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Merge pull request #47 from Alvearie/HIWHC-2612--Add-Commercial,Opt-Drug
Hiwhc 2612 add commercial,opt drug
2 parents e9d3707 + b8d2150 commit b1dc07e

18 files changed

+410
-106
lines changed

‎data/extensions/ClaimExtensions.fsh

Lines changed: 74 additions & 13 deletions
Original file line numberDiff line numberDiff line change
@@ -1,7 +1,13 @@
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Extension: AggregateClaimIndicator
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Id: aggregate-claim-indicator
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Title: "Aggregate Claim Indicator"
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Description: "Indicator that identifies whether this claim record is included in the adjustment processing of the aggregate build logic for admissions, episodes or DCGs"
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* value[x] only string
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Extension: CapitatedServiceIndicator
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Id: capitated-service-indicator
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Title: "Capitated Service Indicator"
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Description: "An indicator that this service (encounter record) was capitated"
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Description: "Indicator that this service (encounter record) was capitated"
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* value[x] only string
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Extension: ClaimItemDetailClassification
@@ -13,32 +19,70 @@ Description: "Classification of the information contained in this claim item
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Extension: ClaimSnapshotProviderName
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Id: claim-snapshot-provider-name
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Title: "Claim Snapshot Provider Name"
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Description: "The original provider name as reported on the claim"
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Description: "Original provider name as reported on the claim"
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* value[x] only string
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Extension: ClaimSnapshotProviderZipCode
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Id: claim-snapshot-provider-zip-code
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Title: "Claim Snapshot Provider Zip Code"
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Description: "The original provider postal code, as reported on the claim"
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Description: "Original provider postal code, as reported on the claim"
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* value[x] only string
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Extension: CompanyCode
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Id: company-code
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Title: "Company Code"
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Description: "The company code of the subscriber as reported on the claim"
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* value[x] only CodeableConcept
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Extension: CompoundCode
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Id: compound-code
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Title: "Compound Code"
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Description: "Indicator of whether the product is a compound drug or not"
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* value[x] only CodeableConcept
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Extension: CrossoverIndicator
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Id: crossover-indicator
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Title: "Crossover Indicator"
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Description: "Indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare"
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* value[x] only string
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Extension: EmployeeBusinessUnit
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Id: employee-business-unit
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Title: "Employee Business Unit"
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Description: "The business unit of the subscriber as reported on the claim"
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Description: "Business unit of the subscriber as reported on the claim"
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* value[x] only CodeableConcept
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Extension: Employer
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Id: employer
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Title: "Employer"
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Description: "Customer-specific code for the employer as reported on the claim record"
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* value[x] only CodeableConcept
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Extension: FinancialSystem
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Id: financial-system
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Title: "Financial System"
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Description: "Customer-specific code for the financial system"
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* value[x] only CodeableConcept
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Extension: FullyInsuredIndicator
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Id: fully-insured-indicator
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Title: "Fully Insured Indicator"
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Description: "Indicator that the claim was for a fully insured plan"
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* value[x] only string
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Extension: ClaimCategory
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Id: claim-category
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Title: "Claim Category"
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Description: "Standard HIPAA code for the category of the claim status"
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* value[x] only CodeableConcept
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* valueCodeableConcept from CLAIM-STATUS-CATEGORY (extensible)
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Extension: ClaimStatus
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Id: claim-status
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Title: "Claim Status"
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Description: "Standard HIPAA code for the status of an entire claim"
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* value[x] only CodeableConcept
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* valueCodeableConcept from CLAIM-STATUS (extensible)
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Extension: LastClaimIndicator
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Id: last-claim-indicator
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Title: "Last Claim Indicator"
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Description: "Indicator that identifies whether this claim record is the last or most recent claim"
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* value[x] only string
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Extension: LocalNumberOfUnitsPerService
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Id: local-number-of-units-per-service
@@ -59,6 +103,12 @@ Title: "Network Id"
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Description: "Customer-specific identifier of the patient provider network in which the member is enrolled"
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* value[x] only string
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Extension: NursingHomeIndicator
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Id: nursing-home-indicator
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Title: "Nursing Home Indicator"
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Description: "Indicator that the claim was for a nursing home patient"
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* value[x] only string
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Extension:      ProcedureGroup
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Id:             procedure-group
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Title:          "Procedure Group"
@@ -69,12 +119,23 @@ Description:    "Groups assigned to categorize related procedures"
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Extension: ReferralIndicator
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Id: referral-indicator
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Title: "Referral Indicator"
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Description: "An indicator signifying the service resulted from a referral"
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Description: "Indicator signifying the service resulted from a referral"
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* value[x] only string
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Extension: RxCount
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Id: rx-count
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Title: "RX Count"
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Description: "Count of prescriptions for the drug claim"
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* value[x] only unsignedInt
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Extension: SubmissionType
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Id: submission-type
133+
Title: "Submission Type"
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Description: "Customer-specific code for the type of electronic submission"
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* value[x] only CodeableConcept
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Extension: WhPayerPcpResponsibilityIndicator
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Id: wh-payer-pcp-responsibility-indicator
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Title: "Health Data Connect PCP Responsibility Indicator"
78-
Description: "An indicator signifying that the primary care physician is the physician considered either responsible or accountable for this claim"
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Description: "Indicator signifying that the primary care physician is the physician considered either responsible or accountable for this claim"
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* value[x] only string
80-

