This wiki has undergone a migration to Confluence found Here
Difference between revisions of "OralHealthClaim FHIR Resource Proposal"
Jump to navigation
Jump to search
Claims - where the provision of goods and services is complete and reimbursement is sought.
Pre-Authorization - where the provision of goods and services is proposed and either authorization and/or the reservation of funds is desired.
Pre-Determination - where the provision of goods and services is explored to determine what services may be covered and to what amount. Essentially a 'what if' claim.
Paul Knapp (talk | contribs) (Created page with "{{subst::Template:FHIR Resource Proposal}}") |
Paul Knapp (talk | contribs) |
||
| Line 13: | Line 13: | ||
| − | = | + | =OralHealthClaim= |
<!-- Resource names should meet the following characteristics: | <!-- Resource names should meet the following characteristics: | ||
| Line 30: | Line 30: | ||
<!-- The name of the committee that is proposed to have responsibility for developing and maintaining the resources. --> | <!-- The name of the committee that is proposed to have responsibility for developing and maintaining the resources. --> | ||
| − | [[ | + | [[Financial Management]] |
==Contributing or Reviewing Work Groups== | ==Contributing or Reviewing Work Groups== | ||
<!-- Additional work groups that may have an interest in contributing to, or reviewing the content of the resource (optional) --> | <!-- Additional work groups that may have an interest in contributing to, or reviewing the content of the resource (optional) --> | ||
| − | * | + | * Claims with Attachments |
| − | * | + | * Patient Administration |
| − | |||
| − | |||
==FHIR Resource Development Project Insight ID== | ==FHIR Resource Development Project Insight ID== | ||
| − | + | 994 | |
<!-- Please specify the id of your work group’s PSS for doing FHIR work. (If submitted but not yet approved, just write “pending”.) The link to the PSS template can be found here: http://gforge.hl7.org/gf/download/docmanfileversion/6832/9398/HL7FHIR_DSTUballotPSS-20120529.doc --> | <!-- Please specify the id of your work group’s PSS for doing FHIR work. (If submitted but not yet approved, just write “pending”.) The link to the PSS template can be found here: http://gforge.hl7.org/gf/download/docmanfileversion/6832/9398/HL7FHIR_DSTUballotPSS-20120529.doc --> | ||
==Scope of coverage== | ==Scope of coverage== | ||
| + | The OralHealthClaim is one of a suite of similar resources (OralClaim, VisionClaim, PharmacyClaim, ProsessionalClaim, InstitutionalClaim) which are used by providers to | ||
| + | exchange the financial information, and supporting clinical information, regarding the provision of healthcare goods and services. The primary uses of this resource is to support eClaims, | ||
| + | the exchange of proposed or supplied products and services to benefit payors, insurers and national health programs, for treatment payment planning and reimbursement. | ||
| + | |||
| + | The Claim is intended to support: | ||
| + | <li>Claims - where the provision of goods and services is <b>complete</b> and reimbursement is sought.</li> | ||
| + | <li>Pre-Authorization - where the provision of goods and services is <b>proposed</b> and either authorization and/or the reservation of funds is desired.</li> | ||
| + | <li>Pre-Determination - where the provision of goods and services is <b>explored</b> to determine what services may be covered and to what amount. Essentially a 'what if' claim.</li> | ||
<!-- Define the full scope of coverage for the resource. The scope must be clearly delineated such that it does not overlap with any other existing or expected resource. The scope will be used to govern "what is the set of potential applications to consider when evaluating what elements are 'core' – i.e. in the 80%" | <!-- Define the full scope of coverage for the resource. The scope must be clearly delineated such that it does not overlap with any other existing or expected resource. The scope will be used to govern "what is the set of potential applications to consider when evaluating what elements are 'core' – i.e. in the 80%" | ||
| Line 57: | Line 63: | ||
==RIM scope== | ==RIM scope== | ||
| − | + | PaymentRequest (classCode=XACT,moodCode=PRP,RQO) | |
<!-- Identify the formal RIM mapping for the root concept of the resource. The expectation is that the RIM mapping will be sufficiently precise so as to not overlap with any other resource definition. --> | <!-- Identify the formal RIM mapping for the root concept of the resource. The expectation is that the RIM mapping will be sufficiently precise so as to not overlap with any other resource definition. --> | ||
==Resource appropriateness== | ==Resource appropriateness== | ||
| − | + | Claims, and the variants of Pre-Determinations and Pre-Authorizations, are the means through which Providers submit patient rendered services to the Patient's insurers for reimbursement. The reimbursement may or may not be assigned to the Provider. | |
| + | There are generally agreed types of claims based on the class of health discipline and adjudication engines are often segmented along these same lines of: OralHealth, Vision, Pharmacy, Professional (Medical and Chiro,Physio, Rehab - typically outpatient care) and Institutional (Hospital, clinic, etc). | ||
