financial management (fm) v3 orientation hl7 baltimore september 30, 2002

Financial Management (FM)v3 Orientation

HL7 Baltimore

September 30, 2002

Outline

• Welcome & Introductions

• Quick Development Background

• Financial Management (FM) Overview– FM Life Cycle

– Scope of Messaging

• FICR – e-Claims– Domain Model Review

– Key FICR Concepts

– Upcoming FICR Projects

• Summary and Wrap-up

Welcome & Introductions

• Round the room

Quick Development Background

How did we get here?

Background

• FM covers 2 domains in v3– FIAB – Account and Billing

– FICR – Claims and Reimbursement

• FIAB (Account and Billing)– Material prepared and submitted by Mark

Shafarman

– Managed and brought forward through the HL7 v3 ballot process by the FM TC

Background

• FICR (Claims & Reimbursement)– Material prepared by

the Canadian National e-Claims Standard (NeCST)

– RIM changes were proposed in spring 2001 to redo Financial Acts• Coverage (insurance)• Invoices• Accounts• Financial Transactions• Remove unused classes

Background

• FICR (continued)– Work in Canada originally in v2

• Still some interest in v2 from international affiliates – Q4 Tuesday in Baltimore

• Moved to v3 in fall 2001

– Managed and brought forward through the HL7 v3 ballot process by the FM TC and the NeCST project in Canada

• Of note– v3 ballot reconciliation Wednesday &

Thursday this week

Financial Management (FM) Overview

What is FM?

FM Life Cycle

Fill Bill Adjudicate Pay

9/30/2002Financial Management Life Cycle

TPA/PayorProvider/Patient Care

Accounts Charges Credits Clinical Events

Invoices/Claims Adjudication Remittance

Adjudication Remittance

FIAB (Billing) FICR (Claims)

Scope of Messaging

• FIAB– Patient Account management

• New/Revise• Cancel• Complete • Nullify/Reactivate

Scope of Messaging

• FICR– Enrollment

• Future

– Eligibility• Query to determine insurance coverage in

effect for a specified date

– Authorization• Request authorization of a Payor to reserve

funds for the delivery of healthcare services

Scope of Messaging

• FICR (continued)– Coverage Extension

• Extending coverage for special circumstances

– e.g. in order to pay for a specific drug, you must first request coverage extension with appropriate supporting documentation

– Pre-Determination• Mock invoice/claim to determine how a

Payor would adjudicate the claim at a single point in time (now)

• Not a guarantee of payment

Scope of Messaging

• FICR (continued)– Invoice

• Submit an invoice for adjudication and possible payment

• Adjudication results• Coordination of benefits support

– Payment• Payment/Remittance advice • Statement of financial activity (SOFA) for

reconciliation

FICR – e-Claims

Digging deeper into the details

FICR Domain Model Review

FICR DMIMv5.7 - 02 Sep 20

1..1representedOrganizationAgentclass_cd <= AGNT

CMET: (ORG) E_Organization

[identified](COCT_MT150002)

Note:Required for Invoice Cancelsif the Invoice has already beenadjudicated. The Payment Intenton an Invoice Cancel indicates thenet effect of the cancel (reversal)

Note:Payee is noted inA_Account CMET

Note:RTO used to specify 15 pills (each)out of a bottle of 100 pills (each) toreflect billing for a portion of apackage (e.g. 0.15 of a bottle)

Note:For re-adjudicated invoices(e.g. audit purposes)

Note:Want sum of all adjudicationdetails (info & non-info) to equalwhat was submitted. For example,the reasons why you refused to paypart of the invoice

Note:Print form specified forEOB statement whenprovided to patient

Note:A_Invoice_element_group cannot be a leaf,A_Invoice_element_detail must be a leaf.

Note:Used to indicateconsent invoice againstpolicy or account.

Note:Can be a single patient, ananimal or a group of patientsand/or a group of animals.

Service target & Covered partymay be different people (e.g.pedestrian in auto-accident)

Note:Contact information is thru Ident_org CMET (not here)

Note:Class cd PAT(PatientRole) ismost generic codeavailable

Note:Used to attachdocuments, image, etc.required to support a health claim

Domain to be added in a subsequent release

Note:Subscriber Identifier;required for X12 837mapping

Note:Covered Person Identifier(Assigned by carrier - root of OID)= Subscriber+Dependents

Note:effective_time is from theperspective of the author

Note:"Please Pay"

Note:Need amount forcontract (maxallowable amount),not needed for e-Claims

Note:Limits included in the authorization such asmaximum dollar amounts, maximum quantities,date ranges, etc..

