No Current Link To VocabularyCoded With ExtensionsCoded No Extensions
FICR_HD600800UV03
Invoice Adjudication Request Hospital

Description: Entry Point for Invoice Adjudication Request message


(Link to Excel View)
Derived from RMIM: FICR_RM600000UV03
 
PaymentRequest

Design Comments: MoodCode: PRP - auth, pre-det, cov ext RQO - invoice "Please Pay"

classCode [1..1] (M)
Act (CS) {CNE:V:ActClassFinancialTransaction, root= "XACT"}
moodCode [1..1] (M)
Act (CS) {CNE:V:ActMoodRequest, root= "RQO"}
id [1..*] (M)
Act (DSET<II>)

Design Comments: Item ID, Tracking #, etc.

amt [1..1] (M)
FinancialTransaction (MO)

Design Comments: amount to be billed

primaryPerformer [0..*] (PaymentRequestAttention)
credit [0..1] (PaymentRequestPayee)
debit [1..1] (Debit)
pertinentInformation [0..*] (PertinentInformation)
reasonOf [1..*] (PaymentRequestReason)
 
PaymentRequestAttention
typeCode [1..1] (M)
Participation (CS) {CNE:V:ParticipationPrimaryPerformer, root= "PPRF"}
contactParty [1..1] (ContactParty)
 
ContactParty
classCode [1..1] (M)
Role (CS) {CNE:V:RoleClassContact, root= "CON"}
id [0..1]
Role (II)
code [1..1] (M)
Role (CS) {CNE:D:AdministrativeContactRoleType}
contactPerson [0..1] (ContactPerson)
 
ContactPerson
classCode [1..1] (M)
Entity (CS) {CNE:V:EntityClassPerson, root= "PSN"}
determinerCode [1..1] (M)
Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"}
name [0..1]
Entity (PN)
telecom [0..1]
Entity (TEL)
 
PaymentRequestPayee
typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipHasCredit, root= "CREDIT"}
account [1..1] (A_AccountPayeeUniversal)

Design Comments: Constrain Payee at the Message Type

 
Debit
typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipHasDebit, root= "DEBIT"}
account [1..1] (A_AccountPayorUniversal)

Design Comments: Constrain Payor at the Message Type

 
PertinentInformation
typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipPertains, root= "PERT"}
providerBillingTaxAccount [1..1] (ProviderBillingTaxAccount)

Design Comments: Can be used to specify the appropriate GST number and other tax numbers.

 
ProviderBillingTaxAccount

Design Comments: Can be used to specify the appropriate GST number and other tax numbers.

classCode [1..1] (M)
Act (CS) {CNE:V:ActClassAccount, root= "ACCT"}
moodCode [1..1] (M)
Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"}
id [1..1] (M)
Act (II)

Design Comments: Tax number, such as GST, PST number

code [1..1] (M)
Act (CS) {CNE:V:ActInvoiceDetailTaxCode}
 
PaymentRequestReason
typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipReason, root= "RSON"}
invoiceElementGroup [1..1] (InvoiceElementGroup)
 
InvoiceElementGroup
classCode [1..1] (M)
Act (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"}
moodCode [1..1] (M)
Act (CS) {CNE:V:ActMoodRequest, root= "RQO"}
id [1..*] (M)
Act (DSET<II>)

Design Comments: may include data centre and sequence numbers

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

effectiveTime [0..1]
Act (IVL<TS>)

Design Comments: time period that invoice covers e.g. month of January

confidentialityCode [0..1]
Act (CS) {CNE:V:x_BasicConfidentialityKind}
netAmt [1..1] (M)
InvoiceElement (MO)
inFulfillmentOf [0..1] (InvoiceElementGroupInFulfillmentOf)
predecessor [0..*] (Predecessor)
reference [0..9] (Reference)

Design Comments: Include 0, 1 or more EOBs from upstream adjudicators for COB Invoices to downstream Adjudicators

coverage [0..*] (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

pertinentInformation1 [0..*] (InvoiceElementGroupAttachment)
pertinentInformation2 [0..*] (BillingSupportObservation)

Design Comments: Attach pre-existing conditions as observations.

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.

triggerFor [0..*] (Suggests)
 
InvoiceElementGroupInFulfillmentOf
typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipFulfills, root= "FLFS"}
financialContract [1..1] (FinancialContract)

Design Comments: Need amount for contract (max allowable amount), not needed for e-Claims

 
FinancialContract

Design Comments: Need amount for contract (max allowable amount), not needed for e-Claims

classCode [1..1] (M)
Act (CS) {CNE:V:ActClassFinancialContract, root= "FCNTRCT"}
moodCode [1..1] (M)
Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"}
id [0..1]
Act (II)

Design Comments: business arrangement identifier, contract identifier

code [1..1] (M)
Act (CS) {CNE:V:ActBillingArrangementCode}

Design Comments: i.e. FFS, Block, Contract, Rostering, Capitation, etc.

 
Predecessor
typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipHasPreviousInstance, root= "PREV"}
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.

