| FICR_HD310500UV03 Authorization Results Oral Health |
Description: Entry Point for Authorization results messages (Link to Excel View) Derived from RMIM: FICR_RM310000UV03 |
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| PaymentIntent [Constraint: " Amt must be positive or 0 for completed Adjudication Results messages Amt must be negative or 0 for Invoice Cancel Results messages "] |
Design Comments: If an Adjudicator adjudicates for multiple insurance policies (EOBs) for multiple Payors and/or Payees, there would be more than 1 Payment Intent payload in the Results message MoodCode: PRMS - auth, cov ext, invoice PRP - pre-det "I Will 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:ActMoodIntent} |
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| id [1..1] (M) Act (II) |
Design Comments: Item ID, Tracking #, etc. |
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| statusCode [1..1] (M) Act (CS) {CNE:D:ActStatus} |
Design Comments: Completed when done, Suspended if waiting for external information, Active if delayed by Adjudicator |
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| effectiveTime [0..1] Act (TS) |
Design Comments: Time Payor intends to make payment |
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| amt [0..1] FinancialTransaction (MO) |
Design Comments: payment amount |
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| credit [0..1] (PaymentIntentPayee) | |||||||||
| debit [0..1] (PaymentIntentPayor) | |||||||||
| reasonOf [0..*] (PaymentIntentReason) | |||||||||
| PaymentIntentPayee | |||||||||
| 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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| PaymentIntentPayor | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasDebit, root= "DEBIT"} |
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| account [1..1] (A_AccountPayorUniversal) |
Design Comments: Constrain Payor at the Message Type |
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| PaymentIntentReason | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipReason, root= "RSON"} |
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| adjudicatedInvoiceElementGroup [1..1] (AdjudicatedInvoiceElementGroup) | |||||||||
| AdjudicatedInvoiceElementGroup | |||||||||
| 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: 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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| statusCode [1..1] (M) Act (CS) {CNE:D:ActStatus} |
Design Comments: Completed when done, Suspended if waiting for external information, Active if delayed by Adjudicator |
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| netAmt [1..1] (M) InvoiceElement (MO) |
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| author [0..1] (AdjudicatedInvoiceAuthor) | |||||||||
| reference [0..1] (Reference2) |
Design Comments: Adjudicator must include EOB package for downstream Adjudicator. |
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| coverage [0..1] (AdjudicatedInvoiceCoverage) |
Design Comments: Allows Payor to adj & pay on different policy |
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| limitation [0..1] (Limitation) | |||||||||
| component [1..*] (AdjudicatedInvoiceElementComponent) | |||||||||
| AdjudicatedInvoiceAuthor | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationAuthorOriginator, root= "AUT"} |
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| time [1..1] (M) Participation (TS) |
Design Comments: adjudication date/time |
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| adjudicatorRole [1..1] (AdjudicatorRole) |
Design Comments: NECST only: To note a contact person (adjudicator) for the Provider to contact in case of questions on the EOB, use Adjudication Information codes |
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| AdjudicatorRole |
Design Comments: NECST only: To note a contact person (adjudicator) for the Provider to contact in case of questions on the EOB, use Adjudication Information codes |
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| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassRoot, root= "ROL"} |
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| id [1..1] (M) Role (II) |
Design Comments: Adjudicator Id |
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| playingAdjudicatorPerson [0..1] (AdjudicatorPerson) | |||||||||
| directAuthority [1..1] (DirectAuthorityOver) | |||||||||
| AdjudicatorPerson | |||||||||
| 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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| id [0..1] Entity (II) |
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| name [0..1] Entity (PN) |
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| DirectAuthorityOver | |||||||||
| typeCode [1..1] (M) RoleLink (CS) {CNE:V:RoleLinkHasDirectAuthorityOver, root= "DIRAUTH"} |
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| insuranceCarrierRole [1..1] (InsuranceCarrierRole) | |||||||||
| InsuranceCarrierRole | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassRoot, root= "ROL"} |
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| id [1..1] (M) Role (II) |
Design Comments: Carrier id |
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| Reference2 |
Design Comments: Adjudicator must include EOB package for downstream Adjudicator. |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipRefersTo, root= "REFR"} |
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| invoiceCoordinationChoice [1..1] (InvoiceCoordinationChoice) | |||||||||
| InvoiceCoordinationChoice | |||||||||
| choice of A_InvoiceCoordinationUniversal | |||||||||
| AdjudicatedInvoiceCoverage |
Design Comments: Allows Payor to adj & pay on different policy |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipCoveredBy, root= "COVBY"} |
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| sequenceNumber [1..1] (M) ActRelationship (INT) |
Design Comments: COB priority as adjudicated primary, secondary, etc. |
