| FICR_HD300600UV03 Authorization Request Vision Care |
Description: Entry Point for authorization request message (Link to Excel View) Derived from RMIM: FICR_RM300000UV03 |
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| PaymentRequest |
Design Comments: MoodCode: PRP - auth, pre-det, cov ext RQO - invoice "Please Pay" |
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| classCode [1..1] (M) Act (CS) {CNE:V:ActClassFinancialTransaction, root= "XACT"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodProposal, root= "PRP"} |
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| id [1..*] (M) Act (DSET<II>) |
Design Comments: Item ID, Tracking #, etc. |
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| amt [0..1] FinancialTransaction (MO) |
Design Comments: amount to be billed |
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| primaryPerformer [0..*] (PaymentRequestAttention) | |||||||||
| credit [0..1] (PaymentRequestPayee) | |||||||||
| reasonOf [1..1] (PaymentRequestReason) | |||||||||
| PaymentRequestAttention | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationPrimaryPerformer, root= "PPRF"} |
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| contactParty [1..1] (ContactParty) | |||||||||
| ContactParty | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassContact, root= "CON"} |
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| id [0..1] Role (II) |
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| code [1..1] (M) Role (CS) {CNE:D:AdministrativeContactRoleType} |
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| contactPerson [0..1] (ContactPerson) | |||||||||
| ContactPerson | |||||||||
| classCode [1..1] (M) Entity (CS) {CNE:V:EntityClassPerson, root= "PSN"} |
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| determinerCode [1..1] (M) Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
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| name [0..1] Entity (PN) |
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| telecom [0..1] Entity (TEL) |
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| PaymentRequestPayee | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasCredit, root= "CREDIT"} |
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| account [1..1] (A_AccountPayeeUniversal) |
Design Comments: Constrain Payee at the Message Type |
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| PaymentRequestReason | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipReason, root= "RSON"} |
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| invoiceElementGroup [1..1] (InvoiceElementGroup) | |||||||||
| InvoiceElementGroup | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodProposal, root= "PRP"} |
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| id [1..*] (M) Act (DSET<II>) |
Design Comments: may include data centre and sequence numbers |
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| code [1..1] (M) Act (CS) {CNE:V:ActInvoiceGroupCode} |
Design Comments: Invoice Type e.g. Healthcare Services, Rx Dispense, Rx Compound, Healthcare Goods, Preferred Accomodation |
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| effectiveTime [0..1] Act (IVL<TS>) |
Design Comments: time period that invoice covers e.g. month of January |
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| confidentialityCode [0..1] Act (CS) {CNE:V:x_BasicConfidentialityKind} |
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| netAmt [1..1] (M) InvoiceElement (MO) |
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| inFulfillmentOf [0..1] (InvoiceElementGroupInFulfillmentOf) | |||||||||
| predecessor [0..*] (Predecessor) | |||||||||
| reference [0..9] (Reference3) | |||||||||
| coverage [0..1] (InvoiceElementCoverage) |
Design Comments: For groups, specify all policies (e.g. WCB claim numbers) with the same coverage.sequenceNumber. Only 1 policy can be specified for authorizations & coverage extentions |
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| pertinentInformation1 [0..*] (InvoiceElementGroupAttachment) | |||||||||
| pertinentInformation2 [0..*] (BillingSupportObservation) |
Design Comments: Attach pre-existing conditions as observations. |
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| component [1..*] (InvoiceElementComponent) |
Design Comments: Sequence number used to sequence invoice elements in an Invoice Grouping and will not be included in Adjudication Results. This allows for an Invoice Grouping to be composed of one or more invoice element groups and/or details. There must be one leaf detail. |
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| triggerFor [0..*] (Suggests) | |||||||||
| InvoiceElementGroupInFulfillmentOf | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipFulfills, root= "FLFS"} |
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| financialContract [1..1] (FinancialContract) |
Design Comments: Need amount for contract (max allowable amount), not needed for e-Claims |
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| FinancialContract |
Design Comments: Need amount for contract (max allowable amount), not needed for e-Claims |
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| classCode [1..1] (M) Act (CS) {CNE:V:ActClassFinancialContract, root= "FCNTRCT"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| id [0..1] Act (II) |
Design Comments: business arrangement identifier, contract identifier |
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| code [1..1] (M) Act (CS) {CNE:V:ActBillingArrangementCode} |
Design Comments: i.e. FFS, Block, Contract, Rostering, Capitation, etc. |
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| Predecessor | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasPreviousInstance, root= "PREV"} |
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| invoiceElementCrossReference [1..1] (InvoiceElementCrossReference) |
Design Comments: May also reference a previous Invoice Grouping to indicate a corrected Invoice Grouping. In some situations, a 2nd Invoice Grouping must follow the submission of a previous Invoice Grouping. In this case, use this reference to point to the previous Invoice Grouping. |
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| InvoiceElementCrossReference |
