FILL and RFL_NBR]5Prescription origin codeRX_ORGN_CDWhether the prescription was transmitted as an electronic prescription, by phone, by fax, or as a written paper copy#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]6Plan reported brand-generic codeBRND_GNRC_CDWhether the plan adjudicated the claim as a brand or generic drug [GNRC_IND]7Pharmacy service type codePHRMCY_SRVC_TYPE_CDType of pharmacy that dispensed the prescription8Patient residence codePTNT_RSDNC_CDWhere the beneficiary lived when the prescription was filled9Submission clarification codeSUBMSN_CLR_CDIndicates how many days’ supply of the medication was dispensed by the long-term care pharmacy and provides some details about the dispensing event. This variable is only populated when beneficiary lives in an LTC facility (i.e., when the PTNT_RSDNC_CD variable equals 03)

17. Claim Line#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]Line Service Details1Service (from) dateLINE_1ST_EXPNS_DTDispense/fill date (Rx). [FST_DT, FILL_DT]2Line numberLINE_NUM[CLMSEQ]3Service to dateLINE_LAST_EXPNS_DT[LST_DT]4Type of serviceLINE_CMS_TYPE_SRVC_CD5Place of service codeLINE_PLACE_OF_SRVC_CD[POS]6Revenue center codeREV_CNTRThe provider-assigned revenue code for each cost center for which a separate charge is billed (type of accommodation or ancillary) [RVNU_CD]7Number of unitsREV_CNTR_UNIT_CNTNum of times service or procedure performed [UNITS]8Allowed number of unitsMaximum allowed number of units9National drug codeLINE_NDC_CD[NDC]#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]10Compound codeCMPND_CDWhether or not the dispensed drug was compounded or mixed. [CMPD_IND]11Quantity dispensedREV_CNTR_NDC_QTY, QTY_DSPNSD_NUMQuantity dispensed for the drug. [QUANTITY]12Quantity qualifier codeREV_CNTR_NDC_QTY_QLFR_CDThe unit of measurement for the drug. (gram, ml, etc)13Line network indicator

18. #CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]6Line payment amount to providerLINE_PRVDR_PMT_AMTPayment made by Payer to the provider for the line item service on the noninstitutional claim. Additional payments may have been made to the provider - including beneficiary deductible and coinsurance amounts and/or other primary payer amounts.* [CALC_ALLWD]7Line patient deductibleLINE_BENE_PTB_DDCTBL_AMT* [DEDUCT]8Line primary payer paid amountLINE_BENE_PRMRY_PYR_PD_AMT*9Line coinsurance amountLINE_COINSRNC_AMT[COINS]10Line submitted amountLINE_SBMTD_CHRG_AMTProvider submitted charges for the line item service on the non-institutional claim* [CHARGE]Claim Line#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]Line Amount Details1Line non covered charged amountREV_CNTR_NCVRD_CHRG_AMTAmount related to a revenue center code for services that are not covered*2Line amount paid to memberLINE_BENE_PMT_AMTPayment (reimbursement) made to the beneficiary related to the line item service on the non-institutional claim* [TOT_MEM_CS]3Line patient paid amountREV_CNTR_PTNT_RSPNSBLTY_PMTAmount paid by the beneficiary to the provider for the line item service (outpatient)*4Drug costTOT_RX_CST_AMTPrice paid for the drug excluding mfr discounts5Line payment amountLINE_NCH_PMT_AMTPayment made by Payer (after deductible and coinsurance amounts have been paid) for the line item service on the non-institutional claim* [AMT_NET_PAID]* = Situational

19. Claim Line#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]11Line allowed amountLINE_ALOWD_CHRG_AMTAllowed charges for the line item service on the noninstitutional claim. This charge is used to compute pay to providers or reimbursement to beneficiaries. The amount includes both the line-item Payer and beneficiary-paid amounts (i.e. deductible and coinsurance)* [CALC_ALLWD]12Line member liabilityE.g. Non-contracted provider*13Line copay amount[COPAY]14Line discount** = Situational

