| COCT_HD680003UV04 A_InvoiceCoordination enhanced |
(Link to Excel View) Derived from RMIM: COCT_RM680003UV04 |
||||||||
| AdjudicatedInvoiceElementGroup | |||||||||
| classCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"} |
|||||||||
| moodCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
|||||||||
| id [0..1] InvoiceElement (II) |
|||||||||
| code [1..1] (M) InvoiceElement (CS) {CNE:V:ActInvoiceGroupCode} |
UsageNotes: ERROR - Business name from Visio is too long and was truncated. Full businessName follows. (Invoice Type e.g. Healthcare Services, Rx Dispense, Rx Compound, Healthcare Goods, Preferred Accomodation |
||||||||
| statusCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActStatus} |
UsageNotes: ERROR - Business name from Visio is too long and was truncated. Full businessName follows. (Completed when done, Suspended if waiting for external) (information, Active if delayed by Adjudicator or the EOB is an estimate |
||||||||
| netAmt [1..1] (M) InvoiceElement (MO) |
|||||||||
| author [0..1] (Author2) | |||||||||
| coverage [0..1] (Coverage) |
Design Comments: Association is required, 1..1 and not mandatory, as EOB may have been generated from a non-HL7 EOB and the Provider s/w will not know the Policy Type to put in the target act. |
||||||||
| component [0..*] (Component2) | |||||||||
| Author2 | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationAuthorOriginator, root= "AUT"} |
|||||||||
| time [1..1] Participation (TS) |
|||||||||
| adjudicatorRole [1..1] (AdjudicatorRole) | |||||||||
| AdjudicatorRole | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassRoot, root= "ROL"} |
|||||||||
| id [0..1] Role (II) |
|||||||||
| Coverage |
Design Comments: Association is required, 1..1 and not mandatory, as EOB may have been generated from a non-HL7 EOB and the Provider s/w will not know the Policy Type to put in the target act. |
||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipCoveredBy, root= "COVBY"} |
|||||||||
| policyOrAccount [1..1] (PolicyOrAccount) | |||||||||
| PolicyOrAccount | |||||||||
| classCode [1..1] (M) FinancialContract (CS) {CNE:V:ActClassCoverage, root= "COV"} |
|||||||||
| moodCode [1..1] (M) FinancialContract (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
|||||||||
| id [0..1] FinancialContract (II) |
|||||||||
| negationInd [0..1] FinancialContract (BL) |
UsageNotes: ERROR - Business name from Visio is too long and was truncated. Full businessName follows. (used to indicate presence of a policy for eligibility - mandatory in eligibility message |
||||||||
| statusCode [0..1] FinancialContract (CS) {CNE:V:ActStatus} |
|||||||||
| beneficiary [1..1] (Beneficiary) | |||||||||
| author [1..1] (Author1) | |||||||||
| Beneficiary | |||||||||
| typeCode [1..1] (M) Participation (CS) {CNE:V:ParticipationBeneficiary, root= "BEN"} |
|||||||||
| coveredPartyAsPatient [1..1] (CoveredPartyAsPatient) | |||||||||
| CoveredPartyAsPatient | |||||||||
| classCode [1..1] (M) Role (CS) {CNE:V:RoleClassCoveredParty, root= "COVPTY"} |
|||||||||
| id [0..1] Role (II) |
|||||||||
| code [0..1] Role (CS) {CNE:V:CoverageRoleType} |
|||||||||
| coveredPartyAsPatientChoice [1..1] (CoveredPartyAsPatientChoice) | |||||||||
| indirectAuthority [0..*] (IndirectAuthorithyOver) |
Design Comments: Used for family relationships only (for CoverageRoleType = FAMDEP) |
||||||||
| CoveredPartyAsPatientChoice | |||||||||
| choice of CoveredPartyAsPatientPerson | |||||||||
| CoveredPartyAsPatientPerson | |||||||||
| classCode [1..1] (M) Person (CS) {CNE:V:EntityClassPerson, root= "PSN"} |
|||||||||
| determinerCode [1..1] (M) Person (CS) {CNE:V:EntityDeterminerSpecific, root= "INSTANCE"} |
|||||||||
| name [1..5] (M) Person (DSET<PN>) |
|||||||||
| administrativeGenderCode [0..1] Person (CS) {CNE:V:AdministrativeGender} |
|||||||||
| birthTime [0..1] Person (TS) |
|||||||||
| 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} |
|||||||||
| Author1 | |||||||||
| 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) |
|||||||||
| Component2 | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasComponent, root= "COMP"} |
|||||||||
| adjudicatedInvoiceElementChoice [1..1] (AdjudicatedInvoiceElementChoice) | |||||||||
| AdjudicatedInvoiceElementChoice | |||||||||
| reference [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). |
||||||||
| outcomeOf [0..1] (Outcome) | |||||||||
| choice of AdjudicatedInvoiceElementGroup | |||||||||
| or AdjudicatedInvoiceElementDetail | |||||||||
| 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"} |
|||||||||
| allowable [1..1] (Allowable) | |||||||||
| Allowable | |||||||||
| classCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"} |
|||||||||
| moodCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActMoodDefinition, root= "DEF"} |
|||||||||
| netAmt [1..1] (M) InvoiceElement (MO) |
|||||||||
| Outcome | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipOutcome, root= "OUTC"} |
|||||||||
| adjudicationResult [1..1] (AdjudicationResult) | |||||||||
| AdjudicationResult | |||||||||
| classCode [1..1] (M) Act (CS) {CNE:V:ActClassFinancialAdjudication, root= "ADJUD"} |
|||||||||
| moodCode [1..1] (M) Act (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
|||||||||
| code [1..1] (M) Act (CS) {CNE:V:ActAdjudicationCode} |
|||||||||
| reference [0..*] (Reference) |
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) |
||||||||
| pertinentInformation [0..*] (PertinentInformation) | |||||||||
| Reference [Constraint: " Each submitted invoice element must have 1 AdjudicationResults instance unless its parent is adjudicated as submitted "] |
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) |
||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipRefersTo, root= "REFR"} |
|||||||||
| invoiceElementChoice [1..1] (InvoiceElementChoice) | |||||||||
| InvoiceElementChoice | |||||||||
| reasonOf [0..*] (Reason) |
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 InvoiceElementGroup | |||||||||
| or InvoiceElementDetail | |||||||||
| Reason |
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) | |||||||||
| InvoiceElementGroup | |||||||||
| classCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"} |
|||||||||
| moodCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActMoodIntent} |
|||||||||
| id [1..*] (M) InvoiceElement (DSET<II>) |
|||||||||
| code [1..1] (M) InvoiceElement (CS) {CNE:V:ActInvoiceGroupCode} |
UsageNotes: ERROR - Business name from Visio is too long and was truncated. Full businessName follows. (Invoice Type e.g. Healthcare Services, Rx Dispense, Rx Compound, Healthcare Goods, Preferred Accomodation |
||||||||
| netAmt [1..1] (M) InvoiceElement (MO) |
|||||||||
| component [1..*] (Component1) | |||||||||
| Inherits associations from InvoiceElementChoice | |||||||||
| Component1 | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipHasComponent, root= "COMP"} |
|||||||||
| invoiceElementChoice [1..1] (InvoiceElementChoice) | |||||||||
| InvoiceElementDetail | |||||||||
| classCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"} |
|||||||||
| moodCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActMoodIntent} |
|||||||||
| code [1..1] (M) InvoiceElement (CD) {CNE:D:ActInvoiceDetailCode} |
UsageNotes: ERROR - Business name from Visio is too long and was truncated. Full businessName follows. (Product/Service Code e.g. Office Visit ,Taxes, Markup, Dispense, including Product/Service Code Modifier e.g. northern isolation, off hours specialty, on call |
||||||||
| netAmt [1..1] (M) InvoiceElement (MO) |
|||||||||
| Inherits associations from InvoiceElementChoice | |||||||||
| PertinentInformation | |||||||||
| typeCode [1..1] (M) ActRelationship (CS) {CNE:V:ActRelationshipPertains, root= "PERT"} |
|||||||||
| adjudicationCodeChoice [1..1] (AdjudicationCodeChoice) | |||||||||
| AdjudicationCodeChoice | |||||||||
| choice of AdjudicationResultReason | |||||||||
| or AdjudicationResultInformation | |||||||||
| AdjudicationResultReason | |||||||||
| classCode [1..1] (M) Observation (CS) {CNE:V:ActClassObservation, root= "OBS"} |
|||||||||
| moodCode [1..1] (M) Observation (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
|||||||||
| value [1..1] (M) Observation (ED) |
|||||||||
| AdjudicationResultInformation | |||||||||
| classCode [1..1] (M) Observation (CS) {CNE:V:ActClassObservation, root= "OBS"} |
|||||||||
| moodCode [1..1] (M) Observation (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
|||||||||
| value [1..1] (M) Observation (ED) |
|||||||||
| AdjudicatedInvoiceElementDetail | |||||||||
| classCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActClassInvoiceElement, root= "INVE"} |
|||||||||
| moodCode [1..1] (M) InvoiceElement (CS) {CNE:V:ActMoodEventOccurrence, root= "EVN"} |
|||||||||
| id [0..*] InvoiceElement (DSET<II>) |
|||||||||
| code [1..1] (M) InvoiceElement (CD) {CNE:D:ActInvoiceDetailCode} |
UsageNotes: ERROR - Business name from Visio is too long and was truncated. Full businessName follows. (Product/Service Code e.g. Office Visit ,Taxes, Markup, Dispense, including Product/Service Code Modifier e.g. northern isolation, off hours specialty, on call |
||||||||
| netAmt [1..1] (M) InvoiceElement (MO) |
|||||||||
| Inherits associations from AdjudicatedInvoiceElementChoice | |||||||||