Product CR

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Product Brief - HL7 V3: Claims & Reimbursements

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Product Name

HL7 V3: Claims & Reimbursements

Topics

  • Authorization
  • Coverage Extension
  • Eligibility
  • Invoice
  • Payment Advice
  • Pre-Determination
  • Pre-Determination-Authorization
  • Poll
  • Special Authorization
  • SOFA (Statement of Financial Activity)

Standard Category

  • Health Information Exchange Standards

Integration Paradigm

  • Messaging

Type

Normative, ANSI standard

Releases

  • ANSI/HL7 V3 CR: R1-2004, R2-2004, R3-2005, R4-2008;
  • DSTU: HL7 V3 CR SA, R4 - Special Authorization R1

Summary

The Claims and Reimbursement (CR) Domain is one of several areas within Healthcare Services for which HL7 is defining messaging standards. CR pertains to the invoicing (including authorization and eligibility verification), adjudication and payment (including adjustments and account queries) of Healthcare Services.

The CR domain is one of two financial domains that make up the Financial (FI) sub-section within the Administrative Management (AM) section. FIAB is the domain for patient accounting (charges, etc.) whereas FICR deals with requests for payments (claims, invoices).

All of the interactions within the CR Domain assume the participants know the detailed information about Providers, Insurance Companies and Patients, because there is a shared repository of information that exists between the receiver and sender and therefore, details on these elements are not expected in messages.

This document provides support for Generic, Pharmacy, Preferred Accommodation, Physician, Oral Health, Vision Care and Hospital claims for eligibility, authorization, coverage extension, pre-determination, invoice adjudication, payment advice and Statement of Financial Activity (SOFA). Release 3 of this document adds claims messaging support for Physician, Oral Health, Vision Care and Hospital claims.

Description

These interactions include Query Eligibility, Authorization, Coverage Extension, Pre-Determination, Invoice (claim), Adjudication Results, Payment Advice and Statement of Financial Activity (SOFA).

Business Case (Intended Use, Customers)

  • Provider: Healthcare Institutions (hospitals, long term care, home care, mental health)
  • Vendor: Health Care IT
  • Payers
  • Local and State Departments of Health

Benefits

Implementations/ Case Studies (Actual Users)

Resources

Work Groups

Financial Management

Education

Certification Available
  • none

Presentations

Relationship to/ Dependencies on, other standards

Links to current projects in development

none

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