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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 [1..1] (M) Act (II) |
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| code [1..1] (M) Act (CS) {CNE:V:ActInsurancePolicyCode} |
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| beneficiary [1..1] (PolicyBeneficiary) | |||||||||
| holder [0..1] (Holder) | |||||||||
| author [1..1] (PolicyUnderwriter) | |||||||||
| 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 [1..1] (M) Role (II) |
Design Comments: covered party in policy, member # |
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| code [1..1] (M) Role (CS) {CNE:V:CoverageRoleType} |
Design Comments: reason for being covered, including family dependent, students, handicapped |
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| indirectAuthority [0..*] (IndirectAuthorithyOver) |
Design Comments: Used for family relationships only (for CoverageRoleType = FAMDEP) |
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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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| Limitation | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipLimitedBy, root= "LIMIT"} |
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| negationInd [0..1] ActRelationship (BL) |
Design Comments: Funds reserved? |
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| reservation [1..1] (Reservation) | |||||||||
| Reservation | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassFinancialTransaction, root= "XACT"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| effectiveTime [0..1] Act (TS) |
Design Comments: Expiry date for reservation |
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| amt [0..1] FinancialTransaction (MO) |
Design Comments: limit of reservation, if distinct from Root Adjudicated Invoice Element Group |
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| AdjudicatedInvoiceElementComponent | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasComponent, root= "COMP"} |
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| adjudicatedInvoiceElementChoice [1..1] (AdjudicatedInvoiceElementChoice) |
Design Comments: Want sum of all adjudication details (info & non-info) to equal what was submitted. For example, the reasons why you refused to pay part of the invoice |
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| AdjudicatedInvoiceElementChoice |
Design Comments: Want sum of all adjudication details (info & non-info) to equal what was submitted. For example, the reasons why you refused to pay part of the invoice |
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| reference1 [0..1] (Reference4) |
Design Comments: Used to indicate what the allowable or eligible amount that was what the policy would normally pay. The adjudicated amount may have been reduced for a number of reasons from this allowable amount (e.g. met annual limits). |
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| outcomeOf [0..1] (AdjudicatedResultOutcome) | |||||||||
| choice of AdjudicatedInvoiceElementDetail | |||||||||
| or AdjudicatedInvoiceElementGroup | |||||||||
| Reference4 |
Design Comments: Used to indicate what the allowable or eligible amount that was what the policy would normally pay. The adjudicated amount may have been reduced for a number of reasons from this allowable amount (e.g. met annual limits). |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipRefersTo, root= "REFR"} |
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| allowable [1..1] (Allowable) | |||||||||
| Allowable | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodDefinition, root= "DEF"} |
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| netAmt [1..1] (M) InvoiceElement (MO) |
Design Comments: Allowable or eligibile amount, as per fee schedule |
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| AdjudicatedResultOutcome | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipOutcome, root= "OUTC"} |
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| adjudicationResult [1..1] (AdjudicationResult) | |||||||||
| AdjudicationResult | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassFinancialAdjudication, root= "ADJUD"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
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| code [1..1] Act (CS) {CNE:V:ActAdjudicationCode} |
Design Comments: Summary of the adjudication processing - as submitted, w/ adjust, refuse. May not be present for active/suspended EOBs |
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| trigger [0..*] (AdjudicationResultTrigger) |
Design Comments: Select association below for required acts that do not have associated adjudication reason & adjudication information codes. |
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| reference [0..*] (AdjudicationResultReference) |
Design Comments: Multiple references to submitted invoice elements provides support for code substitution where the number of submitted fee items is consolidated on the adjudication results (e.g. 3 items to 1) |
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| pertinentInformation [0..*] (AdditionalPertinentInformation) | |||||||||
| reasonOf [0..*] (AdjudicationObservationReason) |
Design Comments: Specific adjudication observations will be added here, such as Drug Contraindications. |
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| AdjudicationResultTrigger |
Design Comments: Select association below for required acts that do not have associated adjudication reason & adjudication information codes. |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasTrigger, root= "TRIG"} |
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| negationInd [0..1] ActRelationship (BL) |
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| adjudicationResultRequiredAct [1..1] (AdjudicationResultRequiredAct) |
