Financial Management (FM) v3 Orientation HL7 Baltimore September 30, 2002
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Transcript of Financial Management (FM) v3 Orientation HL7 Baltimore September 30, 2002
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
Fill Bill Adjudicate Pay
9/30/2002Financial Management Life Cycle
TPA/PayorProvider/Patient Care
Accounts Charges Credits Clinical Events
Invoices/Claims Adjudication Remittance
Adjudication Remittance
FIAB (Billing) FICR (Claims)
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
FICR DMIMv5.7 - 02 Sep 20
1..1representedOrganizationAgentclass_cd <= AGNT
CMET: (ORG) E_Organization
[identified](COCT_MT150002)
Note:Required for Invoice Cancelsif the Invoice has already beenadjudicated. The Payment Intenton an Invoice Cancel indicates thenet effect of the cancel (reversal)
Note:Payee is noted inA_Account CMET
Note:RTO used to specify 15 pills (each)out of a bottle of 100 pills (each) toreflect billing for a portion of apackage (e.g. 0.15 of a bottle)
Note:For re-adjudicated invoices(e.g. audit purposes)
Note:Want sum of all adjudicationdetails (info & non-info) to equalwhat was submitted. For example,the reasons why you refused to paypart of the invoice
Note:Print form specified forEOB statement whenprovided to patient
Note:A_Invoice_element_group cannot be a leaf,A_Invoice_element_detail must be a leaf.
Note:Used to indicateconsent invoice againstpolicy or account.
Note:Can be a single patient, ananimal or a group of patientsand/or a group of animals.
Service target & Covered partymay be different people (e.g.pedestrian in auto-accident)
Note:Contact information is thru Ident_org CMET (not here)
Note:Class cd PAT(PatientRole) ismost generic codeavailable
Note:Used to attachdocuments, image, etc.required to support a health claim
Domain to be added in a subsequent release
Note:Subscriber Identifier;required for X12 837mapping
Note:Covered Person Identifier(Assigned by carrier - root of OID)= Subscriber+Dependents
Note:effective_time is from theperspective of the author
Note:"Please Pay"
Note:Need amount forcontract (maxallowable amount),not needed for e-Claims
Note:Limits included in the authorization such asmaximum dollar amounts, maximum quantities,date ranges, etc..
Note:"Please Adjudicate"
Note:Owner of the contract.
There are other participationsfor a contract, but we are notinterested in them for anInvoice.
Note:If Payment is not invoicedand pertains to a Provider,either a person or anOrganization
Note:"I Paid"
Note:"I Will Pay"
Note:Data centre andsequence numbermust be the samefor each completegroup anddetail hierarchy
Note:Carrier id
Note:Location of incident/accident(e.g. fixed address, sideof road, etc.)
Note:Specific adjudication observationswill be added here, such as DrugContraindications.
Note:This allows for root invoice elementgroup to be composed of invoiceelement groups and/or details. There must be one leaf detail
Note:This is where each benefit groupwill insert their billable act (e.g. PharmacyDispense Billable Act). Each Billable Act isa CMET, contained in the A_Billable_Act CMET.Refer to the CMET for more information.
The act will be in intent (INT) mood whenrequesting authorization
Note:Allows Payor to adj& pay on different policy
Note:id: = Coverage IdentifierAssigned by carrier identified by an OIDwith extension = Policy.Plan.Group.Contract.Division.Section.Version as agreed to byparticipants
0..* priorConfirmationOrderInFulfillmentOfCoverageRequesttype_cd*<= FLFS
0..1 priorActReplacementOftype_cd*<= RPLC
0..* justifiedFinancialTransactionIntent
0..* justifyingInvoiceElementEvent
Reasontype_cd*<= RSON
0..1 priorInvoiceAdjustmentEvent
OutcomeAdjudicatedtype_cd*<= OUTC
0..* limitingInvoiceElementEventCriterion
Limitationtype_cd*<= LIMIT
0..* summarizingInvoiceElementEvent
Summarytype_cd*<= SUMM
0..* priorFinancialTransactionIntentInFulfillmentOfPaymentIntenttype_cd*<= FLFS
0..* justifyingObservationEventReasonOverridetype_cd*<= RSON
0..* justifyingObservationEventReasonOverridetype_cd*<= RSON
0..1 invoiceElementEvent
0..* invoiceAdjustmentEventComponentGrouptype_cd*<= COMP
0..* accountEventCreditDeposittype_cd*<= CREDIT
0..* referedToInvoiceAdjustmentEventReferencePreviousAdjudicationtype_cd*<= REFR
0..* actOrderRequirestype_cd*<= RACTnegation_ind:
0..* justifiedConfirmationOrder
0..* justifyingInvoiceElementOrderReasonJustifiedtype_cd*<= RSON
0..* justifyingActReasonCoveragetype_cd*<= RSON
0..* accountDebitPayortype_cd*<= DEBIT
0..* subjectInvoiceElementEventCriterion
PertinentInformationCoverageCriteriatype_cd*<= PERT
0..* subjectAct
PertinentInformationtype_cd*<= PERT
0..* priorFinancialTransactionIntentInFulfillmentOfPaymentRequesttype_cd*<= FLFS
0..* pertinentObservationEvent
PertinentInformationInjuryCodingtype_cd*<= PERT
0..1 priorCoverageEvent
InFulfillmentOfPollicyOrAccounttype_cd*<= FLFSsequence_nbr*: [1..1] (COB priority as adjudicated primary, secondary, etc.) 0..* summarizingObservationEvent
SummaryRunningTotalstype_cd*<= SUMM
1..1 subjectConsentEvent
PertinentInformationConsenttype_cd*<= PERTnegation_ind:
0..* coverageDefinitionDefinitiontype_cd*<= INST
0..1 pertinentIncidentEventPertinentInformationIncidenttype_cd*<= PERT
0..* priorFinancialContractEventInFulfillmentOfContracttype_cd*<= FLFS
0..* pertinentObservationEventPertinentInformationAttachmenttype_cd*<= PERT
0..* coveringCoverageEventCoveragePolicyOrAccounttype_cd*<= COVBYsequence_nbr: [0..1] (COB priority as submitted. primary, secondary, etc.)