20. Diagnoses & Procedures#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]Diagnosis (0-n)1Diagnosis codePRNCPAL_DGNS_CD, ICD_DGNS_CD(1-25)[ICD10_CM (1-25), DIAG(1-3)]Diagnosis description2Present on admissionCLM_POA_IND_SW(1-25)[POA (1-12)]3Diagnosis code typeICD_DGNS_VRSN_CD(1-25)ICD 9 or ICD 10 [DIAG1, ICD10_CM1]4Diagnosis typePrimary, 1-25primary, secondary, discharge, etc. [ICD10_CM(1-25)]5Is E codeICD_DGNS_E_CD1External cause of injury code. For hospital and emergency department visits, E-codes are used in addition to the diagnostic codes. They can be used as “other diagnosis”.#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]Procedure (0-n)1Procedure codeICD_PRCDR_CD(1-25)[ICD10_PCS(1-25)]Procedure description2Procedure datePRCDR_DT(1-25)[FST_DT]3Procedure code typeCPT/HCPCS/ICD-PCS4Procedure typeprimary, secondary, discharge, etc.5Modifier Code -1HCPCS_1ST_MDFR_CD[PROCMOD]6Modifier Code -2HCPCS_2ND_MDFR_CD[PROCMOD_2]7Modifier Code -3HCPCS_3RD_MDFR_CD[PROCMOD_3]8Modifier Code -4HCPCS_4TH_MDFR_CD[PROCMOD_4]

21. Member#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]1Member idBENE_IDUnique identifier to member [Z_PATID]2Date of birthDOB_DT[YBIRTH(SDDV1) or AGE_BAND_CD (SDDV2)]3Date of death4CountyBENE_COUNTY_CD[CBSA_CD]5StateBENE_STATE_CD[STATE]6Country7Race codeBENE_RACE_CD8Ethnicity9Gender codeGNDR_CD[GDR]10Name11Zip codeBENE_MLG_CNTCT_ZIP_CD[MBR_ZIP_5_CD]12Relationship to subscriber[REL_CD]13Subscriber id

22. Coverage#CPCDS ElementCMS Medicare BB 2.0 ElementNotes [HCCI Data Element]1Subscriber id2Coverage type3Coverage status4Start date5End date6Group id[Z_GROUP_ID]7Group name8Plan9Payer

23. CPCDS Data Dictionary & Resource Mapping

24. Claim#CPCDS ElementR4 ResourceProfile Element1Claim service start dateExplanationOfBenefit.billablePeriod2Claim service end dateExplanationOfBenefit.billablePeriod3Claim paid dateExplanationOfBenefit.payment.date4Claim received dateExplanationOfBenefit.claimReceived (Extension)5Member admission dateExplanationOfBenefit.supportingInfo.valueReference(Encounter).period6Member discharge dateExplanationOfBenefit.supportingInfo.valueReference(Encounter).period7Patient account numberPatient.identifier8Medical record numberPatient.identifier9Claim unique identifierExplanationOfBenefit.identifier10Claim adjusted fromExplanationOfBenefit.related11Claim adjusted toExplanationOfBenefit.related12Claim diagnosis related groupExplanationOfBenefit.supportingInfo.{category, code, valueReference(CodeableConcept)}13Claim inpatient source admission codeExplanationOfBenefit.supportingInfo.valueReference(Encounter).hospitalization.admitSource14Claim inpatient admission type codeExplanationOfBenefit.supportingInfo.valueReference(Encounter).type

25. Claim#CPCDS ElementR4 ResourceProfile Element15Claim bill facility type codeExplanationOfBenefit.supportingInfo.{category, code, valueString}16Claim service classification type codeExplanationOfBenefit.supportingInfo.{category, code, valueString}17Claim frequency codeExplanationOfBenefit.supportingInfo.{category, code, valueString}18Claim status codeExplanationOfBenefit.status19Claim type codeExplanationOfBenefit.type20Claim sub type codeExplanationOfBenefit.subType21Patient discharge status codeExplanationOfBenefit.supportingInfo.valueReference(Encounter).hospitalization.dischargeDisposition (https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd/ ) []22Claim payment denial codeExplanationOfBenefit.adjudication.{category, reason}23Claim primary payer codeExplanationOfBenefit?24Claim payee type codeExplanationOfBenefit.payee.type25Claim payee ExplanationOfBenefit.payee.party

26. Claim#CPCDS ElementR4 ResourceProfile ElementProvider1Claim billing provider NPI2Claim billing provider network status3Claim attending physician NPI4Claim attending physician network status5Claim site of service NPI6Claim referring provider NPI7Claim referring provider network status8Claim performing provider NPI9Claim performing provider network status10Claim operating physician NPI11Claim operating physician network status12Claim other physician NPI