 
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.

classCode [1..1] (M)
Act (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"}
moodCode [1..1] (M)
Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"}
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

 
Reference

Design Comments: Include 0, 1 or more EOBs from upstream adjudicators for COB Invoices to downstream Adjudicators

typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipRefersTo, root= "REFR"}
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

typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipCoveredBy, root= "COVBY"}
sequenceNumber [0..1]
ActRelationship (INT)

Design Comments: COB priority as submitted. primary, secondary, etc.

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

 
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

classCode [1..1] (M)
Act (CS) {CNE:V:ActClassCoverage, root= "COV"}
moodCode [1..1] (M)
Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"}
id [0..1]
Act (II)
code [0..1]
Act (CS) {CNE:V:ActInsurancePolicyCode}
statusCode [0..1]
Act (CS) {CNE:D:ActStatus}
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"}
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.

 
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.

classCode [1..1] (M)
Role (CS) {CNE:V:RoleClassCoveredParty, root= "COVPTY"}
id [0..1]
Role (II)

Design Comments: covered party in policy, member #

code [1..1] (M)
Role (CS) {CNE:V:CoverageRoleType}

Design Comments: reason for being covered, including family dependent, students, handicapped

coveredPartyAsPatientChoice [1..1] (CoveredPartyAsPatientChoice)
subjectOf [0..*] (Consenter)
indirectAuthority [0..*] (IndirectAuthorithyOver)

Design Comments: Used for family relationships only (for CoverageRoleType = FAMDEP)

 
CoveredPartyAsPatientChoice
choice of CoveredPartyAsPatientAnimal
          or CoveredPartyAsPatientPerson
 
CoveredPartyAsPatientAnimal
classCode [1..1] (M)
Entity (CS) {CNE:V:EntityClassLivingSubject, root= "LIV"}
determinerCode [1..1] (M)
Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"}
name [0..1]
Entity (ST)
 
CoveredPartyAsPatientPerson
classCode [1..1] (M)
Entity (CS) {CNE:V:EntityClassPerson, root= "PSN"}
determinerCode [1..1] (M)
Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"}
name [1..5] (M)
Entity (DSET<PN>)
administrativeGenderCode [0..1]
LivingSubject (CS) {CNE:D:AdministrativeGender}
birthTime [0..1]
LivingSubject (TS)
deceasedTime [0..1]
LivingSubject (TS)
multipleBirthInd [0..1]
LivingSubject (BL)
multipleBirthOrderNumber [0..1]
LivingSubject (INT)
addr [0..1]
Person (AD)
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.

 
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.

classCode [1..1] (M)
Role (CS) {CNE:V:RoleClassPersonalRelationship, root= "PRS"}
id [0..1]
Role (II)

Design Comments: id of parent

code [1..1] (M)
Role (CS) {CNE:D:PersonalRelationshipRoleType}
relationshipHolder [0..1] (ParentOrGuardian)
 
ParentOrGuardian
classCode [1..1] (M)
Entity (CS) {CNE:V:EntityClassPerson, root= "PSN"}
determinerCode [1..1] (M)
Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"}
name [1..1] (M)
Entity (PN)
 
Consenter
typeCode [1..1] (M)
Participation (CS) {CNE:V:ParticipationTargetSubject, root= "SBJ"}
signatureText [1..1] (M)
Participation (ST)
patientConsent [1..1] (PatientConsent)

Design Comments: Issue: this may be adjusted based on an expanded view of consent

 
PatientConsent

Design Comments: Issue: this may be adjusted based on an expanded view of consent

classCode [1..1] (M)
Act (CS) {CNE:V:ActClassConsent, root= "CONS"}
moodCode [1..1] (M)
Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"}
code [0..1]
Act (CS) {CNE:D:ActFinancialPatientConsentCode}

Design Comments: The type of consent being granted.

 
IndirectAuthorithyOver

Design Comments: Used for family relationships only (for CoverageRoleType = FAMDEP)

typeCode [1..1] (M)
RoleLink (CS) {CNE:V:RoleLinkHasIndirectAuthorityOver, root= "INDAUTH"}
personalRelationship [1..1] (PersonalRelationship)
 
PersonalRelationship
classCode [1..1] (M)
Role (CS) {CNE:V:RoleClassPersonalRelationship, root= "PRS"}
code [1..1] (M)
Role (CS) {CNE:C:RoleCode:FAMMEMB}

Design Comments: Examples are spouse, child

 
Holder
typeCode [1..1] (M)
Participation (CS) {CNE:V:ParticipationHolder, root= "HLD"}
policyHolder [1..1] (PolicyHolder)

Design Comments: Subscriber Identifier; required for X12 837 mapping

 
PolicyHolder

Design Comments: Subscriber Identifier; required for X12 837 mapping

classCode [1..1] (M)
Role (CS) {CNE:V:RoleClassPolicyHolder, root= "POLHOLD"}
id [0..1]
Role (II)
policyHolderChoice [0..1] (PolicyHolderChoice)
 
PolicyHolderChoice
choice of PolicyHolderPerson
          or PolicyHolderOrganization
 