0..* pertinentInvoiceElementEventCriterion
PertinentInformationTermsConditionstype_cd*<= PERTnegation_ind: (covered/not covered)
0..1 justifyingActReasonAdjudicationSummarytype_cd*<= RSON
0..* authorizingConfirmationEventAuthorizationtype_cd*<= AUTH
0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
0..* justifyingActReasonInvoiceElementtype_cd*<= RSON
0..* justifyingInvoiceElementOrder
ReasonPaymentRequesttype_cd*<= RSON
1..* act
ComponentInvoicetype_cd*<= COMPsequence_nbr:
InvoiceElementEventAdjudicatedclass_cd* <= INVE+INFINVEmood_cd* <= EVNid*: [1..1]cd: CWE <=ActProductServiceBillableItemCode (Product or service code that was adjudicatedand could include substituted codes - e.g. code Awas replaced by code B during adjudication)txt:net_amt: MOunit_qty: RTO<PQ,PQ>unit_price_amt: RTO<MO,PQ>factor_nbr:points_nbr:
IncidentEventclass_cd* <= INCmood_cd* <= EVNid:cd: CNE <= ActIncidentCode (work place related, auto related, etc.)txt:effective_time:
EventAdjudicationResultsclass_cd* <= ADJUDmood_cd* <= EVNid*: [1..1] (EOB identifier)cd: CNE <= ActAdjudicationCode (Summary of the adjudication processing - as submitted, w/ adjust, refuse)txt:status_cd: <= ActStatusreason_cd*: SET<CE> CWE [0..*] <= ActAdjudicationReason
CoverageEventPolicyOrAccountclass_cd* <= COVmood_cd* <= EVNid*: [1..1] (policy id, WCB claim #, auto claim #,HSA account)cd: <= ActPolicyCode (Policy Type)status_cd: <= ActStatuseffective_time:
ConfirmationEventCoverageclass_cd* <= CONFmood_cd* <= EVNid: (authorization/confirmation identifier)cd*: [1..1] <= ActCoverageConfirmationCode (eligible, not eligible, authorized, not authorized)txt:status_cd: [0..1] <= ActStatus (active, cancelled, etc.)effective_time: [0..1] (effective dates for confirmation - expiry)reason_cd: <= ActAdjudicationReason
FinancialContractEventclass_cd* <= FCNTRCTmood_cd* <= EVNid: (business arrangement identifier)cd: <= ActBillingArrangementCode (i.e. FFS, Block, Contract, Rostering, Capitation, etc.)txt:status_cd: <= ActStatuseffective_time:payment_terms_cd: CWE <= PaymentTerms
ObservationEventAttachmentclass_cd* <= OBSmood_cd* <= EVNid*: [1..1] (attachment identifier)cd*: [1..1] (Domain:ClaimsAttatchmentType)value: ED (content or reference)
InvoiceElementEventCriterionCoverageclass_cd* <= INVE+INFINVEmood_cd* <= EVN.CRTid: SET<II>cd: CWE <= ActCoverageLimitCodetxt:effective_time:net_amt:unit_qty:unit_price_amt:factor_nbr:points_nbr:
ObservationEventInvoiceOverrideclass_cd* <= OBSmood_cd* <= EVNcd: <= CNE ActInvoiceOverrideCode (override reason)txt:
ObservationEventInvoiceOverrideclass_cd* <= OBSmood_cd* <= EVNcd: <= CNE ActInvoiceOverrideCode (override reason)txt:
FinancialTransactionOrderPaymentRequestclass_cd* <= XACTmood_cd* <= ORDid*: SET<II> [1..*] (Item ID, Tracking #, etc.)net_amt: MO [0..1] (amount to be billed)
FinancialTransactionIntentPaymentclass_cd* <= XACTmood_cd* <= INTid*: SET<II> [1..1] (Item ID, Tracking #, etc.)txt:status_cd: <= ActStatuseffective_time: (time payor intends to perform transaction)net_amt*: MO [1..1] (amount to be paid for INV, GRP, ITM or ADJ)credit_exchange_rate_qty:debit_exchange_rate_qty:interest_rate_qty:
ConfirmationOrderCoverageclass_cd* <= CONFmood_cd* <= ORDid: SET<II> (Tracking #, etc.)txt:reason_cd: <= ActAuthorizationReason
FinancialTransactionEventPaymentclass_cd* <= XACTmood_cd* <= EVNid*: SET<II> [1..*] (Cheque #, EFT #)cd*: [1..1] <= ActPaymentCode (e.g. EFT, cheque, etc.)txt:effective_time: (time transaction occurred)reason_cd: <= ActPaymentAdjustmentReason (reason for payment such as retroadjustment, fee deduction, etc. when not based on a Payment_intent)net_amt*: MO [1..1] (amount paid)credit_exchange_rate_qty:debit_exchange_rate_qty:
ConsentEventclass_cd* <= CONSmood_cd* <= EVNeffective_time:
InvoiceElementOrderGroupclass_cd* <= INVE+INFINVEmood_cd* <= ORD+INTid: SET<II> [0..*] (may include data centre and sequence numbers)cd: CS CNE [0..1] <= ActInvoiceCode (Invoice Type e.g. Healthcare Services, Rx Dispense, Rx Compound, Healthcare Goods, Preferred Accomodation)effective_time: IVL<TS> [0..1] (time period that invoice covers e.g. month of January)confidentiality_cd: <= ConfidentialityByAccessKindnet_amt: MO [0..1] (= sum of all immediate children Invoice_element_group.net_amt & Invoice_element_detail.net_amt where Class_cd = INVE)modifier_cd: SET<CS> CNE [0..*] <= ActInvoiceElementModifier
InvoiceElementEventCriterionQuestionclass_cd* <= INVEmood_cd* <= EVN.CRTcd: <= ActCoverageInquiryCode (type of criteria)effective_time:net_amt:unit_qty:unit_price_amt:
ObservationEventInjuryCodingclass_cd* <= OBSmood_cd* <= EVNcd: CD <= ActInjuryCode (- nature of injury, body part, side of body SAZ795)
AccountEventBankclass_cd* <= ACCTmood_cd* <= EVNid: SET<II> (Acount number, transit number, EFT#, bank number)
ActOrderRequiredclass_cd* <= ACTmood_cd* <= ORDcd: <= ActAdjudicationResultActionCode (e.g. print on EOB, allow override)txt:effective_time:
InvoiceElementOrderDetailclass_cd* <= INVE+INFINVEmood_cd* <= ORD+INTid*: SET<II> [1..1] (may include data centre and sequence numbers)cd: CD CNE [0..1] <= ActProductServiceBillableItemCode (Product/Service Code e.g. Office Visit ,Taxes, Markup, Dispense + Product/Service Code Modifier e.g. northern isolation, off hours specialty, on call)net_amt: MO [0..1] (= unit_qty * unit_price_amt * factor_nbr * points_nbr. E.g. $150 CAD)unit_qty: RTO<PQ,PQ> [0..1] (e.g. 3 {boxes})unit_price_amt: RTO<MO,PQ> [0..1] (e.g. $50 CAD/ 1 {box})factor_nbr: (multiplier, can be used for tax percentages)points_nbr: (multiplier)
ObservationEventSummaryclass_cd* <= OBSmood_cd* <= EVNcd*: [1..1] <= ActInvoiceElementSummaryCodevalue: (PQ or MO - Value of summary)
CoverageDefinitionclass_cd* <= COVmood_cd* <= DEFid*: [1..1] (plan id, group id)cd: <= ActCoverageCode (e.g. basic, extended, Plan G)effective_time:
InvoiceElementEventGroupingclass_cd* <= INVEmood_cd* <= EVNcd: CNE <= ActAdjudicationGroupCode (defines the 'categorization'. Only really relevant forsummaries.)effective_time*: [1..1] (summary period)
InvoiceElementEventCriterionclass_cd* <= INVE+INFINVEmood_cd* <= EVN.CRTid: SET<II>cd: CWE <= ActProductServiceBillableItemCodetxt:effective_time:
Predecessortype_cd*<= SUCC
0..* priorInvoiceElementEvent
Componenttype_cd*<= COMP
0..* invoiceElementEventA
sequence_nbr:
ComponentPaymentRequesttype_cd*<= COMP
0..* financialTransactionOrderA
sequence_nbr:
ReversalOfPaymentRequesttype_cd*<= REV
0..* priorFinancialTransactionOrder
ComponentCoveragetype_cd*<= COMP
0..*coverageDefinition
ComponentPolicytype_cd*<= COMP
0..* coverageEventA
ReferencePreviousPaymentRequesttype_cd*<= REFR
0..* referedToFinancialTransactionOrder
ComponentSummarizedtype_cd*<= COMP
0..* invoiceElementEventA
ReferencePaymenttype_cd*<= REFR
0..* referedToFinancialTransactionEvent
ComponentPaymenttype_cd*<= COMP
0..* financialTransactionEventA
sequence_nbr:
ReferencePaymentIntenttype_cd*<= REFR
0..* referedToFinancialTransactionIntent
ComponentPaymentIntenttype_cd*<= COMP
0..* financialTransactionIntentA
sequence_nbr:
PredecessorAtype_cd*<= SUCC
0..* priorInvoiceAdjustmentEvent
ManufacturedMaterialForm
class_cd* <= MMATdeterminer_cd* <= INSTANCEcd: <= FormType
EntityProvider
class_cd* <= ENTdeterminer_cd* <= INSTANCEnm:
Organization
class_cd* <= ORGdeterminer_cd* <= INSTANCEid: [0..*]nm: [0..*]
PersonInsured
class_cd* <= PSNdeterminer_cd* <= INSTANCEid: SET<II>nm:telecom:administrative_gender_cd: <= AdministrativeGenderbirth_time:deceased_time:multiple_birth_ind:birth_order_nbr:addr:
LivingSubjectInsuredAnimal
class_cd* <= LIVdeterminer_cd* <= INSTANCEnm:
PersonGuardianOrParent
class_cd* <= PSNdeterminer_cd* <= INSTANCEnm:
LivingSubjectGroup
class_cd* <= LIVdeterminer_cd* <= INSTANCEqty*: [1..1] (number in group)
PersonPatient
class_cd* <= PSNdeterminer_cd* <= INSTANCEnm:telecom:administrative_gender_cd: <= AdministrativeGenderbirth_time:deceased_time:multiple_birth_ind:birth_order_nbr:addr:
LivingSubjectAnimal
class_cd* <= LIVdeterminer_cd* <= INSTANCEnm:
OrganizationSchool
class_cd* <= ORGdeterminer_cd* <= INSTANCEid:nm:
RoleRequestPayeeclass_cd <= ROLcd: <= PayeeRelationshipRoleType (payee relationship to covered party)
0..1playingManufacturedMaterial
RoleEOBPrintFormclass_cd <= ROL
1..1player
RoleProviderclass_cd <= ROLid: [0..*]
0..1scopingOrganization