27. Claim#CPCDS ElementR4 ResourceProfile Element13Claim other physician network status14Claim rendering physician NPI15Claim rendering physician network status16Claim service location NPI17Claim PCP

28. Claim#CPCDS ElementR4 ResourceProfile ElementAmounts1Claim total submitted amountExplanationOfBenefit.total.{category=“submitted”}2Claim total allowed amountExplanationOfBenefit.total.{category=“eligible”}3Amount paid by patientExplanationOfBenefit.total.{category=“paidbypatient”}4Claim amount paid to providerExplanationOfBenefit.total.{category=“paidtoprovider”}5Member reimbursementExplanationOfBenefit.total.{category=“paidtopatient”}6Claim payment amountExplanationOfBenefit.total.{category=“benefit”}7Claim disallowed amountExplanationOfBenefit.adjudication.{category=“non-covered”}8Member paid deductibleExplanationOfBenefit.total.{category=“deductible”}9Co-insurance liability amountExplanationOfBenefit.total.{category=“coins”}10Copay amountExplanationOfBenefit.total.{category=“copay”}

29. Claim#CPCDS ElementR4 ResourceProfile Element11Member liabilityExplanationOfBenefit.total.{category=“patientliability”}12Claim primary payer paid amountExplanationOfBenefit.adjudication.{category=“priorpayerbenefit”}

30. Claim (Pharmacy)#CPCDS ElementR4 ResourceProfile ElementDrug1Days supplyExplanationOfBenefit.supportingInfo.{category, code, valueQuantity}2RX service reference numberExplanationOfBenefit.supportingInfo.{category, code, valueReference(Identifier)}3DAW product selection codeExplanationOfBenefit.supportingInfo.{category, code, valueReference(CodeableConcept)}4Refill numberExplanationOfBenefit.supportingInfo.{category, code, valueQuantity}5Prescription origin codeExplanationOfBenefit.supportingInfo.{category, code, valueReference(CodeableConcept)}6Plan reported brand-generic codeExplanationOfBenefit.supportingInfo.{category, code, valueReference(CodeableConcept)}7Pharmacy service type codeExplanationOfBenefit.supportingInfo.{category, code, valueReference(CodeableConcept)}8Patient residence codeExplanationOfBenefit.supportingInfo.{category, code, valueReference(CodeableConcept)}

31. Claim Line#CPCDS ElementR4 ResourceProfile ElementLine Service Details1Service (from) dateExplanationOfBenefit.item.servicedDate OR .item.servicedPeriod2Line numberExplanationOfBenefit.item.sequence3Service to dateExplanationOfBenefit.item.servicedPeriod4Type of serviceExplanationOfBenefit.item.category5Place of service codeExplanationOfBenefit.item.location[x]6Revenue center codeExplanationOfBenefit.item.revenue7Number of unitsExplanationOfBenefit.item.quantity8Allowed number of unitsExplanationOfBenefit.item.adjudication.{category, value}9National drug codeExplanationOfBenefit.item.productOrService OR .item.detail. productOrService10Compound codeExplanationOfBenefit.item.productOrService11Quantity dispensedExplanationOfBenefit.item.detail.quantity12Quantity qualifier codeExplanationOfBenefit.item.detail.quantity13Line network indicator

32. Claim Line#CPCDS ElementR4 ResourceProfile ElementLine Amount Details1Line non covered charged amount2Line amount paid to member3Line patient paid amountDrug costExplanationOfBenefit.item.net4Line payment amount5Claim payment denial code6Line member reimbursement7Line payment amount to provider8Line patient deductible9Line primary payer paid amount10Line secondary payer paid amount11Line coinsurance amount

33. Claim Line#CPCDS ElementR4 ResourceProfile Element12Line submitted amount13Line allowed amount14Line member liability15Line copay amount

34. Diagnoses#CPCDS ElementR4 ResourceProfile ElementDiagnosis (0-n)1Diagnosis codeExplanationOfBenefit.diagnosis.diagnosisReference(Condition).code.coding.code2Present on admissionExplanationOfBenefit.diagnosis.onAdmission3Diagnosis code typeExplanationOfBenefit.diagnosis.diagnosisReference(Condition).code.coding.system4Diagnosis typeExplanationOfBenefit .diagnosis.type5Is E codeExplanationOfBenefit.diagnosis.type=“external cause code”