Design Comments: Id allows for consolidating identical required acts on 1 form |
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| AdjudicationResultReference |
Design Comments: Multiple references to submitted invoice elements provides support for code substitution where the number of submitted fee items is consolidated on the adjudication results (e.g. 3 items to 1) |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipRefersTo, root= "REFR"} |
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| invoiceElementChoice [1..1] (InvoiceElementChoice) |
Design Comments: MoodCode: PRP - auth, pre-det, cov ext RQO - invoice |
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| InvoiceElementChoice |
Design Comments: MoodCode: PRP - auth, pre-det, cov ext RQO - invoice |
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| choice of InvoiceElementDetail | |||||||||
| or InvoiceElementGroup | |||||||||
| InvoiceElementDetail | |||||||||
| 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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| 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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| 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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| netAmt [1..1] (M) InvoiceElement (MO) |
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| AdditionalPertinentInformation | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipPertains, root= "PERT"} |
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| adjudicationCodeChoice [1..1] (AdjudicationCodeChoice) | |||||||||
| AdjudicationCodeChoice | |||||||||
| trigger [0..*] (Trigger) |
Design Comments: Required actions apply to all associated adjudication result reason codes and adjudicate result information codes |
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| choice of AdjudicationResultInformation | |||||||||
| or AdjudicationResultReason | |||||||||
| Trigger |
Design Comments: Required actions apply to all associated adjudication result reason codes and adjudicate result information codes |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasTrigger, root= "TRIG"} |
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| negationInd [0..1] ActRelationship (BL) |
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| adjudicationResultRequiredAct [1..1] (AdjudicationResultRequiredAct) |
Design Comments: Id allows for consolidating identical required acts on 1 form |
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| AdjudicationResultRequiredAct |
Design Comments: Id allows for consolidating identical required acts on 1 form |
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| classCode [1..1] (M) Act (CS) {CNE:V:ActClassRoot, root= "ACT"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodRequest, root= "RQO"} |
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| id [0..1] Act (II) |
Design Comments: used to consolidate identical required acts on 1 form |
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| code [1..1] (M) Act (CS) {CNE:V:ActAdjudicationResultActionCode} |
Design Comments: e.g. print on EOB, allow override |
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| text [0..1] Act (ST) |
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| directTarget [0..*] (RequiredActDirectTarget) | |||||||||
| RequiredActDirectTarget | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationTargetDirect, root= "DIR"} |
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| formRole [1..1] (FormRole) |
Design Comments: Print form specified for EOB statement when provided to patient |
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| FormRole |
Design Comments: Print form specified for EOB statement when provided to patient |
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| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassRoot, root= "ROL"} |
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| playingForm [0..1] (Form) | |||||||||
| Form | |||||||||
| classCode [1..1] (M) Entity (CS) {CNE:V:EntityClassManufacturedMaterial, root= "MMAT"} |
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| determinerCode [1..1] (M) Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
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| code [0..1] Entity (CD) {CWE:D:FormType} |
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| telecom [0..1] Entity (TEL) |
Design Comments: URL for location for form |
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| AdjudicationResultInformation | |||||||||
| 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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| value [1..1] (M) Observation (ED) |
Design Comments: ActAdjudicationInformationCode |
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| Inherits associations from AdjudicationCodeChoice | |||||||||
| AdjudicationResultReason | |||||||||
| 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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| value [1..1] (M) Observation (ED) |
Design Comments: ActAdjudicationReason |
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| Inherits associations from AdjudicationCodeChoice | |||||||||
| AdjudicationObservationReason |
Design Comments: Specific adjudication observations will be added here, such as Drug Contraindications. |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipReason, root= "RSON"} |
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| actChoice [1..1] (A_AdjudicationObservationUniversal) | |||||||||
| AdjudicatedInvoiceElementDetail | |||||||||
| 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..*] (M) Act (DSET<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 AdjudicatedInvoiceElementChoice |
Design Comments: Want sum of all adjudication details (info & non-info) to equal what was submitted. For example, the reasons why you refused to pay part of the invoice |
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