RoleStudentclass_cd <= ROL
0..* playedRole
1..1guardianPerson
GuardianOrParentclass_cd <= GUARD
0..* guardian
cd: <= PRN (parent - mother or father)id: (id of guardian or parent)
1..1contactPerson
ContactPartyRecipientclass_cd <= CONcd: <= AdministrativeContactRoleType
1..1underwritingOrganization
Underwriterclass_cd <= UNDWRTid*: [1..1]
1..1member
Memberclass_cd <= MBR
0..* memberid: (id within group, if known)
1..1policyHolder
0..1underwritingOrganization
PolicyHolderclass_cd <= POLHOLDid*: [1..1]
0..1coveredParty
0..1underwritingOrganization
CoveredPartyRoleclass_cd <= COVPTYid: (covered party in policy, member #)cd: CE <= CoverageRoleType (reason for being covered, including spouse, child, student, handicapped)
1..1patient
0..1providerOrganization
Patientclass_cd <= PATid: (patient and/or group identifier, if known)
1..1contactPerson
ContactPartyRecipientclass_cd <= CONcd: <= AdministrativeContactRoleType
0..* participantSubjectPayeetype_cd*<= SBJ
0..* participant
DirectTargetPrintOntype_cd*<= DIR
0..* participantLocationIncidenttype_cd*<= LOC
0..1 underwriterAuthorPolicyAccounttype_cd*<= AUT
0..* contactPartyAttentiontype_cd*<= ATTN
0..* patientSubjectPatienttype_cd*<= SBJ
0..* assignedEntityAuthorContracttype_cd*<= AUT
0..1 agentAuthorInvoicetype_cd*<= AUTtime: TS (invoice date/time)
0..1 agentAuthorOverridetype_cd*<= AUT
0..1 agentAuthorOverridetype_cd*<= AUT
0..1 agentAuthorSummarytype_cd*<= AUTtime: (time calculation was made)
0..* agentPerformerProcessedtype_cd*<= PRFtime: (adjudication date/time)signature_txt: (security)
0..1 underwriterAuthorCoveragetype_cd*<= AUT
0..* policyHolder
ParticipantPolicyHoldertype_cd*<= HLD
CoveredPartytype_cd*<= COV
0..* coveredPartyBeneficiarytype_cd*<= BEN
0..* agent
AuthorConfirmationtype_cd*<= AUTtime: [0..1] (date confirmation was created)
0..* contactPartyAttentiontype_cd*<= ATTN
0..1 agentAuthorAuthorizationRequesttype_cd*<= AUTtime: (Request date/time)
0..* participantSubjectPaymenttype_cd*<= SBJ
0..1 agent
ResponsibleProviderGroupingtype_cd*<= RESPROV
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
CMET: (ACT) A_AdjudicationObservation
[universal](COCT_MT320000)
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ORG) Organization
[universal](COCT_MT150002)
CMET: (PSN) E_Person[contact]
(COCT_MT030203)
CMET: (ORG) Organization
[universal](COCT_MT150002)
CMET: (AGNT) R_ResponsibleDevice
[universal](COCT_MT040200)
CMET: (AGNT) R_Responsibility
[universal](COCT_MT040304)
0..*
CMET: (AGNT) R_Responsibility
[universal](COCT_MT040304)
0..*
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
CMET: (ORG) Organization
[universal](COCT_MT150001)
CMET: (ASSIGNED) R_AssignedPerson
[universal](COCT_MT090101)
CMET: (PSN) E_Person[contact]
(COCT_MT030203)
CMET: (ORG) Organization
[universal](COCT_MT150002)
CMET: (ROL) R_LocationServiceDelivery
[detailed](COCT_MT240001)
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
Invoice Re-Adjudication Request(FICR_RM000000)
Entry Point for Invoice Re-adjudication messages
CMET: (ACT) A_Billable[universal]
(COCT_MT280000)
Adjudication Result(FICR_RM000000)
Entry Point for adjudication results messages
Statement of Financial Activity(FICR_RM000000)
Entry point for Statement of Financial Activity messagesClaim Information(FICR_RM000000)
Entry Point for claim supportinformation messages
Eligibility, Authorization, Coverage Extn Results(FICR_RM000000)
Entry Point for Eligibility, Authorization and CoverageExtension Results messages
Invoice, Cancel, Query Requests & Query Results(FICR_RM000000)
Entry Point for Invoice, Cancel (& response), Query, Pre-determinationrequests & query results messages
Eligibility, Authorization, Coverage Extn(FICR_RM000000)
Entry Point for Eligibility, Authorization andCoverage Extension messages
Payment Advice(FICR_RM000000)
Entry point for payment remittance messages
ActChoice
EntityChoice
EntityChoicePatient
EntityChoiceA
0..*communicatesWith
0..*communicatesWith
0..* subordinateCoveredPartyIndirectAuthorithyOvertype_cd*<= INDAUTH
LanguageCommunication(Language_communication)
language_cd*: [1..1] (HumanLanguage)mode_cd: [0..1] (LanguageAbilityMode)preference_ind: BL [1..1]
LanguageCommunication(Language_communication)
language_cd*: [1..1] (HumanLanguage)mode_cd: [0..1] (LanguageAbilityMode)preference_ind: BL [1..1]
Constraint:Each submitted invoiceelement must have 1EventAdjudicationResultsinstance
Constraint:cd: is only optional ineligibility messages
Constraint:DebitPayor must be for the rootInvoiceElementEventGrouping Act.CreditPayee is optional but may only beon the root InvoiceElementEventGrouping Act.
Constraint:DebitPayor must be for the rootFinancialTransactionEventPayment Act.CreditPayee may be specified for anyFinancialTransactionEventPayment.
Constraint:ReasonPaymentRequest may only be specifiedfor a leaf FinancialTransactionOrderPaymentRequest Actand it must enter the root InvoiceElementOrder first.
Constraint:AuthorInvoice and DebitPayor must befor the root FinancialTransactionOrderPaymentRequest Act.CreditPayee is optional but may only beon the root FinancialTransactionOrderPaymentRequest Act.
Constraint:All Relationships to the InvoiceElementOrderGroupcan only be associated with the root level instance
Constraint:Policy holder cannot be an animal
Constraint:ReferencePreviousAdjudication may only enterroot EventAdjudicationResults
Constraint:EventAdjudicationResults.cd mandatoryif target of ReasonAdjudicationSummary referencesnvoiceElementOrderDetail
Note:Can be used foridentification of aservice bureau
Net_amt must be positive or 0 forAdjudication Results messages
Net_amt must be negative or 0 forInvoice Cancel messages
Constraint:
CMET: (ACCT) A_Account[universal]
(COCT_MT110000)
Note:Payee is noted inA_Account CMET
0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
RoleRequestPayeeclass_cd <= ROLcd: <= PayeeRelationshipRoleType (payee relationship to covered party)
0..* participantSubjectPayeetype_cd*<= SBJ
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ACCT) A_Account[universal]
(COCT_MT110000) 0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ACCT) A_Account[universal]
(COCT_MT110000)
0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ACCT) A_Account[universal]
(COCT_MT110000)
PaymentRequest
InvoiceDetails
[lineitems]
Contract
Attachment
Accident
Billable Act
Eligibility+
Authorization
Explanationof
Benefits(EOB)
PaymentIntent
RemittanceAdvice
Statement ofFinancial
Activity (SOFA)
Coverage(insurance)
InvoiceSubject(patient)
CoverageSubject
(insured)
Invoice (Claim)
FICR DMIMv5.7 - 02 Sep 20
1..1representedOrganizationAgentclass_cd <= AGNT
CMET: (ORG) E_Organization
[identified](COCT_MT150002)
Note:Required for Invoice Cancelsif the Invoice has already beenadjudicated. The Payment Intenton an Invoice Cancel indicates thenet effect of the cancel (reversal)
Note:Payee is noted inA_Account CMET
Note:RTO used to specify 15 pills (each)out of a bottle of 100 pills (each) toreflect billing for a portion of apackage (e.g. 0.15 of a bottle)
Note:For re-adjudicated invoices(e.g. audit purposes)
Note:Want sum of all adjudicationdetails (info & non-info) to equalwhat was submitted. For example,the reasons why you refused to paypart of the invoice
Note:Print form specified forEOB statement whenprovided to patient
Note:A_Invoice_element_group cannot be a leaf,A_Invoice_element_detail must be a leaf.
Note:Used to indicateconsent invoice againstpolicy or account.
Note:Can be a single patient, ananimal or a group of patientsand/or a group of animals.
Service target & Covered partymay be different people (e.g.pedestrian in auto-accident)
Note:Contact information is thru Ident_org CMET (not here)
Note:Class cd PAT(PatientRole) ismost generic codeavailable
Note:Used to attachdocuments, image, etc.required to support a health claim
Domain to be added in a subsequent release
Note:Subscriber Identifier;required for X12 837mapping
Note:Covered Person Identifier(Assigned by carrier - root of OID)= Subscriber+Dependents
Note:effective_time is from theperspective of the author
Note:"Please Pay"
Note:Need amount forcontract (maxallowable amount),not needed for e-Claims
Note:Limits included in the authorization such asmaximum dollar amounts, maximum quantities,date ranges, etc..
