| QUCR_HD730100UV01 Payment Advice Query Results |
Description: Entry point for payment advice detail message (Link to Excel View) Derived from RMIM: QUCR_RM730000UV01 |
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| AdjudResultsGroup [Constraint: " The AdjudResultsGroup.netAmt must equal the sum of all immediate children AdjudResultsGroup.netAmt "] |
Design Comments: Associations to the right are used for breaking down a Payment Advice (e.g. provider, sending appl) or a Statement of Financial Activity (e.g. payee, payor). Only 1 association can be specified per instance of this act. |
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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 [0..1] Act (II) |
Design Comments: If specified on a Payment Advice Summary, can be used to request additional detail with a Payment Advice Query message |
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| code [1..1] (M) Act (CS) {CNE:V:ActInvoiceAdjudicationPaymentCode} |
Design Comments: defines the categorization or summary |
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| effectiveTime [1..1] (M) Act (IVL<TS>) |
Design Comments: Time period for the payment or summary period. Can also indicate time period over which the clawback and/or retro adjustment applies |
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| unitQuantity [0..1] InvoiceElement (RTO<PQ,PQ>) |
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| unitPriceAmt [0..1] InvoiceElement (RTO<MO,PQ>) |
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| netAmt [1..1] (M) InvoiceElement (MO) |
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| device [0..1] (Device) | |||||||||
| performer [0..1] (Performer) |
Design Comments: Provider is the health care practitioner or goods provider that is providing the service or good that is being invoiced (e.g. Pharmacist and not Ordering Physician). |
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| author [0..1] (Author) | |||||||||
| location [0..1] (AdjudResultsGroupLocation) |
Design Comments: Location is the health care facility where the service or good is being provided as specified in the Billable Act (e.g. store location, hospital). |
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| reference1 [0..1] (AdjudResultsGroupRef) | |||||||||
| reference2 [0..*] (AdjudResultsRef) |
Design Comments: Running Totals (SOFA) are not included in Query Results as they only apply to Adjudication Results at the time the Adjudication Results are created by the Adjudicator. |
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| pertinentInformation [0..1] (PertinentInformation2) | |||||||||
| component [0..*] (AdjudResultsGroupComponent) | |||||||||
| preconditionFor [0..1] (Precondition) |
Design Comments: This supports retro adjustments, clawbacks & paper invoices. For example, the retro is based on 20 instances of drug "A" at $2.00 per instance for a total of $40.00. The INVE class referenced here indicates the basis for the calculation & identifies which fee code the retro/clawback applies to. |
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| Device | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationTargetDevice, root= "DEV"} |
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| adjudResultsSendingAppRole [1..1] (AdjudResultsSendingAppRole) | |||||||||
| AdjudResultsSendingAppRole | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassRoot, root= "ROL"} |
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| playingAdjudResultsSendingAppDevice [1..1] (AdjudResultsSendingAppDevice) | |||||||||
| AdjudResultsSendingAppDevice | |||||||||
| classCode [1..1] (M) Entity (CS) {CNE:V:EntityClassDevice, root= "DEV"} |
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| determinerCode [1..1] (M) Entity (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
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| id [1..1] (M) Entity (II) |
Design Comments: Sending application identifier |
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| Performer |
Design Comments: Provider is the health care practitioner or goods provider that is providing the service or good that is being invoiced (e.g. Pharmacist and not Ordering Physician). |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationPhysicalPerformer, root= "PRF"} |
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| adjudResultsProviderRole [1..1] (AdjudResultsProviderRole) | |||||||||
| AdjudResultsProviderRole | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassRoot, root= "ROL"} |
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| id [1..1] (M) Role (II) |
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| Author | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationAuthorOriginator, root= "AUT"} |
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| adjudResultsCarrierRole [1..1] (AdjudResultsCarrierRole) | |||||||||
| AdjudResultsCarrierRole | |||||||||
| 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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| AdjudResultsGroupLocation |
Design Comments: Location is the health care facility where the service or good is being provided as specified in the Billable Act (e.g. store location, hospital). |
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| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationTargetLocation, root= "LOC"} |
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| serviceDeliveryLocation [1..1] (R_ServiceDeliveryLocationUniversal) | |||||||||
| AdjudResultsGroupRef | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipRefersTo, root= "REFR"} |