‎data/extensions/ClaimResponseExtensions.fsh

Lines changed: 31 additions & 1 deletion
Original file line numberDiff line numberDiff line change
@@ -1,10 +1,22 @@
1+
Extension: AdjudicationDate
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Id: adjudication-date
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Title: "Adjudication Date"
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Description: "Date on which the payment status of the claim was adjudicated"
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* value[x] only date
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Extension: ClaimAdjustmentType
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Id: claim-adjustment-type
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Title: "Claim Adjustment Type"
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Description: "The code for the claim's adjustment type"
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* value[x] only CodeableConcept
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* valueCodeableConcept from WhPayerClaimAdjustmentTypeValueSet (extensible)
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14+
Extension: ClaimReceivedDate
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Id: claim-received-date
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Title: "Claim Received Date"
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Description: "Date the claim was received"
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* value[x] only date
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Extension: ClaimStatus
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Id: claim-status
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Title: "Claim Status"
@@ -39,5 +51,23 @@ Description: "Payment status of claim item"
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Extension: ClaimResponseBenefitPlan
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Id: claim-response-benefit-plan
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Title: "Claim Response Benefit Plan"
42-
Description: "The Benefit Plan on the claim item."
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Description: "The benefit plan on the claim item"
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* value[x] only Reference(Coverage)
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Extension: DispositionReason
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Id: disposition-reason
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Title: "Disposition Reason"
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Description: "Customer-specific code for the disposition reason, as related to how the claim was paid"
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* value[x] only CodeableConcept
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Extension: SubmissionType
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Id: submission-type
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Title: "Submission Type"
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Description: "Customer-specific code for the type of electronic submission"
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* value[x] only CodeableConcept
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Extension: UsualAndCustomaryAmount
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Id: usual-and-customary-amount
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Title: "Usual And Customary Amount"
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Description: "Usual and customary amount on the drug claim"
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* value[x] only decimal

