 ANSI/HL7 V3 CR, R4-2008 HL7 Version 3 Standard: Claims and Reimbursement, Release 4 02/20/2008 |
Content Last Edited: 2009-09-04T22:38:52
The Predetermination-Authorization suite of interactions provides a mechanism for a Provider to submit a request to determine what his liability may be on a given product(s) or service(s) and to convey the plan coverage details to his patient. This will be used in many cases where the provider does not know the details of the policy that covers his patient and therefore cannot determine whether the payor requires a predetermination to be submitted or an authorization to be submitted.
The combination message allows the provider to submit a single request and receive a result (using a single message type) that will either reflect a predetermination result or an authorization result, depending on the requirements of the policy. In either case, the provider and patient are given the appropriate information to determine their liability and understand policy requirements. If pre-approval for the service and/or product is required by the specific insurance policy and circumstance, this will be included in the result. If pre-approval is not required, the results will reflect a predetermination result.
A predetermination-authorization combination number may also be supplied with the results and may be required for inclusion in an Invoice.
State Transition Diagram
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For details on the interpretation of this section, see the storyboard discussion in the Version 3 Guide.
To demonstrate when and how to request Generic Pre-Determination-Authorization for payment for subsequent treatment. The Request is sent to the Pre-D-Auth Manager to initial or complete a Pre-Det-Auth request.
Mr. Adam Everyman strains his back while at work and goes to see his General Practitioner, Dr. Fay Family, who determines the patient may benefit from physiotherapy. The doctor's office submits a manual form to HC Payor, Inc. to establish a claim. The claim is accepted by the Case Manager, however, Mr. Everyman does not want to go to the physiotherapy clinic that was referred by his health benefit plan for treatment. He would prefer to obtain services from the clinic that a good friend of his works in. Mr. Everyman makes an appointment with the clinic and provides the HC Payor, Inc. claim number and accident date to the receptionist. The receptionist asks for the name of his GP and indicates the first initial visit is covered under his health plan but that if subsequent treatment is required, he would need to determine if HC Payor, Inc. would continue payment.
Seth Stretcher, a practitioner at the clinic and Mr. Everyman's friend sees Mr. Everyman for an initial assessment visit. During his assessment, Seth determines that six treatment visits that include back exercise, ultrasound and external massage to the back should be sufficient and should be started immediately. Not knowing whether HC Payor, Inc. will cover the costs of this recommended treatment, Larry asks the receptionist to determine if HC Payor, Inc. will pay for the treatment.
The receptionist sends a Pre-Determination-Authorization request to HC Payor, Inc. to request payment pre-determination authorization for subsequent treatments.
HC Payor, Inc. responds immediately to the Pre-determination Authorization Results message with Pre-Determination Authorization Results Complete Generic, identifying that if the multi-item invoice is submitted it would likely be paid in full. Note: this is not a commitment to pay by the payor.
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For details on the interpretation of this section, see the discussion of application roles and their relationships in the Version 3 Guide.
An application that is responsible for the submission of a Pre-Determination-Authorization, Chiro Physio for health care services provided and/or products delivered by a generic benefits group on behalf of one or more patients.
A Pre-Determination-Authorization itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination-Authorization Manager (adjudicator) processes the Pre-Determination-Authorization as if it were a real Invoice.
The Pre-Determination-Authorization Requestor will receive an initial response, which may contain partial results and an indication when the Final Pre-Determination-Authorization Results will be forwarded from the Pre-Determination-Authorization Manager.
An application that is responsible for the submission of a Pre-Determination-Authorization, Generic for health care services provided and/or products delivered by a generic benefits group on behalf of one or more patients.
A Pre-Determination-Authorization itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination-Authorization Manager (adjudicator) processes the Pre-Determination-Authorization as if it were a real Invoice.
The Pre-Determination-Authorization Requestor will receive an initial response, which may contain partial results and an indication when the Final Pre-Determination-Authorization Results will be forwarded from the Pre-Determination-Authorization Manager.
An application that is responsible for the submission of a Pre-Determination-Authorization, Oral Health for health care services provided and/or products delivered by a generic benefits group on behalf of one or more patients.
A Pre-Determination-Authorization itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination-Authorization Manager (adjudicator) processes the Pre-Determination-Authorization as if it were a real Invoice.
The Pre-Determination-Authorization Requestor will receive an initial response, which may contain partial results and an indication when the Final Pre-Determination-Authorization Results will be forwarded from the Pre-Determination-Authorization Manager.
An application that is responsible for the submission of a Pre-Determination-Authorization, Pharmacy for health care services provided and/or products delivered by a generic benefits group on behalf of one or more patients.
A Pre-Determination-Authorization itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination-Authorization Manager (adjudicator) processes the Pre-Determination-Authorization as if it were a real Invoice.
