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

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

Welcome & Introductions Round the room

Quick Development Background How did we get here?

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

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

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

Financial Management (FM) Overview What is FM?

FM Life Cycle

Scope of Messaging FIAB –Patient Account management New/Revise Cancel Complete Nullify/Reactivate

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

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

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

FICR – e-Claims Digging deeper into the details

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

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

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

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

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

Invoice Overview

Invoice & Adjudication Example Pharmacy invoice of $ $20.00 for the drug cost 2.$6.00 for the professional fee Payor adjudicates to $ Reduce the drug cost to $ Accepts professional fee of $ Indicates a deductible of -$ Patient copay is -$ Indicates patient is nearing their limit of $1000

Invoice & Adjudication Example

Coordination of Benefits (COB)

Billable Acts & Adjudication Observations

Deferred Adjudication

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

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

Upcoming FICR Projects Whats Next?

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

Financial Management (FM) v3 Orientation Questions? Feedback?