35. Procedures#CPCDS ElementR4 ResourceProfile ElementProcedure (0-n)1Procedure codeExplanationOfBenefit.procedure.procedureReference(Procedure).code.coding.code2Procedure dateExplanationOfBenefit.procedure.procedureReference(Procedure).performedPeriod3Procedure code typeExplanationOfBenefit.procedure.procedureReference(Procedure).code.coding.system4Procedure typeExplanationOfBenefit.procedure.type5Modifier Code -1ExplanationOfBenefit.item.modifier OR Procedure.modifier (Extension)6Modifier Code -2ExplanationOfBenefit.item.modifier7Modifier Code -3ExplanationOfBenefit.item.modifier8Modifier Code -4ExplanationOfBenefit.item.modifier

36. Member#CPCDS ElementR4 ResourceProfile Element1Member idPatient.identifier2Date of birthPatient.birthDate3Date of deathPatient.deceasedDateTime4CountyPatient.address5StatePatient.address6CountryPatient.address7Race codePatient.extension (http://hl7.org/fhir/us/core/StructureDefinition/us-core-race)8EthnicityPatient.extension (http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity)9Gender codePatient.gender10NamePatient.name11Zip codePatient.address12Relationship to subscriberPatient?13Subscriber idPatient.identifier

37. Coverage#CPCDS ElementR4 ResourceProfile Element1Subscriber idCoverage.subscriberId2Coverage typeCoverage.type3Coverage statusCoverage.status4Start dateCoverage.period5End dateCoverage.period6Group idCoverage.class7Group nameCoverage.class8PlanCoverage.class9PayerCoverage.payor

38. Terminologies

39. ExplanationOfBenefit (Elements)#R4 Profile ElementCode SystemNotes, [CMS Medicare BB 2.0/ResDAC]1.related.relationshiphttp://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationshipExample2.statushttp://hl7.org/fhir/explanationofbenefit-statusRequired3.typehttp://terminology.hl7.org/CodeSystem/claim-typeExtensible4.subTypehttp://terminology.hl7.org/CodeSystem/ex-claimsubtypeExample5.diagnosis.typehttp://terminology.hl7.org/CodeSystem/ex-diagnosistypeExample6.supportingInfo.categoryhttp://terminology.hl7.org/CodeSystem/claiminformationcategoryExample7.supportingInfo.codehttp://example.org/fhir/CodeSystem/ms-drg, http://example.org/fhir/CodeSystem/typeofbill-facility-type, etc.Required

40. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinitionhttp://terminology.hl7.org/CodeSystem/claim-type (version=4.0.1)1institutionalInstitutionalHospital, clinic and typically inpatient claims.2oralOralDental, Denture and Hygiene claims.3pharmacyPharmacyPharmacy claims for goods and services.4professionalProfessionalTypically, inpatient and outpatient claims from Physician, Psychological, Chiropractor, Physiotherapy, Speech Pathology, rehabilitative, consulting.5visionVisionVision claims for professional services and products such as glasses and contact lenses.

41. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinitionhttp://terminology.hl7.org/CodeSystem/ex-claimsubtype (version=4.0.1) [claim-type=institutional]1Acute Inpatient FacilityAcute Inpatient FacilityAcute Inpatient Facility2Non Acute Inpatient FacilityNon Acute Inpatient FacilityNon Acute Inpatient Facility3Outpatient FacilityOutpatient FacilityOutpatient Facility4OtherOtherOtherhttp://terminology.hl7.org/CodeSystem/ex-claimsubtype (version=4.0.1) [claim-type=professional]1Clinician InpatientClinician InpatientClinician Inpatient2Clinician OutpatientClinician OutpatientClinician Outpatient3Non ClinicianNon ClinicianNon Clinician

42. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinitionhttp://terminology.hl7.org/CodeSystem/claiminformationcategory (version=4.0.1)1drgDiagnosis Related GroupDiagnosis Related Group2type-of-billType of BillType of bill codes are three-digit codes located on the UB-04 claim form that describe the type of bill a provider is submitting to a payer3prescription-informationPrescription informationPrescription information

43. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinitionhttp://example.org/fhir/CodeSystem/drg-type (version=4.0.1)1CMS-DRGCMS DRGsCMS DRGs2MS-DRGMedicare Severity DRGsMedicare Severity DRGs3R-DRGRefined DRGsRefined DRGs4AP-DRGAll Patient DRGsAll Patient DRGs5S-DRGSeverity DRGsSeverity DRGs6APS-DRGAll Patient, Severity-Adjusted DRGsAll Patient, Severity-Adjusted DRGs7APR-DRGAll Patient Refined DRGsAll Patient Refined DRGs8IR-DRGInternational-Refined DRGsInternational-Refined DRGshttp://example.org/fhir/CodeSystem/cms-drg (version=?)http://example.org/fhir/CodeSystem/ms-drg (version=36)

44. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinitionhttp://example.org/fhir/CodeSystem/type-of-bill (version=4.0.1)1facility-typeType of facilityThe type of facility within the type of bill code structure (1st character)2service-classification-typeType of service provided to the beneficiaryThe type of service within the type of bill code structure (2nd character)3frequencyFrequencyThe sequence in this episode of care within the type of bill code structure (3rd character)

45. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinitionhttp://example.org/fhir/CodeSystem/typeofbill-facility-type (version=4.0.1)11HospitalHospital22Skilled nursing facility (SNF)Skilled nursing facility (SNF)33Home health agency (HHA)Home Health (Includes Home Health PPS claims, for which CMS determines whether the services are paid from the Part A Trust Fund or the Part B Trust Fund.)44Religious Nonmedical (Hospital)Religious Nonmedical (Hospital) (eff. 8/1/00); prior to 8/00 referenced Christian Science (CS)56Intermediate careIntermediate care67Clinic or hospital-based renal dialysis facilityClinic or hospital-based renal dialysis facility (requires special second digit)78Special facility or hospital (Ambulatory Surgical Center – ASC) surgerySpecial facility or hospital (Ambulatory Surgical Center – ASC) surgery (requires special second digit)http://example.org/fhir/CodeSystem/typeofbill-serviceclassification-type (version=4.0.1) [typeofbill-facility-type=1 thru 6]11Inpatient (Part A) Inpatient (Part A) 22Inpatient or Home Health (Part B)Inpatient (Part B) (includes Home Health Agency (HHA) visits under a Part B plan of treatment)33Outpatient (or HHA - covered on Part A)Outpatient (includes HHA visits under a Part A plan of treatment and use of HHA DME under a Part A plan of treatment)44Other (Part B)Other (Part B) - (Includes HHA medical and other health services not under a plan of treatment, hospital or SNF for diagnostic clinical laboratory services for "nonpatients," and referenced diagnostic services. For HHAs under PPS, indicates an osteoporo

46. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinition55Intermediate care - level IIntermediate care - level I66Intermediate care - level IIIntermediate care - level II77Subacute InpatientSubacute Inpatient (revenue code 019X required) (formerly Intermediate care - level III) NOTE: 17X & 27X are discontinued effective 10/1/0588Swing bedSwing bedhttp://example.org/fhir/CodeSystem/typeofbill-serviceclassification-type (version=4.0.1) [typeofbill-facility-type=7]11Rural Health Clinic (RHC)Rural Health Clinic (RHC)22Hospital based or independent renal dialysis facilityHospital based or independent renal dialysis facility33Free-standing provider based federally qualified health center (FQHC)Free-standing provider based federally qualified health center (FQHC) (eff 10/91)44Other Rehabilitation Facility (ORF) and Community Mental Health Center (CMHC)Other Rehabilitation Facility (ORF) and Community Mental Health Center (CMHC) (eff 10/91 - 3/97); ORF only (eff. 4/97)55Comprehensive Outpatient Rehabilitation Facility (CORF)Comprehensive Outpatient Rehabilitation Facility (CORF)66Community Mental Health Center (CMHC) Community Mental Health Center (CMHC) 77Federally Qualified Health Center (FQHC)Federally Qualified Health Center (FQHC)89OtherOtherhttp://example.org/fhir/CodeSystem/typeofbill-serviceclassification-type (version=4.0.1) [typeofbill-facility-type=8]11Hospice (non-hospital based)Hospice (non-hospital based)

47. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinition22Hospice (hospital based)Hospice (hospital based)33Ambulatory surgical center (ASC) in hospital outpatient departmentAmbulatory surgical center (ASC) in hospital outpatient department44Freestanding birthing centerFreestanding birthing center55Critical Access Hospital - Outpatient ServicesCritical Access Hospital - Outpatient Services69OtherOtherhttp://example.org/fhir/CodeSystem/typeofbill-frequency (version=4.0.1)10Non-payment/zero claimsNon-payment/zero claims21Admit thru discharge claimAdmit thru discharge claim32Interim - first claimInterim - first claim43Interim - continuing claimInterim - continuing claim54Interim - last claimInterim - last claim65Late charge(s) only claimLate charge(s) only claim77Replacement of prior claimReplacement of prior claim88Void/cancel prior claimVoid/cancel prior claim99Final claim (for HH PPS = process as a debt/credit to RAP claim)Final claim (for HH PPS = process as a debt/credit to RAP claim)

48. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinition10AAdmission/Election Notice for HospiceAdmission/Election Notice for Hospice11BHospice Termination/Revocation NoticeHospice Termination/Revocation Notice12CHospice Change of Provider NoticeHospice Change of Provider Notice13DHospice Election Void/CancelHospice Election Void/Cancel14EHospice Change of OwnershipHospice Change of Ownership15FBeneficiary Initiated Adjustment ClaimBeneficiary Initiated Adjustment Claim16GCommon Working File (NCH) generated adjustment claimCommon Working File (NCH) generated adjustment claim17HCMS generated adjustment claimCMS generated adjustment claim18IMisc adjustment claim (e.g., initiated by intermediary or QIO)Misc adjustment claim (e.g., initiated by intermediary or QIO)19JInitiated Adjustment Claim – OtherInitiated Adjustment Claim – Other20KOIG Initiated Adjustment ClaimOIG Initiated Adjustment Claim21MMedicare secondary payer (MSP) adjustmentMedicare secondary payer (MSP) adjustment22PAdjustment required by QIOAdjustment required by QIO23QReopening/AdjustmentClaim Subm For Reconsideration Outside Timely

49. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinition24UUnknownUnknown25VInvalidInvalid26XVoid / Cancel a Prior Abbreviated Encounter SubmissionVoid / Cancel a Prior Abbreviated Encounter Submission27YReplacement Of Prior Abbreviated Encounter SubmissionReplacement Of Prior Abbreviated Encounter Submission28ZNew Prior Abbreviated Encounter SubmissionNew Prior Abbreviated Encounter Submission

50. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinitionhttp://example.org/fhir/CodeSystem/prescription-information (version=4.0.1)1days-supplyDays SupplyNumber of days' supply of medication dispensed by the pharmacy2rx-svc-ref-numberPrescription numberAssigned by the pharmacy at the time the prescription is filled3daw-prod-selection-codeDispense as written or product selection codePrescriber's instruction regarding substitution of generic equivalents or order to dispense the specific prescribed medication4refill-numberRefill numberThe number fill of the current dispensed supply (0, 1, 2, etc)5rx-origin-codePrescription origin codeWhether the prescription was transmitted as an electronic prescription, by phone, by fax, or as a written paper copy6brand-generic-codePlan reported brand-generic codeWhether the plan adjudicated the claim as a brand or generic drug7pharmacy-svc-type-codePharmacy service type codeType of pharmacy that dispensed the prescription8patient-residence-codePatient residence codeWhere the beneficiary lived when the prescription was filled

51. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinitionhttp://example.org/fhir/CodeSystem/daw-prod-selection-code (version=4.0.1)10No Product Selection Indicated (may also have missing values)No Product Selection Indicated (may also have missing values)21Substitution Not Allowed by PrescriberSubstitution Not Allowed by Prescriber32Substitution Allowed - Patient Requested That Brand Product Be DispensedSubstitution Allowed - Patient Requested That Brand Product Be Dispensed43Substitution Allowed - Pharmacist Selected Product DispensedSubstitution Allowed - Pharmacist Selected Product Dispensed54Substitution Allowed - Generic Drug Not in StockSubstitution Allowed - Generic Drug Not in Stock65Substitution Allowed - Brand Drug Dispensed as GenericSubstitution Allowed - Brand Drug Dispensed as Generic76OverrideOverride87Substitution Not Allowed - Brand Drug Mandated by LawSubstitution Not Allowed - Brand Drug Mandated by Law98Substitution Allowed - Generic Drug Not Available in MarketplaceSubstitution Allowed - Generic Drug Not Available in Marketplace109OtherOther

52. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinitionhttp://example.org/fhir/CodeSystem/rx-origin-code (version=4.0.1)10Not SpecifiedNot Specified21WrittenWritten32TelephoneTelephone43ElectronicElectronic54FacsimileFacsimile65PharmacyPharmacyhttp://example.org/fhir/CodeSystem/brand-generic-code (version=4.0.1)1BBrandBrand2GGenericGeneric

53. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinitionhttp://example.org/fhir/CodeSystem/pharmacy-svc-type-code (version=4.0.1)101Community/retail pharmacyCommunity/retail pharmacy202Compounding pharmacyCompounding pharmacy303Home infusion therapy providerHome infusion therapy provider404Institutional pharmacyInstitutional pharmacy505Long-term care pharmacyLong-term care pharmacy606Mail order pharmacyMail order pharmacy707Managed care organization (MCO) pharmacyManaged care organization (MCO) pharmacy808Specialty care pharmacySpecialty care pharmacy999OtherOther

54. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinitionhttp://example.org/fhir/CodeSystem/patient-residence-code (version=4.0.1)100Not specified, other patient residence not identified belowNot specified, other patient residence not identified below201HomeHome302Skilled Nursing FacilitySkilled Nursing Facility403Nursing facility (long-term care facility)Nursing facility (long-term care facility)504Assisted Living FacilityAssisted Living Facility605Custodial Care Facility (residential but not medical care)Custodial Care Facility (residential but not medical care)706Group HomeGroup Home (e.g., congregate residential foster care)807Inpatient Psychiatric FacilityInpatient Psychiatric Facility908Psychiatric Facility – Partial HospitalizationPsychiatric Facility – Partial Hospitalization1009Intermediate care facility for the mentally retarded (ICF/MR)Intermediate care facility for the mentally retarded (ICF/MR)1110Residential Substance Abuse Treatment FacilityResidential Substance Abuse Treatment Facility1211HospiceHospice1312Psychiatric Residential Treatment FacilityPsychiatric Residential Treatment Facility

55. ExplanationOfBenefit (Code Systems)#CodeDisplayDefinition1413Comprehensive Inpatient Rehabilitation FacilityComprehensive Inpatient Rehabilitation Facility1514Homeless ShelterHomeless Shelter1615Correctional InstitutionCorrectional Institution

56. Encounter#R4 Profile ElementCode SystemNotes, [CMS Medicare BB 2.0/ResDAC]1.hospitalization.admitSource.coding.codehttp://terminology.hl7.org/CodeSystem/admit-sourcePreferred, [https://bluebutton.cms.gov/resources/variables/clm_src_ip_admsn_cd/]2.type.coding.codehttp://terminology.hl7.org/CodeSystem/encounter-typeExample, [https://www.resdac.org/cms-data/variables/claim-inpatient-admission-type-code-ffs]3.hospitalization.dischargeDisposition.coding.codehttp://terminology.hl7.org/CodeSystem/discharge-dispositionExample, [https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd]

57. Location#R4 Profile ElementCode SystemNotes, [CMS Medicare BB 2.0/ResDAC]1.type.coding.codehttp://terminology.hl7.org/CodeSystem/v3-RoleCodeExtensible, [https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd/]

58. @rryanhowells | ryan.howells@leavittpartners.com @carinalliance | www.carinalliance.com

59. Appendix

60. Health Plan Claims ExtractsHealth Plans send Claims data to their vendors and business associates under several use cases (care coordination, utilization management, predictive analytics) using a variety of custom, one-off, flat file extracts.No industry wide standard exists for Health Plans to send (adjudicated) Claims data to either Covered or Non-covered Entities.EDI X12 standards for Claims only exist for Providers’ HIPAA-covered transactions with Health Plans (i.e. Claim Submission – 837, Claim Acknowledgement – 277CA, and Payment/Remittance Advice – 835)Most Health Plans generate the flat file Claims extracts from their Claims System of Record (SOR) i.e. Claims Adjudication System, using mature, enterprise grade Extract, Transform and Load (ETL) tools and processes.