Note:"Please Adjudicate"

Note:Owner of the contract.

There are other participationsfor a contract, but we are notinterested in them for anInvoice.

Note:If Payment is not invoicedand pertains to a Provider,either a person or anOrganization

Note:"I Paid"

Note:"I Will Pay"

Note:Data centre andsequence numbermust be the samefor each completegroup anddetail hierarchy

Note:Carrier id

Note:Location of incident/accident(e.g. fixed address, sideof road, etc.)

Note:Specific adjudication observationswill be added here, such as DrugContraindications.

Note:This allows for root invoice elementgroup to be composed of invoiceelement groups and/or details. There must be one leaf detail

Note:This is where each benefit groupwill insert their billable act (e.g. PharmacyDispense Billable Act). Each Billable Act isa CMET, contained in the A_Billable_Act CMET.Refer to the CMET for more information.

The act will be in intent (INT) mood whenrequesting authorization

Note:Allows Payor to adj& pay on different policy

Note:id: = Coverage IdentifierAssigned by carrier identified by an OIDwith extension = Policy.Plan.Group.Contract.Division.Section.Version as agreed to byparticipants

0..* priorConfirmationOrderInFulfillmentOfCoverageRequesttype_cd*<= FLFS

0..1 priorActReplacementOftype_cd*<= RPLC

0..* justifiedFinancialTransactionIntent

0..* justifyingInvoiceElementEvent

Reasontype_cd*<= RSON

0..1 priorInvoiceAdjustmentEvent

OutcomeAdjudicatedtype_cd*<= OUTC

0..* limitingInvoiceElementEventCriterion

Limitationtype_cd*<= LIMIT

0..* summarizingInvoiceElementEvent

Summarytype_cd*<= SUMM

0..* priorFinancialTransactionIntentInFulfillmentOfPaymentIntenttype_cd*<= FLFS

0..* justifyingObservationEventReasonOverridetype_cd*<= RSON


0..1 invoiceElementEvent

0..* invoiceAdjustmentEventComponentGrouptype_cd*<= COMP

0..* accountEventCreditDeposittype_cd*<= CREDIT

0..* referedToInvoiceAdjustmentEventReferencePreviousAdjudicationtype_cd*<= REFR

0..* actOrderRequirestype_cd*<= RACTnegation_ind:

0..* justifiedConfirmationOrder

0..* justifyingInvoiceElementOrderReasonJustifiedtype_cd*<= RSON

0..* justifyingActReasonCoveragetype_cd*<= RSON

0..* accountDebitPayortype_cd*<= DEBIT

0..* subjectInvoiceElementEventCriterion

PertinentInformationCoverageCriteriatype_cd*<= PERT

0..* subjectAct

PertinentInformationtype_cd*<= PERT

0..* priorFinancialTransactionIntentInFulfillmentOfPaymentRequesttype_cd*<= FLFS

0..* pertinentObservationEvent

PertinentInformationInjuryCodingtype_cd*<= PERT

0..1 priorCoverageEvent

InFulfillmentOfPollicyOrAccounttype_cd*<= FLFSsequence_nbr*: [1..1] (COB priority as adjudicated primary, secondary, etc.) 0..* summarizingObservationEvent

SummaryRunningTotalstype_cd*<= SUMM

1..1 subjectConsentEvent

PertinentInformationConsenttype_cd*<= PERTnegation_ind:

0..* coverageDefinitionDefinitiontype_cd*<= INST

0..1 pertinentIncidentEventPertinentInformationIncidenttype_cd*<= PERT

0..* priorFinancialContractEventInFulfillmentOfContracttype_cd*<= FLFS

0..* pertinentObservationEventPertinentInformationAttachmenttype_cd*<= PERT

0..* coveringCoverageEventCoveragePolicyOrAccounttype_cd*<= COVBYsequence_nbr: [0..1] (COB priority as submitted. primary, secondary, etc.)