‎data/resources/claim/CDM_Claim.fsh

Lines changed: 50 additions & 15 deletions
Original file line numberDiff line numberDiff line change
@@ -29,24 +29,56 @@ Description: "A provider issued list of professional services and products wh
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* procedure.extension[procedureGroup] ^definition = "Groups assigned to categorize related procedures"
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* item.extension contains CapitatedServiceIndicator named capitatedServiceIndicator 0..1
32-
* item.extension[capitatedServiceIndicator] ^short = "An indicator that this service (encounter record) was capitated"
33-
* item.extension[capitatedServiceIndicator] ^definition = "An indicator that this service (encounter record) was capitated"
32+
* item.extension[capitatedServiceIndicator] ^short = "Indicator that this service (encounter record) was capitated"
33+
* item.extension[capitatedServiceIndicator] ^definition = "Indicator that this service (encounter record) was capitated"
34+
35+
* item.extension contains FullyInsuredIndicator named fullyInsuredIndicator 0..1
36+
* item.extension[fullyInsuredIndicator] ^short = "Indicator that the claim was for a fully insured plan"
37+
* item.extension[fullyInsuredIndicator] ^definition = "Indicator that the claim was for a fully insured plan"
38+
39+
* item.extension contains NursingHomeIndicator named nursingHomeIndicator 0..1
40+
* item.extension[nursingHomeIndicator] ^short = "Indicator that the claim was for a nursing home patient"
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* item.extension[nursingHomeIndicator] ^definition = "Indicator that the claim was for a nursing home patient"
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* insurance.extension contains CrossoverIndicator named crossoverIndicator 0..1
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* insurance.extension[crossoverIndicator] ^short = "Indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare"
45+
* insurance.extension[crossoverIndicator] ^definition = "Indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare"
46+
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* extension contains AggregateClaimIndicator named aggregateClaimIndicator 0..1
48+
* extension[aggregateClaimIndicator] ^short = "Indicator that identifies whether this claim record is included in the adjustment processing of the aggregate build logic for admissions, episodes or DCGs"
49+
* extension[aggregateClaimIndicator] ^definition = "Indicator that identifies whether this claim record is included in the adjustment processing of the aggregate build logic for admissions, episodes or DCGs"
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* extension contains ClaimSnapshotProviderName named claimSnapshotProviderName 0..1
36-
* extension[claimSnapshotProviderName] ^short = "The original provider name as reported on the claim"
37-
* extension[claimSnapshotProviderName] ^definition = "The original provider name as reported on the claim"
52+
* extension[claimSnapshotProviderName] ^short = "Original provider name as reported on the claim"
53+
* extension[claimSnapshotProviderName] ^definition = "Original provider name as reported on the claim"
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* extension contains ClaimSnapshotProviderZipCode named claimSnapshotProviderZipCode 0..1
40-
* extension[claimSnapshotProviderZipCode] ^short = "The original provider postal code, as reported on the claim"
41-
* extension[claimSnapshotProviderZipCode] ^definition = "The original provider postal code, as reported on the claim"
42-
43-
* item.extension contains CompanyCode named companyCode 0..1
44-
* item.extension[companyCode] ^short = "The company code of the subscriber as reported on the claim"
45-
* item.extension[companyCode] ^definition = "The company code of the subscriber as reported on the claim"
56+
* extension[claimSnapshotProviderZipCode] ^short = "Original provider postal code, as reported on the claim"
57+
* extension[claimSnapshotProviderZipCode] ^definition = "Original provider postal code, as reported on the claim"
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4759
* extension contains EmployeeBusinessUnit named employeeBusinessUnit 0..1
48-
* extension[employeeBusinessUnit] ^short = "The business unit of the subscriber as reported on the claim"
49-
* extension[employeeBusinessUnit] ^definition = "The business unit of the subscriber as reported on the claim"
60+
* extension[employeeBusinessUnit] ^short = "Business unit of the subscriber as reported on the claim"
61+
* extension[employeeBusinessUnit] ^definition = "Business unit of the subscriber as reported on the claim"
62+
63+
* extension contains Employer named employer 0..1
64+
* extension[employer] ^short = "Customer-specific code for the employer as reported on the claim record"
65+
* extension[employer] ^definition = "Customer-specific code for the employer as reported on the claim record"
66+
67+
* extension contains FinancialSystem named financialSystem 0..1
68+
* extension[financialSystem] ^short = "Customer-specific code for the financial system"
69+
* extension[financialSystem] ^definition = "Customer-specific code for the financial system"
70+
71+
* extension contains ClaimCategory named claimCategory 0..1
72+
* extension[claimCategory] ^short = "Standard HIPAA code for the category of the claim status"
73+
* extension[claimCategory] ^definition = "Standard HIPAA code for the category of the claim status"
74+
75+
* extension contains ClaimStatus named claimStatus 0..1
76+
* extension[claimStatus] ^short = "Standard HIPAA code for the status of an entire claim"
77+
* extension[claimStatus] ^definition = "Standard HIPAA code for the status of an entire claim"
78+
79+
* extension contains LastClaimIndicator named lastClaimIndicator 0..1
80+
* extension[lastClaimIndicator] ^short = "Indicator that identifies whether this claim record is the last or most recent claim"
81+
* extension[lastClaimIndicator] ^definition = "Indicator that identifies whether this claim record is the last or most recent claim"
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* item.quantity.extension contains LocalNumberOfUnitsPerService named localNumberOfUnitsPerService 0..1
5284
* item.quantity.extension[localNumberOfUnitsPerService] ^short = "Customer-specific quantity of either services or units"
@@ -56,10 +88,13 @@ Description: "A provider issued list of professional services and products wh
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* extension[snapshotAgeInYears] ^short = "The age of the patient in years at the date of service"
5789
* extension[snapshotAgeInYears] ^definition = "The age of the patient in years at the date of service"
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91+
* extension contains SubmissionType named submissionType 0..1
92+
* extension[submissionType] ^short = "Customer-specific code for the type of electronic submission"
93+
* extension[submissionType] ^definition = "Customer-specific code for the type of electronic submission"
94+
5995
* extension contains WhPayerPcpResponsibilityIndicator named whPayerPcpResponsibilityIndicator 0..1
60-
* extension[whPayerPcpResponsibilityIndicator] ^short = "An indicator signifying that the primary care physician is the physician considered either responsible or accountable for this claim"
61-
* extension[whPayerPcpResponsibilityIndicator] ^definition = "An indicator signifying that the primary care physician is the physician considered either responsible or accountable for this claim"
96+
* extension[whPayerPcpResponsibilityIndicator] ^short = "Indicator signifying that the primary care physician is the physician considered either responsible or accountable for this claim"
97+
* extension[whPayerPcpResponsibilityIndicator] ^definition = "Indicator signifying that the primary care physician is the physician considered either responsible or accountable for this claim"
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6399
//Business rule to ensure the correct position of a provider on claim item against the CareTeam sequence
64100
* careTeam.sequence obeys claim-careteam-sequence-check
65-

