| FICR_HD630100UV01 Invoice Nullify Results |
Description: Entry Point for Invoice abort results message (Link to Excel View) Derived from RMIM: FICR_RM630000UV01 |
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| InvoiceElementGroup |
Design Comments: MoodCode: PRP - auth, pre-det, cov ext RQO - invoice |
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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:ActMoodRequest, root= "RQO"} |
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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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| statusCode [1..1] (M) Act (CS) {CNE:C:ActStatus:nullified} |
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| netAmt [1..1] (M) InvoiceElement (MO) |
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| reference [0..*] (PreviousAdjudicationResultReference) |
Design Comments: Required for Invoice Grouping Nullifys if the Invoice has already been adjudicated. A new PaymentIntent & new EOB will be created to indicate the net effect of the nullify (reversal). |
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| PreviousAdjudicationResultReference |
Design Comments: Required for Invoice Grouping Nullifys if the Invoice has already been adjudicated. A new PaymentIntent & new EOB will be created to indicate the net effect of the nullify (reversal). |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipRefersTo, root= "REFR"} |
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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:C:ActStatus:nullified} |
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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| reason [0..1] (PaymentIntentReason) |
Design Comments: Allow walking from AdjudicatedInvoiceElementGroup to PaymentIntent for Nullify Invoice Results only |
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| reference [0..1] (Reference) |
Design Comments: To tie 2 EOBs together (e.g. ESA invoices) and for Invoice Nullify Results to point to previous EOBs. |
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| referencedBy [0..1] (AdjudResultsRef) | |||||||||
| PaymentIntentReason |
Design Comments: Allow walking from AdjudicatedInvoiceElementGroup to PaymentIntent for Nullify Invoice Results only |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipReason, root= "RSON"} |
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| paymentIntent [1..1] (PaymentIntent) |
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 |
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| PaymentIntent |
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 |
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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:ActMoodPromise, root= "PRMS"} |
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| effectiveTime [0..1] Act (TS) |
Design Comments: time Payor intends to make payment |
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| amt [1..1] (M) FinancialTransaction (MO) |
Design Comments: payment amount |
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| credit [1..1] (PaymentIntentPayee) | |||||||||
| debit [1..1] (PaymentIntentPayor) | |||||||||
| 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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| Reference |
Design Comments: To tie 2 EOBs together (e.g. ESA invoices) and for Invoice Nullify Results to point to previous EOBs. |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipRefersTo, root= "REFR"} |
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| adjudicatedInvoiceElementGroup [1..1] (AdjudicatedInvoiceElementGroup) | |||||||||
| AdjudResultsRef | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipRefersTo, root= "REFR"} |
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| adjudResultsGroup [1..1] (AdjudResultsGroup) | |||||||||
| AdjudResultsGroup | |||||||||
| 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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| code [1..1] (M) Act (CS) {CNE:V:ActInvoiceAdjudicationPaymentCode} |
Design Comments: defines the 'categorization'. Only really relevant for summaries. |
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| effectiveTime [1..1] (M) Act (IVL<TS>) |
Design Comments: summary period |
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| netAmt [1..1] (M) InvoiceElement (MO) |
Design Comments: grand total of all SOFA observations contained in this summary |
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| summary [0..*] (AdjudResultsGroupSummary) | |||||||||
| AdjudResultsGroupSummary | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipSummarizedBy, root= "SUMM"} |
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| adjudResultsGroupSummaryData [1..1] (AdjudResultsGroupSummaryData) | |||||||||
| AdjudResultsGroupSummaryData | |||||||||
| 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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| code [1..1] (M) Act (CS) {CNE:V:ActInvoiceElementSummaryCode} |
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| value [1..1] (M) Observation (ANY) |
Design Comments: PQ or MO - Value of summary |
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