Note:"Please Adjudicate"
Note:Owner of the contract.
There are other participationsfor a contract, but we are notinterested in them for anInvoice.
Note:If Payment is not invoicedand pertains to a Provider,either a person or anOrganization
Note:"I Paid"
Note:"I Will Pay"
Note:Data centre andsequence numbermust be the samefor each completegroup anddetail hierarchy
Note:Carrier id
Note:Location of incident/accident(e.g. fixed address, sideof road, etc.)
Note:Specific adjudication observationswill be added here, such as DrugContraindications.
Note:This allows for root invoice elementgroup to be composed of invoiceelement groups and/or details. There must be one leaf detail
Note:This is where each benefit groupwill insert their billable act (e.g. PharmacyDispense Billable Act). Each Billable Act isa CMET, contained in the A_Billable_Act CMET.Refer to the CMET for more information.
The act will be in intent (INT) mood whenrequesting authorization
Note:Allows Payor to adj& pay on different policy
Note:id: = Coverage IdentifierAssigned by carrier identified by an OIDwith extension = Policy.Plan.Group.Contract.Division.Section.Version as agreed to byparticipants
0..* priorConfirmationOrderInFulfillmentOfCoverageRequesttype_cd*<= FLFS
0..1 priorActReplacementOftype_cd*<= RPLC
0..* justifiedFinancialTransactionIntent
0..* justifyingInvoiceElementEvent
Reasontype_cd*<= RSON
0..1 priorInvoiceAdjustmentEvent
OutcomeAdjudicatedtype_cd*<= OUTC
0..* limitingInvoiceElementEventCriterion
Limitationtype_cd*<= LIMIT
0..* summarizingInvoiceElementEvent
Summarytype_cd*<= SUMM
0..* priorFinancialTransactionIntentInFulfillmentOfPaymentIntenttype_cd*<= FLFS
0..* justifyingObservationEventReasonOverridetype_cd*<= RSON
0..* justifyingObservationEventReasonOverridetype_cd*<= RSON
0..1 invoiceElementEvent
0..* invoiceAdjustmentEventComponentGrouptype_cd*<= COMP
0..* accountEventCreditDeposittype_cd*<= CREDIT
0..* referedToInvoiceAdjustmentEventReferencePreviousAdjudicationtype_cd*<= REFR
0..* actOrderRequirestype_cd*<= RACTnegation_ind:
0..* justifiedConfirmationOrder
0..* justifyingInvoiceElementOrderReasonJustifiedtype_cd*<= RSON
0..* justifyingActReasonCoveragetype_cd*<= RSON
0..* accountDebitPayortype_cd*<= DEBIT
0..* subjectInvoiceElementEventCriterion
PertinentInformationCoverageCriteriatype_cd*<= PERT
0..* subjectAct
PertinentInformationtype_cd*<= PERT
0..* priorFinancialTransactionIntentInFulfillmentOfPaymentRequesttype_cd*<= FLFS
0..* pertinentObservationEvent
PertinentInformationInjuryCodingtype_cd*<= PERT
0..1 priorCoverageEvent
InFulfillmentOfPollicyOrAccounttype_cd*<= FLFSsequence_nbr*: [1..1] (COB priority as adjudicated primary, secondary, etc.) 0..* summarizingObservationEvent
SummaryRunningTotalstype_cd*<= SUMM
1..1 subjectConsentEvent
PertinentInformationConsenttype_cd*<= PERTnegation_ind:
0..* coverageDefinitionDefinitiontype_cd*<= INST
0..1 pertinentIncidentEventPertinentInformationIncidenttype_cd*<= PERT
0..* priorFinancialContractEventInFulfillmentOfContracttype_cd*<= FLFS
0..* pertinentObservationEventPertinentInformationAttachmenttype_cd*<= PERT
0..* coveringCoverageEventCoveragePolicyOrAccounttype_cd*<= COVBYsequence_nbr: [0..1] (COB priority as submitted. primary, secondary, etc.)
0..* pertinentInvoiceElementEventCriterion
PertinentInformationTermsConditionstype_cd*<= PERTnegation_ind: (covered/not covered)
0..1 justifyingActReasonAdjudicationSummarytype_cd*<= RSON
0..* authorizingConfirmationEventAuthorizationtype_cd*<= AUTH
0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
0..* justifyingActReasonInvoiceElementtype_cd*<= RSON
0..* justifyingInvoiceElementOrder
ReasonPaymentRequesttype_cd*<= RSON
1..* act
ComponentInvoicetype_cd*<= COMPsequence_nbr:
InvoiceElementEventAdjudicatedclass_cd* <= INVE+INFINVEmood_cd* <= EVNid*: [1..1]cd: CWE <=ActProductServiceBillableItemCode (Product or service code that was adjudicatedand could include substituted codes - e.g. code Awas replaced by code B during adjudication)txt:net_amt: MOunit_qty: RTO<PQ,PQ>unit_price_amt: RTO<MO,PQ>factor_nbr:points_nbr:
IncidentEventclass_cd* <= INCmood_cd* <= EVNid:cd: CNE <= ActIncidentCode (work place related, auto related, etc.)txt:effective_time:
EventAdjudicationResultsclass_cd* <= ADJUDmood_cd* <= EVNid*: [1..1] (EOB identifier)cd: CNE <= ActAdjudicationCode (Summary of the adjudication processing - as submitted, w/ adjust, refuse)txt:status_cd: <= ActStatusreason_cd*: SET<CE> CWE [0..*] <= ActAdjudicationReason
CoverageEventPolicyOrAccountclass_cd* <= COVmood_cd* <= EVNid*: [1..1] (policy id, WCB claim #, auto claim #,HSA account)cd: <= ActPolicyCode (Policy Type)status_cd: <= ActStatuseffective_time:
ConfirmationEventCoverageclass_cd* <= CONFmood_cd* <= EVNid: (authorization/confirmation identifier)cd*: [1..1] <= ActCoverageConfirmationCode (eligible, not eligible, authorized, not authorized)txt:status_cd: [0..1] <= ActStatus (active, cancelled, etc.)effective_time: [0..1] (effective dates for confirmation - expiry)reason_cd: <= ActAdjudicationReason
FinancialContractEventclass_cd* <= FCNTRCTmood_cd* <= EVNid: (business arrangement identifier)cd: <= ActBillingArrangementCode (i.e. FFS, Block, Contract, Rostering, Capitation, etc.)txt:status_cd: <= ActStatuseffective_time:payment_terms_cd: CWE <= PaymentTerms
ObservationEventAttachmentclass_cd* <= OBSmood_cd* <= EVNid*: [1..1] (attachment identifier)cd*: [1..1] (Domain:ClaimsAttatchmentType)value: ED (content or reference)
InvoiceElementEventCriterionCoverageclass_cd* <= INVE+INFINVEmood_cd* <= EVN.CRTid: SET<II>cd: CWE <= ActCoverageLimitCodetxt:effective_time:net_amt:unit_qty:unit_price_amt:factor_nbr:points_nbr:
ObservationEventInvoiceOverrideclass_cd* <= OBSmood_cd* <= EVNcd: <= CNE ActInvoiceOverrideCode (override reason)txt:
ObservationEventInvoiceOverrideclass_cd* <= OBSmood_cd* <= EVNcd: <= CNE ActInvoiceOverrideCode (override reason)txt:
FinancialTransactionOrderPaymentRequestclass_cd* <= XACTmood_cd* <= ORDid*: SET<II> [1..*] (Item ID, Tracking #, etc.)net_amt: MO [0..1] (amount to be billed)
FinancialTransactionIntentPaymentclass_cd* <= XACTmood_cd* <= INTid*: SET<II> [1..1] (Item ID, Tracking #, etc.)txt:status_cd: <= ActStatuseffective_time: (time payor intends to perform transaction)net_amt*: MO [1..1] (amount to be paid for INV, GRP, ITM or ADJ)credit_exchange_rate_qty:debit_exchange_rate_qty:interest_rate_qty:
ConfirmationOrderCoverageclass_cd* <= CONFmood_cd* <= ORDid: SET<II> (Tracking #, etc.)txt:reason_cd: <= ActAuthorizationReason
FinancialTransactionEventPaymentclass_cd* <= XACTmood_cd* <= EVNid*: SET<II> [1..*] (Cheque #, EFT #)cd*: [1..1] <= ActPaymentCode (e.g. EFT, cheque, etc.)txt:effective_time: (time transaction occurred)reason_cd: <= ActPaymentAdjustmentReason (reason for payment such as retroadjustment, fee deduction, etc. when not based on a Payment_intent)net_amt*: MO [1..1] (amount paid)credit_exchange_rate_qty:debit_exchange_rate_qty:
ConsentEventclass_cd* <= CONSmood_cd* <= EVNeffective_time:
InvoiceElementOrderGroupclass_cd* <= INVE+INFINVEmood_cd* <= ORD+INTid: SET<II> [0..*] (may include data centre and sequence numbers)cd: CS CNE [0..1] <= ActInvoiceCode (Invoice Type e.g. Healthcare Services, Rx Dispense, Rx Compound, Healthcare Goods, Preferred Accomodation)effective_time: IVL<TS> [0..1] (time period that invoice covers e.g. month of January)confidentiality_cd: <= ConfidentialityByAccessKindnet_amt: MO [0..1] (= sum of all immediate children Invoice_element_group.net_amt & Invoice_element_detail.net_amt where Class_cd = INVE)modifier_cd: SET<CS> CNE [0..*] <= ActInvoiceElementModifier
InvoiceElementEventCriterionQuestionclass_cd* <= INVEmood_cd* <= EVN.CRTcd: <= ActCoverageInquiryCode (type of criteria)effective_time:net_amt:unit_qty:unit_price_amt:
ObservationEventInjuryCodingclass_cd* <= OBSmood_cd* <= EVNcd: CD <= ActInjuryCode (- nature of injury, body part, side of body SAZ795)
AccountEventBankclass_cd* <= ACCTmood_cd* <= EVNid: SET<II> (Acount number, transit number, EFT#, bank number)
ActOrderRequiredclass_cd* <= ACTmood_cd* <= ORDcd: <= ActAdjudicationResultActionCode (e.g. print on EOB, allow override)txt:effective_time:
InvoiceElementOrderDetailclass_cd* <= INVE+INFINVEmood_cd* <= ORD+INTid*: SET<II> [1..1] (may include data centre and sequence numbers)cd: CD CNE [0..1] <= ActProductServiceBillableItemCode (Product/Service Code e.g. Office Visit ,Taxes, Markup, Dispense + Product/Service Code Modifier e.g. northern isolation, off hours specialty, on call)net_amt: MO [0..1] (= unit_qty * unit_price_amt * factor_nbr * points_nbr. E.g. $150 CAD)unit_qty: RTO<PQ,PQ> [0..1] (e.g. 3 {boxes})unit_price_amt: RTO<MO,PQ> [0..1] (e.g. $50 CAD/ 1 {box})factor_nbr: (multiplier, can be used for tax percentages)points_nbr: (multiplier)
ObservationEventSummaryclass_cd* <= OBSmood_cd* <= EVNcd*: [1..1] <= ActInvoiceElementSummaryCodevalue: (PQ or MO - Value of summary)
CoverageDefinitionclass_cd* <= COVmood_cd* <= DEFid*: [1..1] (plan id, group id)cd: <= ActCoverageCode (e.g. basic, extended, Plan G)effective_time:
InvoiceElementEventGroupingclass_cd* <= INVEmood_cd* <= EVNcd: CNE <= ActAdjudicationGroupCode (defines the 'categorization'. Only really relevant forsummaries.)effective_time*: [1..1] (summary period)
InvoiceElementEventCriterionclass_cd* <= INVE+INFINVEmood_cd* <= EVN.CRTid: SET<II>cd: CWE <= ActProductServiceBillableItemCodetxt:effective_time:
Predecessortype_cd*<= SUCC
0..* priorInvoiceElementEvent
Componenttype_cd*<= COMP
0..* invoiceElementEventA
sequence_nbr:
ComponentPaymentRequesttype_cd*<= COMP
0..* financialTransactionOrderA
sequence_nbr:
ReversalOfPaymentRequesttype_cd*<= REV
0..* priorFinancialTransactionOrder
ComponentCoveragetype_cd*<= COMP
0..*coverageDefinition
ComponentPolicytype_cd*<= COMP
0..* coverageEventA
ReferencePreviousPaymentRequesttype_cd*<= REFR
0..* referedToFinancialTransactionOrder
ComponentSummarizedtype_cd*<= COMP
0..* invoiceElementEventA
ReferencePaymenttype_cd*<= REFR
0..* referedToFinancialTransactionEvent
ComponentPaymenttype_cd*<= COMP
0..* financialTransactionEventA
sequence_nbr:
ReferencePaymentIntenttype_cd*<= REFR
0..* referedToFinancialTransactionIntent
ComponentPaymentIntenttype_cd*<= COMP
0..* financialTransactionIntentA
sequence_nbr:
PredecessorAtype_cd*<= SUCC
0..* priorInvoiceAdjustmentEvent
ManufacturedMaterialForm
class_cd* <= MMATdeterminer_cd* <= INSTANCEcd: <= FormType
EntityProvider
class_cd* <= ENTdeterminer_cd* <= INSTANCEnm:
Organization
class_cd* <= ORGdeterminer_cd* <= INSTANCEid: [0..*]nm: [0..*]
PersonInsured
class_cd* <= PSNdeterminer_cd* <= INSTANCEid: SET<II>nm:telecom:administrative_gender_cd: <= AdministrativeGenderbirth_time:deceased_time:multiple_birth_ind:birth_order_nbr:addr:
LivingSubjectInsuredAnimal
class_cd* <= LIVdeterminer_cd* <= INSTANCEnm:
PersonGuardianOrParent
class_cd* <= PSNdeterminer_cd* <= INSTANCEnm:
LivingSubjectGroup
class_cd* <= LIVdeterminer_cd* <= INSTANCEqty*: [1..1] (number in group)
PersonPatient
class_cd* <= PSNdeterminer_cd* <= INSTANCEnm:telecom:administrative_gender_cd: <= AdministrativeGenderbirth_time:deceased_time:multiple_birth_ind:birth_order_nbr:addr:
LivingSubjectAnimal
class_cd* <= LIVdeterminer_cd* <= INSTANCEnm:
OrganizationSchool
class_cd* <= ORGdeterminer_cd* <= INSTANCEid:nm:
RoleRequestPayeeclass_cd <= ROLcd: <= PayeeRelationshipRoleType (payee relationship to covered party)
0..1playingManufacturedMaterial
RoleEOBPrintFormclass_cd <= ROL
1..1player
RoleProviderclass_cd <= ROLid: [0..*]
0..1scopingOrganization
RoleStudentclass_cd <= ROL
0..* playedRole
1..1guardianPerson
GuardianOrParentclass_cd <= GUARD
0..* guardian
cd: <= PRN (parent - mother or father)id: (id of guardian or parent)
1..1contactPerson
ContactPartyRecipientclass_cd <= CONcd: <= AdministrativeContactRoleType
1..1underwritingOrganization
Underwriterclass_cd <= UNDWRTid*: [1..1]
1..1member
Memberclass_cd <= MBR
0..* memberid: (id within group, if known)
1..1policyHolder
0..1underwritingOrganization
PolicyHolderclass_cd <= POLHOLDid*: [1..1]
0..1coveredParty
0..1underwritingOrganization
CoveredPartyRoleclass_cd <= COVPTYid: (covered party in policy, member #)cd: CE <= CoverageRoleType (reason for being covered, including spouse, child, student, handicapped)
1..1patient
0..1providerOrganization
Patientclass_cd <= PATid: (patient and/or group identifier, if known)
1..1contactPerson
ContactPartyRecipientclass_cd <= CONcd: <= AdministrativeContactRoleType
0..* participantSubjectPayeetype_cd*<= SBJ
0..* participant
DirectTargetPrintOntype_cd*<= DIR
0..* participantLocationIncidenttype_cd*<= LOC
0..1 underwriterAuthorPolicyAccounttype_cd*<= AUT
0..* contactPartyAttentiontype_cd*<= ATTN
0..* patientSubjectPatienttype_cd*<= SBJ
0..* assignedEntityAuthorContracttype_cd*<= AUT
0..1 agentAuthorInvoicetype_cd*<= AUTtime: TS (invoice date/time)
0..1 agentAuthorOverridetype_cd*<= AUT
0..1 agentAuthorOverridetype_cd*<= AUT
0..1 agentAuthorSummarytype_cd*<= AUTtime: (time calculation was made)
0..* agentPerformerProcessedtype_cd*<= PRFtime: (adjudication date/time)signature_txt: (security)
0..1 underwriterAuthorCoveragetype_cd*<= AUT
0..* policyHolder
ParticipantPolicyHoldertype_cd*<= HLD
CoveredPartytype_cd*<= COV
0..* coveredPartyBeneficiarytype_cd*<= BEN
0..* agent
AuthorConfirmationtype_cd*<= AUTtime: [0..1] (date confirmation was created)
0..* contactPartyAttentiontype_cd*<= ATTN
0..1 agentAuthorAuthorizationRequesttype_cd*<= AUTtime: (Request date/time)
0..* participantSubjectPaymenttype_cd*<= SBJ
0..1 agent
ResponsibleProviderGroupingtype_cd*<= RESPROV
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
CMET: (ACT) A_AdjudicationObservation
[universal](COCT_MT320000)
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ORG) Organization