Design Comments: May also reference a previous Invoice Grouping to indicate a corrected Invoice Grouping. In some situations, a 2nd Invoice Grouping must follow the submission of a previous Invoice Grouping. In this case, use this reference to point to the previous Invoice Grouping. |
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| classCode [1..1] (M) Act (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| id [1..1] (M) Act (II) |
Design Comments: includes references to authorization, coverage extension and pre-determination results. Previous adjudication results are not referenced with this mechanism |
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| Reference3 | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipRefersTo, root= "REFR"} |
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| invoiceCoordinationChoice [1..1] (InvoiceCoordinationChoice) | |||||||||
| InvoiceCoordinationChoice | |||||||||
| choice of A_InvoiceCoordinationUniversal | |||||||||
| InvoiceElementCoverage |
Design Comments: For groups, specify all policies (e.g. WCB claim numbers) with the same coverage.sequenceNumber. Only 1 policy can be specified for authorizations & coverage extentions |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipCoveredBy, root= "COVBY"} |
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| policyOrAccount [1..1] (PolicyOrAccount) |
Design Comments: id: = Coverage Identifier, extension = Policy.Plan.Group.Contract. Division.Section.Version (or similar). Carrier noted in author participation, and may not be same namespace as OID of id |
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| PolicyOrAccount |
Design Comments: id: = Coverage Identifier, extension = Policy.Plan.Group.Contract. Division.Section.Version (or similar). Carrier noted in author participation, and may not be same namespace as OID of id |
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| classCode [1..1] (M) Act (CS) {CNE:V:ActClassCoverage, root= "COV"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| id [0..1] Act (II) |
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| code [0..1] Act (CS) {CNE:V:ActInsurancePolicyCode} |
Design Comments: Policy Type |
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| beneficiary [1..1] (PolicyBeneficiary) | |||||||||
| holder [0..1] (Holder) | |||||||||
| author [1..1] (PolicyUnderwriter) | |||||||||
| pertinentInformation [0..1] (PolicyAccident) | |||||||||
| pertainsTo [0..1] (PolicyConsentPertinentInformation) | |||||||||
| PolicyBeneficiary | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationBeneficiary, root= "BEN"} |
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| coveredPartyAsPatient [1..1] (CoveredPartyAsPatient) |
Design Comments: Covered Person Identifier (Assigned by carrier - root of OID) = Subscriber+Dependents Can be a single covered party, an organization, an animal or a group of patients and/or a group of animals. Covered party may be a patient who for the purposes of the invoice is a covered party. |
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| CoveredPartyAsPatient |
Design Comments: Covered Person Identifier (Assigned by carrier - root of OID) = Subscriber+Dependents Can be a single covered party, an organization, an animal or a group of patients and/or a group of animals. Covered party may be a patient who for the purposes of the invoice is a covered party. |
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| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassCoveredParty, root= "COVPTY"} |
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| id [0..1] Role (II) |
Design Comments: covered party in policy, member # |
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| code [0..1] Role (CS) {CNE:V:CoverageRoleType} |
Design Comments: reason for being covered, including family dependent, students, handicapped |
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| coveredPartyAsPatientChoice [1..1] (CoveredPartyAsPatientChoice) | |||||||||
| subjectOf [0..*] (Consenter) | |||||||||
| indirectAuthority [0..*] (IndirectAuthorithyOver) |
Design Comments: Used for family relationships only (for CoverageRoleType = FAMDEP) |
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| CoveredPartyAsPatientChoice | |||||||||
| choice of CoveredPartyAsPatientAnimal | |||||||||
| or CoveredPartyAsPatientPerson | |||||||||
| CoveredPartyAsPatientAnimal | |||||||||
| classCode [1..1] (M) Entity (CS) {CNE:V:EntityClassLivingSubject, root= "LIV"} |
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| determinerCode [1..1] (M) Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
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| name [0..1] Entity (ST) |
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| CoveredPartyAsPatientPerson | |||||||||
| classCode [1..1] (M) Entity (CS) {CNE:V:EntityClassPerson, root= "PSN"} |
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| determinerCode [1..1] (M) Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
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| name [1..5] (M) Entity (DSET<PN>) |
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| administrativeGenderCode [0..1] LivingSubject (CS) {CNE:D:AdministrativeGender} |
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| birthTime [0..1] LivingSubject (TS) |
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| deceasedTime [0..1] LivingSubject (TS) |
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| multipleBirthInd [0..1] LivingSubject (BL) |
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| multipleBirthOrderNumber [0..1] LivingSubject (INT) |
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| addr [0..1] Person (AD) |
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| parentOrGuardianRole [0..1] (ParentOrGuardianRole) |
Design Comments: Role code can be used as [1] parent (mother, father) for newborns w/o identifiers that require an identifier for the parent. [2] adopted parent to note that CoveredPartyAsPersonPatient is adopted. |
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| ParentOrGuardianRole |
Design Comments: Role code can be used as [1] parent (mother, father) for newborns w/o identifiers that require an identifier for the parent. [2] adopted parent to note that CoveredPartyAsPersonPatient is adopted. |