The Pre-Determination-Authorization Requestor will receive an initial response, which may contain partial results and an indication when the Final Pre-Determination-Authorization Results will be forwarded from the Pre-Determination-Authorization Manager.
An application that is responsible for the submission of a Pre-Determination-Authorization, Physician for health care services provided and/or products delivered by a generic benefits group on behalf of one or more patients.
A Pre-Determination-Authorization itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination-Authorization Manager (adjudicator) processes the Pre-Determination-Authorization as if it were a real Invoice.
The Pre-Determination-Authorization Requestor will receive an initial response, which may contain partial results and an indication when the Final Pre-Determination-Authorization Results will be forwarded from the Pre-Determination-Authorization Manager.
An application that is responsible for the submission of a Pre-Determination-Authorization, Preferred Accomodation for health care services provided and/or products delivered by a generic benefits group on behalf of one or more patients.
A Pre-Determination-Authorization itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination-Authorization Manager (adjudicator) processes the Pre-Determination-Authorization as if it were a real Invoice.
The Pre-Determination-Authorization Requestor will receive an initial response, which may contain partial results and an indication when the Final Pre-Determination-Authorization Results will be forwarded from the Pre-Determination-Authorization Manager.
An application that is responsible for the submission of a Pre-Determination-Authorization, Vision Care for health care services provided and/or products delivered by a generic benefits group on behalf of one or more patients.
A Pre-Determination-Authorization itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination-Authorization Manager (adjudicator) processes the Pre-Determination-Authorization as if it were a real Invoice.
The Pre-Determination-Authorization Requestor will receive an initial response, which may contain partial results and an indication when the Final Pre-Determination-Authorization Results will be forwarded from the Pre-Determination-Authorization Manager.
An application that responds to a Pre-Determination-Authorization, Chiro Physio with Final Pre-Determination-Authorization Results if possible. If Final Pre-Determination-Authorization Results are not possible, then the Pre-Determination-Authorization Manager may respond with Initial Pre-Determination-Authorization Results that can include partial or incomplete processing results and an indication of when the Final Pre-Determination-Authorization Results will be available.
When the Pre-Determination-Authorization Manager, Initial/Final Results sends the Final Pre-Determination-Authorization Results, they act as a Pre-Determination-Authorization Notifier. This Application Role includes the Notifier Application Role.
A Pre-Determination-Authorization itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination-Authorization Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice.
An application that responds to a Pre-Determination-Authorization, Generic with Final Pre-Determination-Authorization Results if possible. If Final Pre-Determination-Authorization Results are not possible, then the Pre-Determination-Authorization Manager may respond with Initial Pre-Determination-Authorization Results that can include partial or incomplete processing results and an indication of when the Final Pre-Determination-Authorization Results will be available.
When the Pre-Determination-Authorization Manager, Initial/Final Results sends the Final Pre-Determination-Authorization Results, they act as a Pre-Determination-Authorization Notifier. This Application Role includes the Notifier Application Role.
A Pre-Determination-Authorization itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination-Authorization Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice.
An application that responds to a Pre-Determination-Authorization, Oral Health with Final Pre-Determination-Authorization Results if possible. If Final Pre-Determination-Authorization Results are not possible, then the Pre-Determination-Authorization Manager may respond with Initial Pre-Determination-Authorization Results that can include partial or incomplete processing results and an indication of when the Final Pre-Determination-Authorization Results will be available.
When the Pre-Determination-Authorization Manager, Initial/Final Results sends the Final Pre-Determination-Authorization Results, they act as a Pre-Determination-Authorization Notifier. This Application Role includes the Notifier Application Role.
A Pre-Determination-Authorization itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination-Authorization Manager (adjudicator) processes the Pre-Determination-Authorization as if it were a real Invoice.
An application that responds to a Pre-Determination-Authorization, Pharmacy with Final Pre-Determination-Authorization Results if possible. If Final Pre-Determination-Authorization Results are not possible, then the Pre-Determination-Authorization Manager may respond with Initial Pre-Determination-Authorization Results that can include partial or incomplete processing results and an indication of when the Final Pre-Determination-Authorization Results will be available.
When the Pre-Determination-Authorization Manager, Initial/Final Results sends the Final Pre-Determination-Authorization Results, they act as a Pre-Determination-Authorization Notifier. This Application Role includes the Notifier Application Role.
A Pre-Determination-Authorization itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination-Authorization Manager (adjudicator) processes the Pre-Determination-Authorization as if it were a real Invoice.
An application that responds to a Pre-Determination-Authorization, Physician with Final Pre-Determination-Authorization Results if possible. If Final Pre-Determination-Authorization Results are not possible, then the Pre-Determination-Authorization Manager may respond with Initial Pre-Determination-Authorization Results that can include partial or incomplete processing results and an indication of when the Final Pre-Determination-Authorization Results will be available.
