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Financial Management (FM) v3 Orientation HL7 Baltimore September 30, 2002

This document provides an outline and overview of Financial Management (FM) in HL7 v3, including the scope of messaging, key concepts, and upcoming projects.

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Financial Management (FM) v3 Orientation HL7 Baltimore September 30, 2002

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  1. Financial Management (FM)v3 OrientationHL7 BaltimoreSeptember 30, 2002

  2. Outline • Welcome & Introductions • Quick Development Background • Financial Management (FM) Overview • FM Life Cycle • Scope of Messaging • FICR – e-Claims • Domain Model Review • Key FICR Concepts • Upcoming FICR Projects • Summary and Wrap-up

  3. Welcome & Introductions • Round the room

  4. Quick Development Background How did we get here?

  5. Background • FM covers 2 domains in v3 • FIAB – Account and Billing • FICR – Claims and Reimbursement • FIAB (Account and Billing) • Material prepared and submitted by Mark Shafarman • Managed and brought forward through the HL7 v3 ballot process by the FM TC

  6. Background • FICR (Claims & Reimbursement) • Material prepared by the Canadian National e-Claims Standard (NeCST) • RIM changes were proposed in spring 2001 to redo Financial Acts • Coverage (insurance) • Invoices • Accounts • Financial Transactions • Remove unused classes

  7. Background • FICR (continued) • Work in Canada originally in v2 • Still some interest in v2 from international affiliates – Q4 Tuesday in Baltimore • Moved to v3 in fall 2001 • Managed and brought forward through the HL7 v3 ballot process by the FM TC and the NeCST project in Canada • Of note • v3 ballot reconciliation Wednesday & Thursday this week

  8. Financial Management (FM) Overview What is FM?

  9. FM Life Cycle

  10. Scope of Messaging • FIAB • Patient Account management • New/Revise • Cancel • Complete • Nullify/Reactivate

  11. Scope of Messaging • FICR • Enrollment • Future • Eligibility • Query to determine insurance coverage in effect for a specified date • Authorization • Request authorization of a Payor to reserve funds for the delivery of healthcare services

  12. Scope of Messaging • FICR (continued) • Coverage Extension • Extending coverage for special circumstances • e.g. in order to pay for a specific drug, you must first request coverage extension with appropriate supporting documentation • Pre-Determination • Mock invoice/claim to determine how a Payor would adjudicate the claim at a single point in time (now) • Not a guarantee of payment

  13. Scope of Messaging • FICR (continued) • Invoice • Submit an invoice for adjudication and possible payment • Adjudication results • Coordination of benefits support • Payment • Payment/Remittance advice • Statement of financial activity (SOFA) for reconciliation

  14. FICR – e-Claims Digging deeper into the details

  15. FICR Domain Model Review Payment Request Payment Intent Remittance Advice Explanation of Benefits (EOB) Invoice Details [line items] Contract Statement of Financial Activity (SOFA) Attachment Accident Billable Act Coverage (insurance) Eligibility + Authorization Invoice Subject (patient) Coverage Subject (insured)

  16. Explanation of Benefits (EOB) Eligibility + Authorization Invoice (Claim) Payment Request Invoice Details [line items] Contract Attachment Accident Billable Act Coverage (insurance) Invoice Subject (patient) Coverage Subject (insured)

  17. Invoice Details [line items] Statement of Financial Activity (SOFA) Coverage (insurance) Adjudication Results Payment Intent Explanation of Benefits (EOB)

  18. Payment Intent Explanation of Benefits (EOB) Statement of Financial Activity (SOFA) Payment/Remittance Advice Remittance Advice

  19. FICR Key Concepts • Concepts • Invoice Structure • Coordination of Benefits • Billable Acts & Adjudication Observations • Deferred Adjudication • Other concepts • Statement of Financial Activity (SOFA) • Re-Adjudication Request • Unsolicited Re-Adjudication Results

  20. Invoice Overview

  21. Invoice & Adjudication Example • Pharmacy invoice of $26.00 • $20.00 for the drug cost • $6.00 for the professional fee • Payor adjudicates to $11.08 • Reduce the drug cost to $15.00 • Accepts professional fee of $6.00 • Indicates a deductible of -$5.00 • Patient copay is -$4.92 • Indicates patient is nearing their limit of $1000

  22. Invoice & Adjudication Example

  23. Coordination of Benefits (COB)

  24. Billable Acts & Adjudication Observations

  25. Deferred Adjudication

  26. Other Concepts • Statement of Financial Activity (SOFA) • Can be included on adjudication results • Number/amount of submitted, adjudicated, paid invoices • Used to help keep Provider and Payor systems synchronized • Queries for SOFA summary & details • Summary of counts and amounts ($) for a number of categories • Detail query supplies the adjudicated details that make up the counts and amounts

  27. Other Concepts • Re-Adjudication Request • Request by Provider to re-adjudicate an Invoice based on new circumstances • Text only with reference to Invoice • Unsolicited Re-Adjudication Results • Payor performs audit function and determines that previous adjudication results were incorrect • May not be messaged but included in a Payment/Remittance Advice

  28. Upcoming FICR Projects What’s Next?

  29. Upcoming FICR Projects • Messages • Enrollment • Requests for Information & Results • Supporting Documents • Look at HL7 CDA • Mappings • X12/HIPAA to HL7 • NCPDP to HL7 • Others…

  30. Financial Management (FM)v3 Orientation Questions?Feedback?

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