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CARIN BB RESTful API  

 

The EOB Resource is the focal Consumer-Directed Payer Data Exchange (CDPDE) Resource.   Several Reference Resources are defined directly/indirectly from the EOB:   Coverage, Patient, Organization (Payer ID), Practioner, Organization (Facility), PractionerRole, Location.  

 

The Coverage Reference Resource SHALL be returned with data that was effective as of the date of service of the claim; for example, the data will reflect the employer name in effect at that time.  However, for other reference resources, if payers have the data as of the date of service that data SHALL be provided in the reference resource and they SHALL populate meta.lastUpdated with the date that the payer record for that resource was created.  If payers do not have the data as of the date of service, they SHALL provide their available data in the reference resource and they SHALL populate meta.lastUpdated with the date the data was updated. 

 

RESTful Capabilities by Resource/Profile

 

A server will always treat an EOB search request as if a client indicated "_include=*" and SHALL return all EOB & reference resources in the response bundle. Bundle.link.url (self) would show that "_include=*" was added by the server as an additional parameter. Bundle.total will count only EOB resources (this is a normal practice in FHIR to only count the searched resources and not the included / reference resources)


 


Summary of Search Criteria

Resource Type

Supported Profiles

Required  Search Parameters (SHALL)

_includes

(SHALL)

ExplanationOfBenefit

Required search parameters:

  • _id,
  • patient,
  • _lastUpdated*
  • type (Claim Type)
  • identifier (Business / Claim Identifier of EOB
  • service-date**

 

 

Implicit: _include=*

 

The following resources will be included:

 

Coverage & Organization (Payor): ExplanationOfBenefit:coverage

Coverage:payor

 

Patient : ExplanationOfBenefit:patient

 

Provider : ExplanationOfBenefit:provider 

 

PractitionerRole, Practitioner & Organization (CareTeam) : ExplanationOfBenefit:care-team

PractitionerRole:practitioner    PractitionerRole:organization

 

Organization (Insurer) : ExplanationOfBenefit:insurer

 

Location: ExplanationOfBenefit:facility

(FHIR-26700, FHIR-26734, FHIR-26808)

 

Ballot feedback from BCBSA will note that a search parameter needs to be defined for this IG: "name": "service-date", "type": "date", "description" = "Date of the service", "expression": "ExplanationOfBenefit. billablePeriod | ExplanationOfBenefit.serviced as dateTime |  ExplanationOfBenefit.serviced as Period"

(FHIR-26701, FHIR-26735, FHIR-26809)

 

 

 

 

 

 

 

 

*_lastUpdated

 

Add a new logical CPCDS new data element, EOBLastUpdated,that defines the date the EOB was created or updated, whichever is later. The payer could choose how they want to map it to this CPCDS element. Map to meta.lastUpdated.  Cardinality is 1..1. Search parameter uses the logical EOBLastUpdated field. 

 

** service-date

The goal of service-date is to simplify the search, so that a client doesn't need to know that for inpatient and outpatient admission dates they need to search by billablePeriod.period.start, for a pharmacy by servicedDate, for professional services - by servicedPeriod.period.start.   Change the cardinality of these data elements to 1..1. 

 

search by service-date definition:  

"expression": "ExplanationOfBenefit.billablePeriod | ExplanationOfBenefit.serviced as Date |  ExplanationOfBenefit.serviced as Period",

"xpath": "f:ExplanationOfBenefit/f:billablePeriod | f:ExplanationOfBenefit/f:serviced/f:servicedDate | f:ExplanationOfBenefit/f:serviced/f:servicedPeriod"


ExplanationOfBenefit

 

Supported Profiles:   CARIN BB ExplanationOfBenefit Profile ;   CARIN BB ExplanationOfBenefit Inpatient Facility Profile ;   CARIN BB ExplanationOfBenefit Outpatient Facility Profile ;   CARIN BB ExplanationOfBenefit Pharmacy Profile ;   CARIN BB ExplanationOfBenefit Professional NonClinician Profile  

Resource Specific Documentation:

The ExplanationOfBenefit   resources can represent a Patient, Provider, Insurer, Care Team, Facility and Coverage with references to Patient, Organization, Practioner, PractitionerRole, Location and Coverage resources. A server SHALL return all Patient, Practitioner, Organization, PractitionerRole, Location and Coverage reference resources for an ExplanationOfBenefit via implicit use of the "_include=*" parameter. 

For example, a server SHALL interpret the following request:
GET [base]/ExplanationOfBenefit?patient=[patient] &_lastUpdated=[prefix][date]

as GET [base]/ExplanationOfBenefit?patient=[patient] &_lastUpdated=[prefix][date] &_include=* and return all reference resources in the EOB search response bundle

Search Parameter Summary:

 

Conformance

Parameter

Type

Example

1

SHALL

_id

token

GET [base]/ExplanationOfBenefit?_id=[id]

2

SHALL

patient

reference

GET [base]/ExplanationOfBenefit?patient=[patient]

3

SHALL

_lastUpdated  

date

GET [base]/ExplanationOfBenefit? _lastUpdated= [prefix][date]

* Shall only be supported in a combination with patient

4

SHALL

type

token

GET [base]/ExplanationOfBenefit?type = [system]|[code]

* Shall only be supported in a combination with patient

5

SHALL

identifier

token

GET [base]/ExplanationOfBenefit?identifier = [system]|[value]

6

SHALL

service-date

date

GET [base]/ExplanationOfBenefit? service-date= [prefix][date]

* Shall only be supported in a combination with patient

All searches, other than by__id and identifier, are required in combination with the patient search parameter.