When the Pre-Determination-Authorization Manager, Initial/Final Results sends the Final Pre-Determination-Authorization Results, they act as a Pre-Determination-Authorization Notifier. This Application Role includes the Notifier Application Role.
A Pre-Determination-Authorization itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination-Authorization Manager (adjudicator) processes the Pre-Determination-Authorization as if it were a real Invoice.
An application that responds to a Pre-Determination-Authorization, Preferred Accomodation with Final Pre-Determination-Authorization Results if possible. If Final Pre-Determination-Authorization Results are not possible, then the Pre-Determination-Authorization Manager may respond with Initial Pre-Determination-Authorization Results that can include partial or incomplete processing results and an indication of when the Final Pre-Determination-Authorization Results will be available.
When the Pre-Determination-Authorization Manager, Initial/Final Results sends the Final Pre-Determination-Authorization Results, they act as a Pre-Determination-Authorization Notifier. This Application Role includes the Notifier Application Role.
A Pre-Determination-Authorization itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination-Authorization Manager (adjudicator) processes the Pre-Determination-Authorization as if it were a real Invoice.
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For details on the interpretation of this section, see the definition of Interactions in the Version 3 Guide.
The sender sends a Pre-Determination-Authorization Results message containing the completed results of a Pre-Determination-Authorization Request for Chiropractic and/or Physiotherapy services and/or products.
Pre-Determination-Authorization Results indicate adjudication results for specified services and/or products, but does not generate a payment.
| Trigger Event | Pre-D Auth Notification | FICR_TE110101UV03 |
| Sender | Pred-Auth Rqster, ChiroPhysio | FICR_AR011004UV04 |
| Receiver | Pred-Auth Mgr, ChiroPhysio | FICR_AR013004UV04 |
The sender sends a Pre-Determination-Authorization Results message containing the completed results of a Pre-Determination-Authorization Request for Generic services and/or products.
Pre-Determination-Authorization Results indicate adjudication results for specified services and/or products, but does not generate a payment.
| Trigger Event | Pre-D Auth Notification | FICR_TE110101UV03 |
| Sender | Pred-Auth, Gen | FICR_AR011001UV04 |
| Receiver | Pred-Auth Mgr, Gen | FICR_AR013001UV04 |
The sender sends a Pre-Determination-Authorization Results message containing the completed results of a Pre-Determination-Authorization Request for Oral Health services and/or products.
Pre-Determination-Authorization Results indicate adjudication results for specified services and/or products, but does not generate a payment.
| Trigger Event | Pre-D Auth Notification | FICR_TE110101UV03 |
| Sender | Pred-Auth Rqstr, OralHealth | FICR_AR011005UV04 |
| Receiver | Pred-Auth Mgr, OralHealth | FICR_AR013005UV04 |
The sender sends a Pre-Determination-Authorization Results message containing the completed results of a Pre-Determination-Authorization Request for Pharmacy services and/or products.
Pre-Determination-Authorization Results indicate adjudication results for specified services and/or products, but does not generate a payment.
| Trigger Event | Pre-D Auth Notification | FICR_TE110101UV03 |
| Sender | Pred-Auth Rqstr, Rx | FICR_AR011003UV04 |
| Receiver | Pred-Auth Mgr, Pharmacy | FICR_AR013003UV04 |
The sender sends a Pre-Determination-Authorization Results message containing the completed results of a Pre-Determination-Authorization Request for Physician services and/or products.
Pre-Determination-Authorization Results indicate adjudication results for specified services and/or products, but does not generate a payment.
| Trigger Event | Pre-D Auth Notification | FICR_TE110101UV03 |
| Sender | Pred-Auth, Phys | FICR_AR011007UV04 |
| Receiver | Pred-Auth Mgr, Physician | FICR_AR013007UV04 |
The sender sends a Pre-Determination-Authorization Results message containing the completed results of a Pre-Determination-Authorization Request for Preferred Accomodation services and/or products.
Pre-Determination-Authorization Results indicate adjudication results for specified services and/or products, but does not generate a payment.
| Trigger Event | Pre-D Auth Notification | FICR_TE110101UV03 |
| Sender | Pred-Auth Rqstr, PAccom | FICR_AR011002UV04 |
| Receiver | Pred-Auth Mgr, PAccom | FICR_AR013002UV04 |
The sender sends a Pre-Determination-Authorization Results message containing the completed results of a Pre-Determination-Authorization Request for Vision Care services and/or products.
Pre-Determination-Authorization Results indicate adjudication results for specified services and/or products, but does not generate a payment.
| Trigger Event | Pre-D Auth Notification | FICR_TE110101UV03 |
| Sender | Pred-Auth Rqstr, Vision Care | FICR_AR011006UV04 |
| Receiver | Pred-Auth Mgr, Vision Care | FICR_AR013006UV04 |
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