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| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassPersonalRelationship, root= "PRS"} |
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| id [0..1] Role (II) |
Design Comments: id of parent |
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| code [1..1] (M) Role (CS) {CNE:D:PersonalRelationshipRoleType} |
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| relationshipHolder [0..1] (ParentOrGuardian) | |||||||||
| ParentOrGuardian | |||||||||
| classCode [1..1] (M) Entity (CS) {CNE:V:EntityClassPerson, root= "PSN"} |
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| determinerCode [1..1] (M) Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
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| name [1..1] (M) Entity (PN) |
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| Consenter | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationTargetSubject, root= "SBJ"} |
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| signatureText [1..1] (M) Participation (ST) |
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| patientConsent [1..1] (PatientConsent) |
Design Comments: Issue: this may be adjusted based on an expanded view of consent |
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| PatientConsent |
Design Comments: Issue: this may be adjusted based on an expanded view of consent |
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| classCode [1..1] (M) Act (CS) {CNE:V:ActClassConsent, root= "CONS"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| code [0..1] Act (CS) {CNE:D:ActFinancialPatientConsentCode} |
Design Comments: The type of consent being granted. |
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| IndirectAuthorithyOver |
Design Comments: Used for family relationships only (for CoverageRoleType = FAMDEP) |
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| typeCode [1..1] (M) RoleLink (CS) {CNE:V:RoleLinkHasIndirectAuthorityOver, root= "INDAUTH"} |
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| personalRelationship [1..1] (PersonalRelationship) | |||||||||
| PersonalRelationship | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassPersonalRelationship, root= "PRS"} |
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| code [1..1] (M) Role (CS) {CNE:C:RoleCode:FAMMEMB} |
Design Comments: Examples are spouse, child |
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| Holder | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationHolder, root= "HLD"} |
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| policyHolder [1..1] (PolicyHolder) |
Design Comments: Subscriber Identifier; required for X12 837 mapping |
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| PolicyHolder |
Design Comments: Subscriber Identifier; required for X12 837 mapping |
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| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassPolicyHolder, root= "POLHOLD"} |
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| id [0..1] Role (II) |
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| policyHolderChoice [0..1] (PolicyHolderChoice) | |||||||||
| PolicyHolderChoice | |||||||||
| choice of PolicyHolderPerson | |||||||||
| or PolicyHolderOrganization | |||||||||
| PolicyHolderPerson | |||||||||
| classCode [1..1] (M) Entity (CS) {CNE:V:EntityClassPerson, root= "PSN"} |
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| determinerCode [1..1] (M) Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
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| name [1..1] (M) Entity (PN) |
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| birthTime [0..1] LivingSubject (TS) |
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| PolicyHolderOrganization | |||||||||
| classCode [1..1] (M) Entity (CS) {CNE:V:EntityClassOrganization, root= "ORG"} |
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| determinerCode [1..1] (M) Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
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| name [0..1] Entity (TN) |
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| addr [0..1] Organization (AD) |
Design Comments: e.g. Employer's address for Workers Compensation policies |
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| PolicyUnderwriter | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationAuthorOriginator, root= "AUT"} |
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| carrierRole [1..1] (CarrierRole) | |||||||||
| CarrierRole | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassUnderwriter, root= "UNDWRT"} |
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| id [1..1] (M) Role (II) |
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| PolicyAccident | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipPertains, root= "PERT"} |
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| accident [1..1] (Accident) | |||||||||
| Accident | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassIncident, root= "INC"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| code [1..1] (M) Act (CS) {CNE:D:ActIncidentCode} |
Design Comments: work place related, auto related, etc. |
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| effectiveTime [1..1] (M) Act (TS) |
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| PolicyConsentPertinentInformation | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipPertains, root= "PERT"} |
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| negationInd [0..1] ActRelationship (BL) |
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| policyConsent [1..1] (PolicyConsent) |
Design Comments: Used to indicate consent given (or not) against a particular policy or account. |
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| PolicyConsent |
Design Comments: Used to indicate consent given (or not) against a particular policy or account. |
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| classCode [1..1] (M) Act (CS) {CNE:V:ActClassConsent, root= "CONS"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| InvoiceElementGroupAttachment | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipPertains, root= "PERT"} |