<!-- Does the resource meet the following characteristics? | <!-- Does the resource meet the following characteristics? | ||
| Line 76: | Line 83: | ||
==Expected implementations== | ==Expected implementations== | ||
| − | + | This is a key resource expected by most Healthcare billing implementations where Oral Health care is provided. | |
<!--Key resources are justified by CCDA, for resources not deemed "key", what interest is there by implementers in using this particular resource. Provide named implementations if possible - ideally provide multiple independent implementations. --> | <!--Key resources are justified by CCDA, for resources not deemed "key", what interest is there by implementers in using this particular resource. Provide named implementations if possible - ideally provide multiple independent implementations. --> | ||
==Content sources== | ==Content sources== | ||
| − | + | Existing normative V3 and V2 specifications | |
| + | Canadian Specifications | ||
| + | X12 | ||
<!-- List all of the specifications (beyond those in the "standard" (FHIR_Design_Requirements_Sources) list of source specifications) that you’re planning to consult | <!-- List all of the specifications (beyond those in the "standard" (FHIR_Design_Requirements_Sources) list of source specifications) that you’re planning to consult | ||
| Line 90: | Line 99: | ||
==Resource Relationships== | ==Resource Relationships== | ||
| − | + | Refers to Patient, Practitioner, Organization, Coverage, Referral, ClaimResponse. | |
| + | Is referred to by ClaimResponse, ReconciliationResponse, Reversal, Readjudication, PaymentNotice, StatusRequest, FinancialAttachment, InformationCheck, ExplanationOfBenefit and occasionally by a Claim resource. | ||
<!-- What are the resources do you expect will reference this resource and in what context? | <!-- What are the resources do you expect will reference this resource and in what context? | ||
| Line 101: | Line 111: | ||
==Timelines== | ==Timelines== | ||
| − | + | Ready for DSTU 2 | |
<!-- Indicate the target date for having the resource complete from a committee perspective and ready for vetting and voting --> | <!-- Indicate the target date for having the resource complete from a committee perspective and ready for vetting and voting --> | ||
| Line 107: | Line 117: | ||
<!-- Identify the userids who will require commit access to gForge to maintain the resource. (Ensure all users have registered for gForge.) --> | <!-- Identify the userids who will require commit access to gForge to maintain the resource. (Ensure all users have registered for gForge.) --> | ||
| + | paulknapp | ||
Revision as of 00:42, 22 October 2014
This page documents a Pending FHIR Resource Proposal
Contents
- 1 OralHealthClaim
- 1.1 Owning committee name
- 1.2 Contributing or Reviewing Work Groups
- 1.3 FHIR Resource Development Project Insight ID
- 1.4 Scope of coverage
- 1.5 RIM scope
- 1.6 Resource appropriateness
- 1.7 Expected implementations
- 1.8 Content sources
- 1.9 Example Scenarios
- 1.10 Resource Relationships
- 1.11 Timelines
- 1.12 gForge Users
OralHealthClaim
Owning committee name
Contributing or Reviewing Work Groups
- Claims with Attachments
- Patient Administration
FHIR Resource Development Project Insight ID
994
Scope of coverage
The OralHealthClaim is one of a suite of similar resources (OralClaim, VisionClaim, PharmacyClaim, ProsessionalClaim, InstitutionalClaim) which are used by providers to exchange the financial information, and supporting clinical information, regarding the provision of healthcare goods and services. The primary uses of this resource is to support eClaims, the exchange of proposed or supplied products and services to benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.
The Claim is intended to support:
RIM scope
PaymentRequest (classCode=XACT,moodCode=PRP,RQO)
Resource appropriateness
Claims, and the variants of Pre-Determinations and Pre-Authorizations, are the means through which Providers submit patient rendered services to the Patient's insurers for reimbursement. The reimbursement may or may not be assigned to the Provider. There are generally agreed types of claims based on the class of health discipline and adjudication engines are often segmented along these same lines of: OralHealth, Vision, Pharmacy, Professional (Medical and Chiro,Physio, Rehab - typically outpatient care) and Institutional (Hospital, clinic, etc).
Expected implementations
This is a key resource expected by most Healthcare billing implementations where Oral Health care is provided.
Content sources
Existing normative V3 and V2 specifications Canadian Specifications X12
Example Scenarios
Resource Relationships
Refers to Patient, Practitioner, Organization, Coverage, Referral, ClaimResponse. Is referred to by ClaimResponse, ReconciliationResponse, Reversal, Readjudication, PaymentNotice, StatusRequest, FinancialAttachment, InformationCheck, ExplanationOfBenefit and occasionally by a Claim resource.
Timelines
Ready for DSTU 2
gForge Users
paulknapp