0..* pertinentInvoiceElementEventCriterion

PertinentInformationTermsConditionstype_cd*<= PERTnegation_ind: (covered/not covered)

0..1 justifyingActReasonAdjudicationSummarytype_cd*<= RSON

0..* authorizingConfirmationEventAuthorizationtype_cd*<= AUTH

0..1 accountDebitPayortype_cd*<= DEBIT

0..1 accountCreditPayeetype_cd*<= CREDIT

0..* justifyingActReasonInvoiceElementtype_cd*<= RSON

0..* justifyingInvoiceElementOrder

ReasonPaymentRequesttype_cd*<= RSON

1..* act

ComponentInvoicetype_cd*<= COMPsequence_nbr:

InvoiceElementEventAdjudicatedclass_cd* <= INVE+INFINVEmood_cd* <= EVNid*: [1..1]cd: CWE <=ActProductServiceBillableItemCode (Product or service code that was adjudicatedand could include substituted codes - e.g. code Awas replaced by code B during adjudication)txt:net_amt: MOunit_qty: RTO<PQ,PQ>unit_price_amt: RTO<MO,PQ>factor_nbr:points_nbr:

IncidentEventclass_cd* <= INCmood_cd* <= EVNid:cd: CNE <= ActIncidentCode (work place related, auto related, etc.)txt:effective_time:

EventAdjudicationResultsclass_cd* <= ADJUDmood_cd* <= EVNid*: [1..1] (EOB identifier)cd: CNE <= ActAdjudicationCode (Summary of the adjudication processing - as submitted, w/ adjust, refuse)txt:status_cd: <= ActStatusreason_cd*: SET<CE> CWE [0..*] <= ActAdjudicationReason

CoverageEventPolicyOrAccountclass_cd* <= COVmood_cd* <= EVNid*: [1..1] (policy id, WCB claim #, auto claim #,HSA account)cd: <= ActPolicyCode (Policy Type)status_cd: <= ActStatuseffective_time:

ConfirmationEventCoverageclass_cd* <= CONFmood_cd* <= EVNid: (authorization/confirmation identifier)cd*: [1..1] <= ActCoverageConfirmationCode (eligible, not eligible, authorized, not authorized)txt:status_cd: [0..1] <= ActStatus (active, cancelled, etc.)effective_time: [0..1] (effective dates for confirmation - expiry)reason_cd: <= ActAdjudicationReason

FinancialContractEventclass_cd* <= FCNTRCTmood_cd* <= EVNid: (business arrangement identifier)cd: <= ActBillingArrangementCode (i.e. FFS, Block, Contract, Rostering, Capitation, etc.)txt:status_cd: <= ActStatuseffective_time:payment_terms_cd: CWE <= PaymentTerms

ObservationEventAttachmentclass_cd* <= OBSmood_cd* <= EVNid*: [1..1] (attachment identifier)cd*: [1..1] (Domain:ClaimsAttatchmentType)value: ED (content or reference)

InvoiceElementEventCriterionCoverageclass_cd* <= INVE+INFINVEmood_cd* <= EVN.CRTid: SET<II>cd: CWE <= ActCoverageLimitCodetxt:effective_time:net_amt:unit_qty:unit_price_amt:factor_nbr:points_nbr:

ObservationEventInvoiceOverrideclass_cd* <= OBSmood_cd* <= EVNcd: <= CNE ActInvoiceOverrideCode (override reason)txt:


FinancialTransactionOrderPaymentRequestclass_cd* <= XACTmood_cd* <= ORDid*: SET<II> [1..*] (Item ID, Tracking #, etc.)net_amt: MO [0..1] (amount to be billed)

FinancialTransactionIntentPaymentclass_cd* <= XACTmood_cd* <= INTid*: SET<II> [1..1] (Item ID, Tracking #, etc.)txt:status_cd: <= ActStatuseffective_time: (time payor intends to perform transaction)net_amt*: MO [1..1] (amount to be paid for INV, GRP, ITM or ADJ)credit_exchange_rate_qty:debit_exchange_rate_qty:interest_rate_qty:

ConfirmationOrderCoverageclass_cd* <= CONFmood_cd* <= ORDid: SET<II> (Tracking #, etc.)txt:reason_cd: <= ActAuthorizationReason

FinancialTransactionEventPaymentclass_cd* <= XACTmood_cd* <= EVNid*: SET<II> [1..*] (Cheque #, EFT #)cd*: [1..1] <= ActPaymentCode (e.g. EFT, cheque, etc.)txt:effective_time: (time transaction occurred)reason_cd: <= ActPaymentAdjustmentReason (reason for payment such as retroadjustment, fee deduction, etc. when not based on a Payment_intent)net_amt*: MO [1..1] (amount paid)credit_exchange_rate_qty:debit_exchange_rate_qty:

ConsentEventclass_cd* <= CONSmood_cd* <= EVNeffective_time:

InvoiceElementOrderGroupclass_cd* <= INVE+INFINVEmood_cd* <= ORD+INTid: SET<II> [0..*] (may include data centre and sequence numbers)cd: CS CNE [0..1] <= ActInvoiceCode (Invoice Type e.g. Healthcare Services, Rx Dispense, Rx Compound, Healthcare Goods, Preferred Accomodation)effective_time: IVL<TS> [0..1] (time period that invoice covers e.g. month of January)confidentiality_cd: <= ConfidentialityByAccessKindnet_amt: MO [0..1] (= sum of all immediate children Invoice_element_group.net_amt & Invoice_element_detail.net_amt where Class_cd = INVE)modifier_cd: SET<CS> CNE [0..*] <= ActInvoiceElementModifier

InvoiceElementEventCriterionQuestionclass_cd* <= INVEmood_cd* <= EVN.CRTcd: <= ActCoverageInquiryCode (type of criteria)effective_time:net_amt:unit_qty:unit_price_amt:

ObservationEventInjuryCodingclass_cd* <= OBSmood_cd* <= EVNcd: CD <= ActInjuryCode (- nature of injury, body part, side of body SAZ795)

AccountEventBankclass_cd* <= ACCTmood_cd* <= EVNid: SET<II> (Acount number, transit number, EFT#, bank number)

ActOrderRequiredclass_cd* <= ACTmood_cd* <= ORDcd: <= ActAdjudicationResultActionCode (e.g. print on EOB, allow override)txt:effective_time:

InvoiceElementOrderDetailclass_cd* <= INVE+INFINVEmood_cd* <= ORD+INTid*: SET<II> [1..1] (may include data centre and sequence numbers)cd: CD CNE [0..1] <= ActProductServiceBillableItemCode (Product/Service Code e.g. Office Visit ,Taxes, Markup, Dispense + Product/Service Code Modifier e.g. northern isolation, off hours specialty, on call)net_amt: MO [0..1] (= unit_qty * unit_price_amt * factor_nbr * points_nbr. E.g. $150 CAD)unit_qty: RTO<PQ,PQ> [0..1] (e.g. 3 {boxes})unit_price_amt: RTO<MO,PQ> [0..1] (e.g. $50 CAD/ 1 {box})factor_nbr: (multiplier, can be used for tax percentages)points_nbr: (multiplier)

ObservationEventSummaryclass_cd* <= OBSmood_cd* <= EVNcd*: [1..1] <= ActInvoiceElementSummaryCodevalue: (PQ or MO - Value of summary)

CoverageDefinitionclass_cd* <= COVmood_cd* <= DEFid*: [1..1] (plan id, group id)cd: <= ActCoverageCode (e.g. basic, extended, Plan G)effective_time:

InvoiceElementEventGroupingclass_cd* <= INVEmood_cd* <= EVNcd: CNE <= ActAdjudicationGroupCode (defines the 'categorization'. Only really relevant forsummaries.)effective_time*: [1..1] (summary period)

InvoiceElementEventCriterionclass_cd* <= INVE+INFINVEmood_cd* <= EVN.CRTid: SET<II>cd: CWE <= ActProductServiceBillableItemCodetxt:effective_time:

Predecessortype_cd*<= SUCC

0..* priorInvoiceElementEvent

Componenttype_cd*<= COMP

0..* invoiceElementEventA

sequence_nbr:

ComponentPaymentRequesttype_cd*<= COMP

0..* financialTransactionOrderA

sequence_nbr:

ReversalOfPaymentRequesttype_cd*<= REV

0..* priorFinancialTransactionOrder

ComponentCoveragetype_cd*<= COMP

0..*coverageDefinition

ComponentPolicytype_cd*<= COMP

0..* coverageEventA

ReferencePreviousPaymentRequesttype_cd*<= REFR

0..* referedToFinancialTransactionOrder

ComponentSummarizedtype_cd*<= COMP


ReferencePaymenttype_cd*<= REFR

0..* referedToFinancialTransactionEvent

ComponentPaymenttype_cd*<= COMP

0..* financialTransactionEventA

sequence_nbr:

ReferencePaymentIntenttype_cd*<= REFR

0..* referedToFinancialTransactionIntent

ComponentPaymentIntenttype_cd*<= COMP

0..* financialTransactionIntentA

sequence_nbr:

PredecessorAtype_cd*<= SUCC

0..* priorInvoiceAdjustmentEvent

ManufacturedMaterialForm

class_cd* <= MMATdeterminer_cd* <= INSTANCEcd: <= FormType

EntityProvider

class_cd* <= ENTdeterminer_cd* <= INSTANCEnm:

Organization

class_cd* <= ORGdeterminer_cd* <= INSTANCEid: [0..*]nm: [0..*]

PersonInsured

class_cd* <= PSNdeterminer_cd* <= INSTANCEid: SET<II>nm:telecom:administrative_gender_cd: <= AdministrativeGenderbirth_time:deceased_time:multiple_birth_ind:birth_order_nbr:addr:

LivingSubjectInsuredAnimal

class_cd* <= LIVdeterminer_cd* <= INSTANCEnm:

PersonGuardianOrParent

class_cd* <= PSNdeterminer_cd* <= INSTANCEnm:

LivingSubjectGroup

class_cd* <= LIVdeterminer_cd* <= INSTANCEqty*: [1..1] (number in group)

PersonPatient

class_cd* <= PSNdeterminer_cd* <= INSTANCEnm:telecom:administrative_gender_cd: <= AdministrativeGenderbirth_time:deceased_time:multiple_birth_ind:birth_order_nbr:addr:

LivingSubjectAnimal


OrganizationSchool

class_cd* <= ORGdeterminer_cd* <= INSTANCEid:nm:

RoleRequestPayeeclass_cd <= ROLcd: <= PayeeRelationshipRoleType (payee relationship to covered party)

0..1playingManufacturedMaterial

RoleEOBPrintFormclass_cd <= ROL

1..1player

RoleProviderclass_cd <= ROLid: [0..*]

0..1scopingOrganization

RoleStudentclass_cd <= ROL

0..* playedRole

1..1guardianPerson

GuardianOrParentclass_cd <= GUARD

0..* guardian

cd: <= PRN (parent - mother or father)id: (id of guardian or parent)

1..1contactPerson

ContactPartyRecipientclass_cd <= CONcd: <= AdministrativeContactRoleType

1..1underwritingOrganization

Underwriterclass_cd <= UNDWRTid*: [1..1]

1..1member

Memberclass_cd <= MBR

0..* memberid: (id within group, if known)

1..1policyHolder


PolicyHolderclass_cd <= POLHOLDid*: [1..1]

0..1coveredParty


CoveredPartyRoleclass_cd <= COVPTYid: (covered party in policy, member #)cd: CE <= CoverageRoleType (reason for being covered, including spouse, child, student, handicapped)

1..1patient

0..1providerOrganization

Patientclass_cd <= PATid: (patient and/or group identifier, if known)

1..1contactPerson


0..* participantSubjectPayeetype_cd*<= SBJ

0..* participant

DirectTargetPrintOntype_cd*<= DIR

0..* participantLocationIncidenttype_cd*<= LOC

0..1 underwriterAuthorPolicyAccounttype_cd*<= AUT

0..* contactPartyAttentiontype_cd*<= ATTN

0..* patientSubjectPatienttype_cd*<= SBJ

0..* assignedEntityAuthorContracttype_cd*<= AUT

0..1 agentAuthorInvoicetype_cd*<= AUTtime: TS (invoice date/time)

0..1 agentAuthorOverridetype_cd*<= AUT


0..1 agentAuthorSummarytype_cd*<= AUTtime: (time calculation was made)

0..* agentPerformerProcessedtype_cd*<= PRFtime: (adjudication date/time)signature_txt: (security)

0..1 underwriterAuthorCoveragetype_cd*<= AUT

0..* policyHolder

ParticipantPolicyHoldertype_cd*<= HLD

CoveredPartytype_cd*<= COV

0..* coveredPartyBeneficiarytype_cd*<= BEN

0..* agent

AuthorConfirmationtype_cd*<= AUTtime: [0..1] (date confirmation was created)


0..1 agentAuthorAuthorizationRequesttype_cd*<= AUTtime: (Request date/time)

0..* participantSubjectPaymenttype_cd*<= SBJ

0..1 agent

ResponsibleProviderGroupingtype_cd*<= RESPROV

CMET: (AGNT) R_Responsible

[universal](COCT_MT040000)