[universal](COCT_MT150002)
CMET: (PSN) E_Person[contact]
(COCT_MT030203)
CMET: (ORG) Organization
[universal](COCT_MT150002)
CMET: (AGNT) R_ResponsibleDevice
[universal](COCT_MT040200)
CMET: (AGNT) R_Responsibility
[universal](COCT_MT040304)
0..*
CMET: (AGNT) R_Responsibility
[universal](COCT_MT040304)
0..*
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
CMET: (ORG) Organization
[universal](COCT_MT150001)
CMET: (ASSIGNED) R_AssignedPerson
[universal](COCT_MT090101)
CMET: (PSN) E_Person[contact]
(COCT_MT030203)
CMET: (ORG) Organization
[universal](COCT_MT150002)
CMET: (ROL) R_LocationServiceDelivery
[detailed](COCT_MT240001)
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
Invoice Re-Adjudication Request(FICR_RM000000)
Entry Point for Invoice Re-adjudication messages
CMET: (ACT) A_Billable[universal]
(COCT_MT280000)
Adjudication Result(FICR_RM000000)
Entry Point for adjudication results messages
Statement of Financial Activity(FICR_RM000000)
Entry point for Statement of Financial Activity messagesClaim Information(FICR_RM000000)
Entry Point for claim supportinformation messages
Eligibility, Authorization, Coverage Extn Results(FICR_RM000000)
Entry Point for Eligibility, Authorization and CoverageExtension Results messages
Invoice, Cancel, Query Requests & Query Results(FICR_RM000000)
Entry Point for Invoice, Cancel (& response), Query, Pre-determinationrequests & query results messages
Eligibility, Authorization, Coverage Extn(FICR_RM000000)
Entry Point for Eligibility, Authorization andCoverage Extension messages
Payment Advice(FICR_RM000000)
Entry point for payment remittance messages
ActChoice
EntityChoice
EntityChoicePatient
EntityChoiceA
0..*communicatesWith
0..*communicatesWith
0..* subordinateCoveredPartyIndirectAuthorithyOvertype_cd*<= INDAUTH
LanguageCommunication(Language_communication)
language_cd*: [1..1] (HumanLanguage)mode_cd: [0..1] (LanguageAbilityMode)preference_ind: BL [1..1]
LanguageCommunication(Language_communication)
language_cd*: [1..1] (HumanLanguage)mode_cd: [0..1] (LanguageAbilityMode)preference_ind: BL [1..1]
Constraint:Each submitted invoiceelement must have 1EventAdjudicationResultsinstance
Constraint:cd: is only optional ineligibility messages
Constraint:DebitPayor must be for the rootInvoiceElementEventGrouping Act.CreditPayee is optional but may only beon the root InvoiceElementEventGrouping Act.
Constraint:DebitPayor must be for the rootFinancialTransactionEventPayment Act.CreditPayee may be specified for anyFinancialTransactionEventPayment.
Constraint:ReasonPaymentRequest may only be specifiedfor a leaf FinancialTransactionOrderPaymentRequest Actand it must enter the root InvoiceElementOrder first.
Constraint:AuthorInvoice and DebitPayor must befor the root FinancialTransactionOrderPaymentRequest Act.CreditPayee is optional but may only beon the root FinancialTransactionOrderPaymentRequest Act.
Constraint:All Relationships to the InvoiceElementOrderGroupcan only be associated with the root level instance
Constraint:Policy holder cannot be an animal
Constraint:ReferencePreviousAdjudication may only enterroot EventAdjudicationResults
Constraint:EventAdjudicationResults.cd mandatoryif target of ReasonAdjudicationSummary referencesnvoiceElementOrderDetail
Note:Can be used foridentification of aservice bureau
Net_amt must be positive or 0 forAdjudication Results messages
Net_amt must be negative or 0 forInvoice Cancel messages
Constraint:
CMET: (ACCT) A_Account[universal]
(COCT_MT110000)
Note:Payee is noted inA_Account CMET
0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
RoleRequestPayeeclass_cd <= ROLcd: <= PayeeRelationshipRoleType (payee relationship to covered party)
0..* participantSubjectPayeetype_cd*<= SBJ
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ACCT) A_Account[universal]
(COCT_MT110000) 0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ACCT) A_Account[universal]
(COCT_MT110000)
0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ACCT) A_Account[universal]
(COCT_MT110000)
Billable Act
Coverage(insurance)
InvoiceSubject(patient)
CoverageSubject
(insured)
Contract
Attachment
Accident
PaymentRequest
InvoiceDetails
[lineitems]Eligibility
+Authorization
Explanationof
Benefits(EOB)
Adjudication Results
FICR DMIMv5.7 - 02 Sep 20
1..1representedOrganizationAgentclass_cd <= AGNT
CMET: (ORG) E_Organization
[identified](COCT_MT150002)
Note:Required for Invoice Cancelsif the Invoice has already beenadjudicated. The Payment Intenton an Invoice Cancel indicates thenet effect of the cancel (reversal)
Note:Payee is noted inA_Account CMET
Note:RTO used to specify 15 pills (each)out of a bottle of 100 pills (each) toreflect billing for a portion of apackage (e.g. 0.15 of a bottle)
Note:For re-adjudicated invoices(e.g. audit purposes)
Note:Want sum of all adjudicationdetails (info & non-info) to equalwhat was submitted. For example,the reasons why you refused to paypart of the invoice
Note:Print form specified forEOB statement whenprovided to patient
Note:A_Invoice_element_group cannot be a leaf,A_Invoice_element_detail must be a leaf.
Note:Used to indicateconsent invoice againstpolicy or account.
Note:Can be a single patient, ananimal or a group of patientsand/or a group of animals.
Service target & Covered partymay be different people (e.g.pedestrian in auto-accident)
Note:Contact information is thru Ident_org CMET (not here)
Note:Class cd PAT(PatientRole) ismost generic codeavailable
Note:Used to attachdocuments, image, etc.required to support a health claim
Domain to be added in a subsequent release
Note:Subscriber Identifier;required for X12 837mapping
Note:Covered Person Identifier(Assigned by carrier - root of OID)= Subscriber+Dependents
Note:effective_time is from theperspective of the author
Note:"Please Pay"
Note:Need amount forcontract (maxallowable amount),not needed for e-Claims
Note:Limits included in the authorization such asmaximum dollar amounts, maximum quantities,date ranges, etc..
Note:"Please Adjudicate"
Note:Owner of the contract.
There are other participationsfor a contract, but we are notinterested in them for anInvoice.
Note:If Payment is not invoicedand pertains to a Provider,either a person or anOrganization
Note:"I Paid"
Note:"I Will Pay"
Note:Data centre andsequence numbermust be the samefor each completegroup anddetail hierarchy
Note:Carrier id
Note:Location of incident/accident(e.g. fixed address, sideof road, etc.)
Note:Specific adjudication observationswill be added here, such as DrugContraindications.
Note:This allows for root invoice elementgroup to be composed of invoiceelement groups and/or details. There must be one leaf detail
Note:This is where each benefit groupwill insert their billable act (e.g. PharmacyDispense Billable Act). Each Billable Act isa CMET, contained in the A_Billable_Act CMET.Refer to the CMET for more information.