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| healthDocumentAttachment [1..1] (HealthDocumentAttachment) |
Design Comments: Used to attach documents, image, etc. required to support a health claim. Value is not mandatory to allow for case where just a reference to an existing attachment is required. |
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| HealthDocumentAttachment |
Design Comments: Used to attach documents, image, etc. required to support a health claim. Value is not mandatory to allow for case where just a reference to an existing attachment is required. |
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| classCode [1..1] (M) Act (CS) {CNE:V:ActClassObservation, root= "OBS"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| id [1..*] (M) Act (DSET<II>) |
Design Comments: attachment identifier |
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| code [1..1] (M) Act (CS) {CNE:D:ActClaimAttachmentCode} |
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| value [0..1] Observation (ED) |
Design Comments: attachment content |
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| BillingSupportObservation |
Design Comments: Attach pre-existing conditions as observations. |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipPertains, root= "PERT"} |
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| billingSupportObservation [1..1] (A_BillingSupportInformationUniversal) | |||||||||
| InvoiceElementComponent |
Design Comments: Sequence number used to sequence invoice elements in an Invoice Grouping and will not be included in Adjudication Results. This allows for an Invoice Grouping to be composed of one or more invoice element groups and/or details. There must be one leaf detail. |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasComponent, root= "COMP"} |
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| sequenceNumber [0..1] ActRelationship (INT) |
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| invoiceElementChoice [1..1] (InvoiceElementChoice) |
Design Comments: Data centre and sequence number must be the same for each complete group and detail hierarchy A_Invoice_element_group cannot be a leaf, A_Invoice_element_detail must be a leaf. "Please Adjudicate" MoodCode: PRP - auth, pre-det, cov ext RQO - invoice |
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| InvoiceElementChoice |
Design Comments: Data centre and sequence number must be the same for each complete group and detail hierarchy A_Invoice_element_group cannot be a leaf, A_Invoice_element_detail must be a leaf. "Please Adjudicate" MoodCode: PRP - auth, pre-det, cov ext RQO - invoice |
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| reasonOf [0..*] (InvoiceElementReason) |
Design Comments: This is where each benefit group will insert their billable act (e.g. Pharmacy Dispense Billable Act). Each Billable Act is a CMET, contained in the A_Billable CMET. Refer to the CMET for more information. The act will be in intent (INT) mood when requesting authorization |
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| choice of InvoiceElementDetail |
Design Comments: RTO used to specify 15 pills (each) out of a bottle of 100 pills (each) to reflect billing for a portion of a package (e.g. 0.15 of a bottle) |
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| or InvoiceElementGroup | |||||||||
| InvoiceElementReason |
Design Comments: This is where each benefit group will insert their billable act (e.g. Pharmacy Dispense Billable Act). Each Billable Act is a CMET, contained in the A_Billable CMET. Refer to the CMET for more information. The act will be in intent (INT) mood when requesting authorization |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipReason, root= "RSON"} |
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| billableActChoice [1..1] (A_BillableUniversal) | |||||||||
| InvoiceElementDetail |
Design Comments: RTO used to specify 15 pills (each) out of a bottle of 100 pills (each) to reflect billing for a portion of a package (e.g. 0.15 of a bottle) |
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| classCode [1..1] (M) Act (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodProposal, root= "PRP"} |
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| id [1..1] (M) Act (II) |
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| code [1..1] (M) Act (CD) {CNE:D:ActInvoiceDetailCode} |
Design Comments: Product/Service Code e.g. Office Visit ,Taxes, Markup, Dispense, including Product/Service Code Modifier e.g. northern isolation, off hours specialty, on call |
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| unitQuantity [1..1] (M) InvoiceElement (RTO<PQ,PQ>) |
Design Comments: e.g. 3 {boxes} |
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| unitPriceAmt [1..1] (M) InvoiceElement (RTO<MO,PQ>) |
Design Comments: e.g. $50 CAD/ 1 {box} |
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| netAmt [1..1] (M) InvoiceElement (MO) |
Design Comments: = unit_qty * unit_price_amt * factor_nbr * points_nbr. E.g. $150 CAD |
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| factorNumber [0..1] InvoiceElement (REAL) |
Design Comments: multiplier, can be used for tax percentages such as 0.07 |
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| Inherits associations from InvoiceElementChoice |
Design Comments: Data centre and sequence number must be the same for each complete group and detail hierarchy A_Invoice_element_group cannot be a leaf, A_Invoice_element_detail must be a leaf. "Please Adjudicate" MoodCode: PRP - auth, pre-det, cov ext RQO - invoice |
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| Suggests | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasTrigger, root= "TRIG"} |
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| invoiceElementOverride [1..1] (InvoiceElementOverride) | |||||||||
| InvoiceElementOverride | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassRoot, root= "ACT"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| code [1..1] (M) Act (CS) {CNE:V:ActInvoiceOverrideCode} |
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| text [0..1] Act (ST) |
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