PolicyHolderPerson
classCode [1..1] (M)
Entity (CS) {CNE:V:EntityClassPerson, root= "PSN"}
determinerCode [1..1] (M)
Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"}
name [1..1] (M)
Entity (PN)
birthTime [0..1]
LivingSubject (TS)
 
PolicyHolderOrganization
classCode [1..1] (M)
Entity (CS) {CNE:V:EntityClassOrganization, root= "ORG"}
determinerCode [1..1] (M)
Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"}
name [0..1]
Entity (TN)
addr [0..1]
Organization (AD)

Design Comments: e.g. Employer's address for Workers Compensation policies

 
PolicyUnderwriter
typeCode [1..1] (M)
Participation (CS) {CNE:V:ParticipationAuthorOriginator, root= "AUT"}
carrierRole [1..1] (CarrierRole)
 
CarrierRole
classCode [1..1] (M)
Role (CS) {CNE:V:RoleClassUnderwriter, root= "UNDWRT"}
id [1..1] (M)
Role (II)
 
PolicyAccident
typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipPertains, root= "PERT"}
accident [1..1] (Accident)
 
Accident
classCode [1..1] (M)
Act (CS) {CNE:V:ActClassIncident, root= "INC"}
moodCode [1..1] (M)
Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"}
code [1..1] (M)
Act (CS) {CNE:D:ActIncidentCode}

Design Comments: work place related, auto related, etc.

effectiveTime [1..1] (M)
Act (TS)

Design Comments: accident date

 
PolicyConsentPertinentInformation
typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipPertains, root= "PERT"}
negationInd [0..1]
ActRelationship (BL)
policyConsent [1..1] (PolicyConsent)

Design Comments: Used to indicate consent given (or not) against a particular policy or account.

 
PolicyConsent

Design Comments: Used to indicate consent given (or not) against a particular policy or account.

classCode [1..1] (M)
Act (CS) {CNE:V:ActClassConsent, root= "CONS"}
moodCode [1..1] (M)
Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"}
 
InvoiceElementGroupAttachment
typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipPertains, root= "PERT"}
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.

 
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.

classCode [1..1] (M)
Act (CS) {CNE:V:ActClassObservation, root= "OBS"}
moodCode [1..1] (M)
Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"}
id [1..*] (M)
Act (DSET<II>)

Design Comments: attachment identifier

code [1..1] (M)
Act (CS) {CNE:D:ActClaimAttachmentCode}
value [0..1]
Observation (ED)

Design Comments: attachment content

 
BillingSupportObservation

Design Comments: Attach pre-existing conditions as observations.

typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipPertains, root= "PERT"}
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.

typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipHasComponent, root= "COMP"}
sequenceNumber [0..1]
ActRelationship (INT)
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. MoodCode: PRP - auth, pre-det, cov ext RQO - invoice "Please Adjudicate"

 
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. MoodCode: PRP - auth, pre-det, cov ext RQO - invoice "Please Adjudicate"

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).

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

choice of InvoiceElementDetail

Design Comments: RTO for unitQuantity 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)

          or InvoiceElementGroup
 
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).

typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipRefersTo, root= "REFR"}
submittedAllowable [1..1] (SubmittedAllowable)
 
SubmittedAllowable
classCode [1..1] (M)
Act (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"}
moodCode [1..1] (M)
Act (CS) {CNE:V:ActMoodDefinition, root= "DEF"}
netAmt [1..1] (M)
InvoiceElement (MO)

Design Comments: Allowable or eligibile amount, as per fee schedule

 
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

typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipReason, root= "RSON"}
billableActChoice [1..1] (A_BillableUniversal)
 
InvoiceElementDetail

Design Comments: RTO for unitQuantity 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)

classCode [1..1] (M)
Act (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"}
moodCode [1..1] (M)
Act (CS) {CNE:V:ActMoodRequest, root= "RQO"}
id [1..1] (M)
Act (II)
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

unitQuantity [1..1] (M)
InvoiceElement (RTO<PQ,PQ>)

Design Comments: e.g. 3 {boxes}

unitPriceAmt [1..1] (M)
InvoiceElement (RTO<MO,PQ>)

Design Comments: e.g. $50 CAD/ 1 {box}

netAmt [1..1] (M)
InvoiceElement (MO)

Design Comments: = unit_qty * unit_price_amt * factor_nbr * points_nbr. E.g. $150 CAD

factorNumber [0..1]
InvoiceElement (REAL)

Design Comments: multiplier, can be used for tax percentages such as 0.07

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. MoodCode: PRP - auth, pre-det, cov ext RQO - invoice "Please Adjudicate"

 
Suggests
typeCode [1..1] (M)
ActRelationship (CS) {CNE:V:ActRelationshipHasTrigger, root= "TRIG"}
invoiceElementOverride [1..1] (InvoiceElementOverride)
 
InvoiceElementOverride
classCode [1..1] (M)
Act (CS) {CNE:V:ActClassRoot, root= "ACT"}
moodCode [1..1] (M)
Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"}
code [1..1] (M)
Act (CS) {CNE:V:ActInvoiceOverrideCode}
text [0..1]
Act (ST)