CMET: (ACT) A_AdjudicationObservation




CMET: (ACCT) A_Account[universal]

(COCT_MT110002)

CMET: (ORG) Organization


CMET: (PSN) E_Person[contact]

(COCT_MT030203)



CMET: (AGNT) R_ResponsibleDevice


CMET: (AGNT) R_Responsibility


0..*



0..*





CMET: (ASSIGNED) R_AssignedPerson



(COCT_MT030203)



CMET: (ROL) R_LocationServiceDelivery

[detailed](COCT_MT240001)


(COCT_MT110002)



Invoice Re-Adjudication Request(FICR_RM000000)

Entry Point for Invoice Re-adjudication messages

CMET: (ACT) A_Billable[universal]

(COCT_MT280000)

Adjudication Result(FICR_RM000000)

Entry Point for adjudication results messages

Statement of Financial Activity(FICR_RM000000)

Entry point for Statement of Financial Activity messagesClaim Information(FICR_RM000000)

Entry Point for claim supportinformation messages

Eligibility, Authorization, Coverage Extn Results(FICR_RM000000)

Entry Point for Eligibility, Authorization and CoverageExtension Results messages

Invoice, Cancel, Query Requests & Query Results(FICR_RM000000)

Entry Point for Invoice, Cancel (& response), Query, Pre-determinationrequests & query results messages

Eligibility, Authorization, Coverage Extn(FICR_RM000000)

Entry Point for Eligibility, Authorization andCoverage Extension messages

Payment Advice(FICR_RM000000)

Entry point for payment remittance messages

ActChoice

EntityChoice

EntityChoicePatient

EntityChoiceA

0..*communicatesWith


0..* subordinateCoveredPartyIndirectAuthorithyOvertype_cd*<= INDAUTH

LanguageCommunication(Language_communication)

language_cd*: [1..1] (HumanLanguage)mode_cd: [0..1] (LanguageAbilityMode)preference_ind: BL [1..1]



Constraint:Each submitted invoiceelement must have 1EventAdjudicationResultsinstance

Constraint:cd: is only optional ineligibility messages

Constraint:DebitPayor must be for the rootInvoiceElementEventGrouping Act.CreditPayee is optional but may only beon the root InvoiceElementEventGrouping Act.

Constraint:DebitPayor must be for the rootFinancialTransactionEventPayment Act.CreditPayee may be specified for anyFinancialTransactionEventPayment.

Constraint:ReasonPaymentRequest may only be specifiedfor a leaf FinancialTransactionOrderPaymentRequest Actand it must enter the root InvoiceElementOrder first.

Constraint:AuthorInvoice and DebitPayor must befor the root FinancialTransactionOrderPaymentRequest Act.CreditPayee is optional but may only beon the root FinancialTransactionOrderPaymentRequest Act.

Constraint:All Relationships to the InvoiceElementOrderGroupcan only be associated with the root level instance

Constraint:Policy holder cannot be an animal

Constraint:ReferencePreviousAdjudication may only enterroot EventAdjudicationResults

Constraint:EventAdjudicationResults.cd mandatoryif target of ReasonAdjudicationSummary referencesnvoiceElementOrderDetail

Note:Can be used foridentification of aservice bureau

Net_amt must be positive or 0 forAdjudication Results messages

Net_amt must be negative or 0 forInvoice Cancel messages

Constraint:


(COCT_MT110000)







(COCT_MT110002)


(COCT_MT110000) 0..1 accountDebitPayortype_cd*<= DEBIT



(COCT_MT110002)


(COCT_MT110000)




(COCT_MT110002)


(COCT_MT110000)

PaymentRequest

InvoiceDetails

[lineitems]

Contract

Attachment

Accident

Billable Act

Eligibility+

Authorization

Explanationof

Benefits(EOB)

PaymentIntent

RemittanceAdvice

Statement ofFinancial

Activity (SOFA)

Coverage(insurance)

InvoiceSubject(patient)

CoverageSubject

(insured)

Invoice (Claim)






















Note:"Please Pay"







Note:"I Paid"

Note:"I Will Pay"


Note:Carrier id

































0..* subjectAct
























1..* act































sequence_nbr:



sequence_nbr:






0..* coverageEventA









sequence_nbr:





sequence_nbr:





EntityProvider


Organization


PersonInsured






LivingSubjectGroup


PersonPatient


LivingSubjectAnimal


OrganizationSchool





1..1player




0..* playedRole

1..1guardianPerson


0..* guardian


1..1contactPerson




1..1member



1..1policyHolder



0..1coveredParty



1..1patient



1..1contactPerson



0..* participant













0..* policyHolder




0..* agent





0..1 agent









(COCT_MT110002)




(COCT_MT030203)







0..*



0..*








(COCT_MT030203)






(COCT_MT110002)






(COCT_MT280000)














ActChoice

EntityChoice

EntityChoicePatient

EntityChoiceA





















Constraint:


(COCT_MT110000)







(COCT_MT110002)





(COCT_MT110002)


(COCT_MT110000)




(COCT_MT110002)


(COCT_MT110000)

Billable Act

Coverage(insurance)

InvoiceSubject(patient)

CoverageSubject

(insured)

Contract

Attachment

Accident

PaymentRequest

InvoiceDetails

[lineitems]Eligibility

+Authorization

Explanationof

Benefits(EOB)

Adjudication Results






















Note:"Please Pay"







Note:"I Paid"

Note:"I Will Pay"


Note:Carrier id

































0..* subjectAct
























1..* act































sequence_nbr:



sequence_nbr:






0..* coverageEventA









sequence_nbr:





sequence_nbr:





EntityProvider


Organization


PersonInsured






LivingSubjectGroup


PersonPatient


LivingSubjectAnimal


OrganizationSchool





1..1player




0..* playedRole

1..1guardianPerson


0..* guardian


1..1contactPerson




1..1member



1..1policyHolder



0..1coveredParty



1..1patient



1..1contactPerson



0..* participant













0..* policyHolder




0..* agent





0..1 agent









(COCT_MT110002)




(COCT_MT030203)







0..*



0..*








(COCT_MT030203)






(COCT_MT110002)






(COCT_MT280000)














ActChoice

EntityChoice

EntityChoicePatient

EntityChoiceA





















Constraint:


(COCT_MT110000)







(COCT_MT110002)





(COCT_MT110002)


(COCT_MT110000)




(COCT_MT110002)


(COCT_MT110000)

Explanationof

Benefits(EOB)

PaymentIntent

Coverage(insurance)

InvoiceDetails

[lineitems]


Activity (SOFA)

Payment/Remittance Advice






















Note:"Please Pay"







Note:"I Paid"

Note:"I Will Pay"


Note:Carrier id

































0..* subjectAct
























1..* act































sequence_nbr:



sequence_nbr:






0..* coverageEventA









sequence_nbr:





sequence_nbr:





EntityProvider


Organization


PersonInsured






LivingSubjectGroup


PersonPatient


LivingSubjectAnimal


OrganizationSchool





1..1player




0..* playedRole

1..1guardianPerson


0..* guardian


1..1contactPerson




1..1member



1..1policyHolder



0..1coveredParty



1..1patient



1..1contactPerson



0..* participant













0..* policyHolder




0..* agent





0..1 agent









(COCT_MT110002)




(COCT_MT030203)







0..*



0..*








(COCT_MT030203)






(COCT_MT110002)






(COCT_MT280000)














ActChoice

EntityChoice

EntityChoicePatient

EntityChoiceA





















Constraint:


(COCT_MT110000)







(COCT_MT110002)





(COCT_MT110002)


(COCT_MT110000)




(COCT_MT110002)


(COCT_MT110000)

RemittanceAdvice

Explanationof

Benefits(EOB)

PaymentIntent


Activity (SOFA)

FICR Key Concepts

• Concepts– Invoice Structure

– Coordination of Benefits

– Billable Acts & Adjudication Observations

– Deferred Adjudication

• Other concepts– Statement of Financial Activity (SOFA)

– Re-Adjudication Request

– Unsolicited Re-Adjudication Results

Invoice Overview

InvoiceElementDetail

InvoiceElementGroup



InvoiceElementGroup

Root InvoiceElement Group

PaymentRequest

AdjudicationTransform

Adjudicate as: Submitted with Adjustment Refuse

+ Reason Codes


InvoiceElementGroup



InvoiceElementGroup

Root InvoiceElement Group

PaymentIntent

Invoice & Adjudication Example

• Pharmacy invoice of $26.001. $20.00 for the drug cost

2. $6.00 for the professional fee

• Payor adjudicates to $11.081. Reduce the drug cost to $15.00

2. Accepts professional fee of $6.00

3. Indicates a deductible of -$5.00

4. Patient copay is -$4.92

5. Indicates patient is nearing their limit of $1000

Invoice & Adjudication Example

InvoiceAmt.

