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CPCDS Data Dictionary & Resource Mapping

CPCDS Data Dictionary & Resource Mapping. Claim. Non Payer Resource (TBD). Claim. Non Payer Resource (TBD). Claim. Claim. Non Payer Resource (TBD). 1 – http://hl7.org/fhir/us/phcp/StructureDefinition/PhCP-MedicationDispense

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CPCDS Data Dictionary & Resource Mapping

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  1. CPCDS Data Dictionary & Resource Mapping

  2. Claim Non Payer Resource (TBD)

  3. Claim Non Payer Resource (TBD)

  4. Claim

  5. Claim Non Payer Resource (TBD) 1 – http://hl7.org/fhir/us/phcp/StructureDefinition/PhCP-MedicationDispense 2 – http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest 3 – http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication

  6. Claim

  7. Claim

  8. Claim

  9. Claim Line

  10. Claim Line

  11. Diagnoses

  12. Procedures

  13. Member

  14. Coverage

  15. Terminology Bindings

  16. ExplanationOfBenefit (Elements)

  17. ExplanationOfBenefit (Code Systems)

  18. ExplanationOfBenefit (Code Systems)

  19. ExplanationOfBenefit (Code Systems)

  20. Encounter (Elements)

  21. Encounter (Code Systems)

  22. MedicationDispense

  23. Location

  24. @rryanhowells | ryan.howells@leavittpartners.com @carinalliance | www.carinalliance.com

  25. Appendix

  26. Health Plan Claims Extracts Health Plans send Claims data to their vendors and business associates under several use cases (care coordination, utilization management, predictive analytics) using a variety of custom, one-off, flat file extracts. No industry wide standard exists for Health Plans to send (adjudicated) Claims data to either Covered or Non-covered Entities. EDI X12 standards for Claims only exist for Providers’ HIPAA-covered transactions with Health Plans (i.e. Claim Submission – 837, Claim Acknowledgement – 277CA, and Payment/Remittance Advice – 835) Most Health Plans generate the flat file Claims extracts from their Claims System of Record (SOR) i.e. Claims Adjudication System, using mature, enterprise grade Extract, Transform and Load (ETL) tools and processes.

  27. EDI X12 and CPCDS Covered Entities/BAs EDI Clearinghouse Health Plan A Provider A Data Hub A CARIN Blue Button Framework Facets v4 (EOB) CPCDS FHIR Server Multi-plan Data Warehouse (EOB) Health Plan B CARIN Blue Button IG (FHIR Profiles) Claims SOR1 (EOB) 270 Provider B Health Plan C 271 837-I/CMS1450/UB04 Facets v3 (EOB) 837-P/CMS1500 999 277CA Claims SOR2 (EOB) 835 Health Plan D Claims SOR3 (EOB) 270 Eligibility & Benefits Inquiry Key 270 Eligibility & Benefits Response 837 Claims Submission SOR System of Record Covered Entity/BA 999 Claims Submission Acknowledgement EDI X12 Transactions 277CA Individual Claim Acknowledgement Mappings 835 Electronic Remittance Advice

  28. CARIN BB IG Proposed EOB Profile Options Inpatient Facility EOB Outpatient Facility Professional/Non-Clinician Pharmacy Vision Oral Comprehensive/Generic Inpatient Facility Outpatient Facility Professional/Non-Clinician Pharmacy Vision Oral Comprehensive/Generic Option 1 Option 2 CPCDS CPCDS

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