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| adjudResultsFinancialContract [1..1] (AdjudResultsFinancialContract) | |||||||||
| AdjudResultsFinancialContract | |||||||||
| 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 [1..1] (M) Act (II) |
Design Comments: business arrangement identifier |
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| AdjudResultsRef |
Design Comments: Running Totals (SOFA) are not included in Query Results as they only apply to Adjudication Results at the time the Adjudication Results are created by the Adjudicator. |
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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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| netAmt [1..1] (M) InvoiceElement (MO) |
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| author [0..1] (AdjudicatedInvoiceAuthor) |
Design Comments: This is used to indicate that the submitted Invoice Grouping was adjudicated (& submitted) electronic or written (manual). This is important for Payment Advices, where it can be used to indicate manually adjudicated Invoice Groupings. |
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| predecessor [0..1] (AdjudicatedInvoicePredecessor) |
Design Comments: For re-adjudicated (or restated) EOBs and Invoice Nullify Results ONLY (e.g. audit purposes) |
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| outcomeOf [0..1] (AdjudicatedResultOutcome) | |||||||||
| AdjudicatedInvoiceAuthor |
Design Comments: This is used to indicate that the submitted Invoice Grouping was adjudicated (& submitted) electronic or written (manual). This is important for Payment Advices, where it can be used to indicate manually adjudicated Invoice Groupings. |
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| 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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| modeCode [0..1] Participation (CS) {CNE:D:ParticipationMode, default= "RWR"} |
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| adjudicatorRole [1..1] (AdjudicatorRole) | |||||||||
| AdjudicatorRole | |||||||||
| 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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| AdjudicatedInvoicePredecessor |
Design Comments: For re-adjudicated (or restated) EOBs and Invoice Nullify Results ONLY (e.g. audit purposes) |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipSucceeds, root= "SUCC"} |
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| adjudicatedInvoiceElementGroup [1..1] (AdjudicatedInvoiceElementGroup) | |||||||||
| 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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| reference [1..1] (AdjudicationResultReference) | |||||||||
| AdjudicationResultReference | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipRefersTo, root= "REFR"} |
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| invoiceElementGroup [1..1] (InvoiceElementGroup) |
Design Comments: MoodCode: PRP - auth, pre-det, cov ext RQO - invoice |
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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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| PertinentInformation2 | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipPertains, root= "PERT"} |
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| adjudResultsInvoiceElement [1..1] (AdjudResultsInvoiceElement) |
Design Comments: Breakdown by Invoice Type is not present on SOFA Summary Query Results. |
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| AdjudResultsInvoiceElement |
Design Comments: Breakdown by Invoice Type is not present on SOFA Summary Query Results. |
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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:ActMoodDefinition, root= "DEF"} |
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| code [1..1] (M) Act (CD) {CNE:V:ActInvoiceGroupCode} |
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| AdjudResultsGroupComponent | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasComponent, root= "COMP"} |
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| adjudResultsGroup [1..1] (AdjudResultsGroup) |
Design Comments: Associations to the right are used for breaking down a Payment Advice (e.g. provider, sending appl) or a Statement of Financial Activity (e.g. payee, payor). Only 1 association can be specified per instance of this act. |
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| Precondition |
Design Comments: This supports retro adjustments, clawbacks & paper invoices. For example, the retro is based on 20 instances of drug "A" at $2.00 per instance for a total of $40.00. The INVE class referenced here indicates the basis for the calculation & identifies which fee code the retro/clawback applies to. |
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| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasPre-condition, root= "PRCN"} |
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| adjudResultsInvoiceElementRef [1..1] (AdjudResultsInvoiceElementRef) | |||||||||
| AdjudResultsInvoiceElementRef | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"} |
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| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventCriterion, root= "EVN.CRT"} |
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| code [1..1] (M) Act (CD) {CNE:D:ActInvoiceDetailCode} |
Design Comments: identifies the product and/or service over which the clawback and/or retro adjustment applies |
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