$26.00

Prof Fee$6.00

Drug$20.00

Total Due$26.00

Drug$15.00

Adjud w/Adjust

Prof Fee$6.00

Adjud asSubmit

NearingMax

$1000

InformationItem

Adjud w/Adjust

InvoiceAmt.

$11.08

TotalPayable$11.08

Deduct.-$5.00

CoPay-$4.92

PayorAdjustments

Coordination of Benefits (COB)

InvoiceAmt.

$26.00

Prof Fee$6.00

Drug$20.00

Total Due$26.00

Drug$15.00

Adjud w/Adjust

Prof Fee$6.00

Adjud asSubmit

Deduct.-$5.00

CoPay-$4.92

PayorAdjustments

NearingMax $1000

InformationItem

Adjud w/Adjust

Invoice Amt.$11.08

Explanation of Benefits(EOB)

To Payor 2

Drug$15.00

Adjud w/Adjust

Prof Fee$6.00

Adjud asSubmit

Deduct.-$5.00

CoPay-$4.92

PayorAdjustments

NearingMax $1000

InformationItem

Adjud w/Adjust

Invoice Amt.$11.08


To Payor 3

To Payor 3

Billable Acts & Adjudication Observations

InvoiceAmt.

$26.00

Prof Fee$6.00

Drug$20.00

Total Due$26.00

Product Service

RxDispense

PrefAccom

Billable Acts

DrugInteraction

AdjudicationObservations

Drug$15.00

Adjud w/Adjust

Prof Fee$6.00

Adjud asSubmit

Adjud w/Adjust

InvoiceAmt.

$21.00

TotalPayable$21.00

Deferred Adjudication

Referencesto submitted

invoice(not shown)Drug

$15.00Adjud w/Adjust

Prof Fee$6.00

Adjud asSubmit

Deduct.-$5.00

CoPay-$4.92

PayorAdjustments

NearingMax $1000

InformationItem

Adjud w/Adjust

Invoice Amt.$11.08

Explanation ofBenefits (EOB)

Invoice #1 - $11.08

Invoice Amt.$26.00

Prof Fee$6.00

Drug$20.00

Total Due$26.00

Invoice #1 - $26.00 Send Invoice toPayor for Payment

Payor sends backacknowledgementand will respondwith completed

adjudication resultslater

Invoice Amt.$36.00

Prof Fee$4.00

Drug$30.00

Total Due$36.00

Invoice #2 - $36.00

Upcharge$2.00

Send Invoice toPayor for Payment

Payor sends backacknowledgementand will respondwith completed

adjudication resultslater

Referencesto submitted

invoice(not shown)

Drug$30.00

Adjud asSubmit

Prof Fee$4.00

Adjud asSubmit

Adjud asSubmit

Invoice Amt.$36.00


Invoice #2 - $36.00

Upcharge$2.00

Adjud asSubmit

Total Payable$47.08

Other Concepts

• Statement of Financial Activity (SOFA)– Can be included on adjudication results

• Number/amount of submitted, adjudicated, paid invoices

• Used to help keep Provider and Payor systems synchronized

– Queries for SOFA summary & details• Summary of counts and amounts ($) for a

number of categories• Detail query supplies the adjudicated details

that make up the counts and amounts

Other Concepts

• Re-Adjudication Request– Request by Provider to re-adjudicate an

Invoice based on new circumstances

– Text only with reference to Invoice

• Unsolicited Re-Adjudication Results– Payor performs audit function and

determines that previous adjudication results were incorrect

– May not be messaged but included in a Payment/Remittance Advice

Upcoming FICR Projects

What’s Next?

Upcoming FICR Projects

• Messages– Enrollment

– Requests for Information & Results

– Supporting Documents• Look at HL7 CDA

• Mappings– X12/HIPAA to HL7

– NCPDP to HL7

• Others…

Financial Management (FM)v3 Orientation

Questions?

Feedback?

financial management (fm) v3 orientation hl7 baltimore september 30, 2002

Documents

hl7 v3 ballot process

insurance coverage

v3fiab account

reimbursementfiab account

canadian national e

request coverage extension

paragraph width

necst project