‎data/resources/claim/CDM_ClaimResponse.fsh

Lines changed: 13 additions & 1 deletion
Original file line numberDiff line numberDiff line change
@@ -13,7 +13,15 @@ Description: "This resource provides the adjudication details from the proce
1313
* identifier.value 1..1
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* identifier.type from IdentifierTypeValueSet (extensible)
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16-
* type from ClaimTypeValueSet (extensible)
16+
* adjudication.extension contains AdjudicationDate named adjudicationDate 0..1
17+
* adjudication.extension[adjudicationDate] ^short = "Date on which the payment status of the claim was adjudicated"
18+
* adjudication.extension[adjudicationDate] ^definition = "Date on which the payment status of the claim was adjudicated"
19+
20+
* type from ClaimTypeValueSet (extensible)
21+
22+
* extension contains ClaimReceivedDate named claimReceivedDate 0..1
23+
* extension[claimReceivedDate] ^short = "Date the claim was received"
24+
* extension[claimReceivedDate] ^definition = "Date the claim was received"
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1826
* extension contains ClaimStatus named claimStatus 0..1
1927
* extension[claimStatus] ^short = "Custom code for the claim status"
@@ -23,6 +31,10 @@ Description: "This resource provides the adjudication details from the proce
2331
* payment.extension[claimAdjustmentType] ^short = "The code for the type of adjustment for the claim"
2432
* payment.extension[claimAdjustmentType] ^definition = "The code for the type of adjustment for the claim"
2533

34+
* payment.extension contains DispositionReason named dispositionReason 0..*
35+
* payment.extension[dispositionReason] ^short = "Customer-specific code for the disposition reason, as related to how the claim was paid"
36+
* payment.extension[dispositionReason] ^definition = "Customer-specific code for the disposition reason, as related to how the claim was paid"
37+
2638
* item.adjudication.category from AdjudicationCategoryValueSet (example)
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2840
//Extension for claim status at item level

‎data/resources/claim/CDM_ClaimResponse_Drug.fsh

Lines changed: 4 additions & 0 deletions
Original file line numberDiff line numberDiff line change
@@ -4,6 +4,10 @@ Id: cdm-claim-response-drug
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Title: "CDM Claim Response Drug"
55
Description: "This resource provides the adjudication details from the processing of a Claim resource. The CDMClaimResponseDrug profile extends the CDMClaimResponse resource with additional adjudication details that are specific to pharmacy claims."
66

7+
* item.extension contains UsualAndCustomaryAmount named usualAndCustomaryAmount 0..1
8+
* item.extension[usualAndCustomaryAmount] ^short = "Usual and customary amount on the drug claim"
9+
* item.extension[usualAndCustomaryAmount] ^definition = "Usual and customary amount on the drug claim"
10+
711
* item.extension contains RxFormularyIndicator named rxFormularyIndicator 0..1
812
* item.extension[rxFormularyIndicator] ^short = "An indicator that the prescription drug is included in the formulary"
913
* item.extension[rxFormularyIndicator] ^definition = "An indicator that the prescription drug is included in the formulary"

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