The act will be in intent (INT) mood whenrequesting authorization
Note:Allows Payor to adj& pay on different policy
Note:id: = Coverage IdentifierAssigned by carrier identified by an OIDwith extension = Policy.Plan.Group.Contract.Division.Section.Version as agreed to byparticipants
0..* priorConfirmationOrderInFulfillmentOfCoverageRequesttype_cd*<= FLFS
0..1 priorActReplacementOftype_cd*<= RPLC
0..* justifiedFinancialTransactionIntent
0..* justifyingInvoiceElementEvent
Reasontype_cd*<= RSON
0..1 priorInvoiceAdjustmentEvent
OutcomeAdjudicatedtype_cd*<= OUTC
0..* limitingInvoiceElementEventCriterion
Limitationtype_cd*<= LIMIT
0..* summarizingInvoiceElementEvent
Summarytype_cd*<= SUMM
0..* priorFinancialTransactionIntentInFulfillmentOfPaymentIntenttype_cd*<= FLFS
0..* justifyingObservationEventReasonOverridetype_cd*<= RSON
0..* justifyingObservationEventReasonOverridetype_cd*<= RSON
0..1 invoiceElementEvent
0..* invoiceAdjustmentEventComponentGrouptype_cd*<= COMP
0..* accountEventCreditDeposittype_cd*<= CREDIT
0..* referedToInvoiceAdjustmentEventReferencePreviousAdjudicationtype_cd*<= REFR
0..* actOrderRequirestype_cd*<= RACTnegation_ind:
0..* justifiedConfirmationOrder
0..* justifyingInvoiceElementOrderReasonJustifiedtype_cd*<= RSON
0..* justifyingActReasonCoveragetype_cd*<= RSON
0..* accountDebitPayortype_cd*<= DEBIT
0..* subjectInvoiceElementEventCriterion
PertinentInformationCoverageCriteriatype_cd*<= PERT
0..* subjectAct
PertinentInformationtype_cd*<= PERT
0..* priorFinancialTransactionIntentInFulfillmentOfPaymentRequesttype_cd*<= FLFS
0..* pertinentObservationEvent
PertinentInformationInjuryCodingtype_cd*<= PERT
0..1 priorCoverageEvent
InFulfillmentOfPollicyOrAccounttype_cd*<= FLFSsequence_nbr*: [1..1] (COB priority as adjudicated primary, secondary, etc.) 0..* summarizingObservationEvent
SummaryRunningTotalstype_cd*<= SUMM
1..1 subjectConsentEvent
PertinentInformationConsenttype_cd*<= PERTnegation_ind:
0..* coverageDefinitionDefinitiontype_cd*<= INST
0..1 pertinentIncidentEventPertinentInformationIncidenttype_cd*<= PERT
0..* priorFinancialContractEventInFulfillmentOfContracttype_cd*<= FLFS
0..* pertinentObservationEventPertinentInformationAttachmenttype_cd*<= PERT
0..* coveringCoverageEventCoveragePolicyOrAccounttype_cd*<= COVBYsequence_nbr: [0..1] (COB priority as submitted. primary, secondary, etc.)
0..* pertinentInvoiceElementEventCriterion
PertinentInformationTermsConditionstype_cd*<= PERTnegation_ind: (covered/not covered)
0..1 justifyingActReasonAdjudicationSummarytype_cd*<= RSON
0..* authorizingConfirmationEventAuthorizationtype_cd*<= AUTH
0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
0..* justifyingActReasonInvoiceElementtype_cd*<= RSON
0..* justifyingInvoiceElementOrder
ReasonPaymentRequesttype_cd*<= RSON
1..* act
ComponentInvoicetype_cd*<= COMPsequence_nbr:
InvoiceElementEventAdjudicatedclass_cd* <= INVE+INFINVEmood_cd* <= EVNid*: [1..1]cd: CWE <=ActProductServiceBillableItemCode (Product or service code that was adjudicatedand could include substituted codes - e.g. code Awas replaced by code B during adjudication)txt:net_amt: MOunit_qty: RTO<PQ,PQ>unit_price_amt: RTO<MO,PQ>factor_nbr:points_nbr:
IncidentEventclass_cd* <= INCmood_cd* <= EVNid:cd: CNE <= ActIncidentCode (work place related, auto related, etc.)txt:effective_time:
EventAdjudicationResultsclass_cd* <= ADJUDmood_cd* <= EVNid*: [1..1] (EOB identifier)cd: CNE <= ActAdjudicationCode (Summary of the adjudication processing - as submitted, w/ adjust, refuse)txt:status_cd: <= ActStatusreason_cd*: SET<CE> CWE [0..*] <= ActAdjudicationReason
CoverageEventPolicyOrAccountclass_cd* <= COVmood_cd* <= EVNid*: [1..1] (policy id, WCB claim #, auto claim #,HSA account)cd: <= ActPolicyCode (Policy Type)status_cd: <= ActStatuseffective_time:
ConfirmationEventCoverageclass_cd* <= CONFmood_cd* <= EVNid: (authorization/confirmation identifier)cd*: [1..1] <= ActCoverageConfirmationCode (eligible, not eligible, authorized, not authorized)txt:status_cd: [0..1] <= ActStatus (active, cancelled, etc.)effective_time: [0..1] (effective dates for confirmation - expiry)reason_cd: <= ActAdjudicationReason
FinancialContractEventclass_cd* <= FCNTRCTmood_cd* <= EVNid: (business arrangement identifier)cd: <= ActBillingArrangementCode (i.e. FFS, Block, Contract, Rostering, Capitation, etc.)txt:status_cd: <= ActStatuseffective_time:payment_terms_cd: CWE <= PaymentTerms
ObservationEventAttachmentclass_cd* <= OBSmood_cd* <= EVNid*: [1..1] (attachment identifier)cd*: [1..1] (Domain:ClaimsAttatchmentType)value: ED (content or reference)
InvoiceElementEventCriterionCoverageclass_cd* <= INVE+INFINVEmood_cd* <= EVN.CRTid: SET<II>cd: CWE <= ActCoverageLimitCodetxt:effective_time:net_amt:unit_qty:unit_price_amt:factor_nbr:points_nbr:
ObservationEventInvoiceOverrideclass_cd* <= OBSmood_cd* <= EVNcd: <= CNE ActInvoiceOverrideCode (override reason)txt:
ObservationEventInvoiceOverrideclass_cd* <= OBSmood_cd* <= EVNcd: <= CNE ActInvoiceOverrideCode (override reason)txt:
FinancialTransactionOrderPaymentRequestclass_cd* <= XACTmood_cd* <= ORDid*: SET<II> [1..*] (Item ID, Tracking #, etc.)net_amt: MO [0..1] (amount to be billed)
FinancialTransactionIntentPaymentclass_cd* <= XACTmood_cd* <= INTid*: SET<II> [1..1] (Item ID, Tracking #, etc.)txt:status_cd: <= ActStatuseffective_time: (time payor intends to perform transaction)net_amt*: MO [1..1] (amount to be paid for INV, GRP, ITM or ADJ)credit_exchange_rate_qty:debit_exchange_rate_qty:interest_rate_qty:
ConfirmationOrderCoverageclass_cd* <= CONFmood_cd* <= ORDid: SET<II> (Tracking #, etc.)txt:reason_cd: <= ActAuthorizationReason
FinancialTransactionEventPaymentclass_cd* <= XACTmood_cd* <= EVNid*: SET<II> [1..*] (Cheque #, EFT #)cd*: [1..1] <= ActPaymentCode (e.g. EFT, cheque, etc.)txt:effective_time: (time transaction occurred)reason_cd: <= ActPaymentAdjustmentReason (reason for payment such as retroadjustment, fee deduction, etc. when not based on a Payment_intent)net_amt*: MO [1..1] (amount paid)credit_exchange_rate_qty:debit_exchange_rate_qty:
ConsentEventclass_cd* <= CONSmood_cd* <= EVNeffective_time:
InvoiceElementOrderGroupclass_cd* <= INVE+INFINVEmood_cd* <= ORD+INTid: SET<II> [0..*] (may include data centre and sequence numbers)cd: CS CNE [0..1] <= ActInvoiceCode (Invoice Type e.g. Healthcare Services, Rx Dispense, Rx Compound, Healthcare Goods, Preferred Accomodation)effective_time: IVL<TS> [0..1] (time period that invoice covers e.g. month of January)confidentiality_cd: <= ConfidentialityByAccessKindnet_amt: MO [0..1] (= sum of all immediate children Invoice_element_group.net_amt & Invoice_element_detail.net_amt where Class_cd = INVE)modifier_cd: SET<CS> CNE [0..*] <= ActInvoiceElementModifier
InvoiceElementEventCriterionQuestionclass_cd* <= INVEmood_cd* <= EVN.CRTcd: <= ActCoverageInquiryCode (type of criteria)effective_time:net_amt:unit_qty:unit_price_amt:
ObservationEventInjuryCodingclass_cd* <= OBSmood_cd* <= EVNcd: CD <= ActInjuryCode (- nature of injury, body part, side of body SAZ795)
AccountEventBankclass_cd* <= ACCTmood_cd* <= EVNid: SET<II> (Acount number, transit number, EFT#, bank number)
ActOrderRequiredclass_cd* <= ACTmood_cd* <= ORDcd: <= ActAdjudicationResultActionCode (e.g. print on EOB, allow override)txt:effective_time:
InvoiceElementOrderDetailclass_cd* <= INVE+INFINVEmood_cd* <= ORD+INTid*: SET<II> [1..1] (may include data centre and sequence numbers)cd: CD CNE [0..1] <= ActProductServiceBillableItemCode (Product/Service Code e.g. Office Visit ,Taxes, Markup, Dispense + Product/Service Code Modifier e.g. northern isolation, off hours specialty, on call)net_amt: MO [0..1] (= unit_qty * unit_price_amt * factor_nbr * points_nbr. E.g. $150 CAD)unit_qty: RTO<PQ,PQ> [0..1] (e.g. 3 {boxes})unit_price_amt: RTO<MO,PQ> [0..1] (e.g. $50 CAD/ 1 {box})factor_nbr: (multiplier, can be used for tax percentages)points_nbr: (multiplier)
ObservationEventSummaryclass_cd* <= OBSmood_cd* <= EVNcd*: [1..1] <= ActInvoiceElementSummaryCodevalue: (PQ or MO - Value of summary)
CoverageDefinitionclass_cd* <= COVmood_cd* <= DEFid*: [1..1] (plan id, group id)cd: <= ActCoverageCode (e.g. basic, extended, Plan G)effective_time:
InvoiceElementEventGroupingclass_cd* <= INVEmood_cd* <= EVNcd: CNE <= ActAdjudicationGroupCode (defines the 'categorization'. Only really relevant forsummaries.)effective_time*: [1..1] (summary period)
InvoiceElementEventCriterionclass_cd* <= INVE+INFINVEmood_cd* <= EVN.CRTid: SET<II>cd: CWE <= ActProductServiceBillableItemCodetxt:effective_time:
Predecessortype_cd*<= SUCC
0..* priorInvoiceElementEvent
Componenttype_cd*<= COMP
0..* invoiceElementEventA
sequence_nbr:
ComponentPaymentRequesttype_cd*<= COMP
0..* financialTransactionOrderA
sequence_nbr:
ReversalOfPaymentRequesttype_cd*<= REV
0..* priorFinancialTransactionOrder
ComponentCoveragetype_cd*<= COMP
0..*coverageDefinition
ComponentPolicytype_cd*<= COMP
0..* coverageEventA
ReferencePreviousPaymentRequesttype_cd*<= REFR
0..* referedToFinancialTransactionOrder
ComponentSummarizedtype_cd*<= COMP
0..* invoiceElementEventA
ReferencePaymenttype_cd*<= REFR
0..* referedToFinancialTransactionEvent
ComponentPaymenttype_cd*<= COMP
0..* financialTransactionEventA
sequence_nbr:
ReferencePaymentIntenttype_cd*<= REFR
0..* referedToFinancialTransactionIntent
ComponentPaymentIntenttype_cd*<= COMP
0..* financialTransactionIntentA
sequence_nbr:
PredecessorAtype_cd*<= SUCC
0..* priorInvoiceAdjustmentEvent
ManufacturedMaterialForm
class_cd* <= MMATdeterminer_cd* <= INSTANCEcd: <= FormType
EntityProvider
class_cd* <= ENTdeterminer_cd* <= INSTANCEnm:
Organization
class_cd* <= ORGdeterminer_cd* <= INSTANCEid: [0..*]nm: [0..*]
PersonInsured
class_cd* <= PSNdeterminer_cd* <= INSTANCEid: SET<II>nm:telecom:administrative_gender_cd: <= AdministrativeGenderbirth_time:deceased_time:multiple_birth_ind:birth_order_nbr:addr:
LivingSubjectInsuredAnimal
class_cd* <= LIVdeterminer_cd* <= INSTANCEnm:
PersonGuardianOrParent
class_cd* <= PSNdeterminer_cd* <= INSTANCEnm:
LivingSubjectGroup
class_cd* <= LIVdeterminer_cd* <= INSTANCEqty*: [1..1] (number in group)
PersonPatient
class_cd* <= PSNdeterminer_cd* <= INSTANCEnm:telecom:administrative_gender_cd: <= AdministrativeGenderbirth_time:deceased_time:multiple_birth_ind:birth_order_nbr:addr:
LivingSubjectAnimal
class_cd* <= LIVdeterminer_cd* <= INSTANCEnm:
OrganizationSchool
class_cd* <= ORGdeterminer_cd* <= INSTANCEid:nm:
RoleRequestPayeeclass_cd <= ROLcd: <= PayeeRelationshipRoleType (payee relationship to covered party)
0..1playingManufacturedMaterial
RoleEOBPrintFormclass_cd <= ROL
1..1player
RoleProviderclass_cd <= ROLid: [0..*]
0..1scopingOrganization
RoleStudentclass_cd <= ROL
0..* playedRole
1..1guardianPerson
GuardianOrParentclass_cd <= GUARD
0..* guardian
cd: <= PRN (parent - mother or father)id: (id of guardian or parent)
1..1contactPerson
ContactPartyRecipientclass_cd <= CONcd: <= AdministrativeContactRoleType
1..1underwritingOrganization
Underwriterclass_cd <= UNDWRTid*: [1..1]
1..1member
Memberclass_cd <= MBR
0..* memberid: (id within group, if known)
1..1policyHolder
0..1underwritingOrganization
PolicyHolderclass_cd <= POLHOLDid*: [1..1]
0..1coveredParty
0..1underwritingOrganization
CoveredPartyRoleclass_cd <= COVPTYid: (covered party in policy, member #)cd: CE <= CoverageRoleType (reason for being covered, including spouse, child, student, handicapped)
1..1patient
0..1providerOrganization
Patientclass_cd <= PATid: (patient and/or group identifier, if known)
1..1contactPerson
ContactPartyRecipientclass_cd <= CONcd: <= AdministrativeContactRoleType
0..* participantSubjectPayeetype_cd*<= SBJ
0..* participant
DirectTargetPrintOntype_cd*<= DIR
0..* participantLocationIncidenttype_cd*<= LOC
0..1 underwriterAuthorPolicyAccounttype_cd*<= AUT
0..* contactPartyAttentiontype_cd*<= ATTN
0..* patientSubjectPatienttype_cd*<= SBJ
0..* assignedEntityAuthorContracttype_cd*<= AUT
0..1 agentAuthorInvoicetype_cd*<= AUTtime: TS (invoice date/time)
0..1 agentAuthorOverridetype_cd*<= AUT
0..1 agentAuthorOverridetype_cd*<= AUT
0..1 agentAuthorSummarytype_cd*<= AUTtime: (time calculation was made)
0..* agentPerformerProcessedtype_cd*<= PRFtime: (adjudication date/time)signature_txt: (security)
0..1 underwriterAuthorCoveragetype_cd*<= AUT
0..* policyHolder
ParticipantPolicyHoldertype_cd*<= HLD
CoveredPartytype_cd*<= COV
0..* coveredPartyBeneficiarytype_cd*<= BEN
0..* agent
AuthorConfirmationtype_cd*<= AUTtime: [0..1] (date confirmation was created)
0..* contactPartyAttentiontype_cd*<= ATTN
0..1 agentAuthorAuthorizationRequesttype_cd*<= AUTtime: (Request date/time)
0..* participantSubjectPaymenttype_cd*<= SBJ
0..1 agent
ResponsibleProviderGroupingtype_cd*<= RESPROV
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
CMET: (ACT) A_AdjudicationObservation
[universal](COCT_MT320000)
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ORG) Organization
[universal](COCT_MT150002)
CMET: (PSN) E_Person[contact]
(COCT_MT030203)
CMET: (ORG) Organization
[universal](COCT_MT150002)
CMET: (AGNT) R_ResponsibleDevice
[universal](COCT_MT040200)
CMET: (AGNT) R_Responsibility
[universal](COCT_MT040304)
0..*
CMET: (AGNT) R_Responsibility
[universal](COCT_MT040304)
0..*
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
CMET: (ORG) Organization
[universal](COCT_MT150001)
CMET: (ASSIGNED) R_AssignedPerson
[universal](COCT_MT090101)
CMET: (PSN) E_Person[contact]
(COCT_MT030203)
CMET: (ORG) Organization
[universal](COCT_MT150002)
CMET: (ROL) R_LocationServiceDelivery
[detailed](COCT_MT240001)
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
Invoice Re-Adjudication Request(FICR_RM000000)
Entry Point for Invoice Re-adjudication messages
CMET: (ACT) A_Billable[universal]
(COCT_MT280000)
Adjudication Result(FICR_RM000000)
Entry Point for adjudication results messages
Statement of Financial Activity(FICR_RM000000)
Entry point for Statement of Financial Activity messagesClaim Information(FICR_RM000000)
Entry Point for claim supportinformation messages
Eligibility, Authorization, Coverage Extn Results(FICR_RM000000)
Entry Point for Eligibility, Authorization and CoverageExtension Results messages
Invoice, Cancel, Query Requests & Query Results(FICR_RM000000)
Entry Point for Invoice, Cancel (& response), Query, Pre-determinationrequests & query results messages
Eligibility, Authorization, Coverage Extn(FICR_RM000000)
Entry Point for Eligibility, Authorization andCoverage Extension messages
Payment Advice(FICR_RM000000)
Entry point for payment remittance messages
ActChoice
EntityChoice
EntityChoicePatient
EntityChoiceA
0..*communicatesWith
0..*communicatesWith
0..* subordinateCoveredPartyIndirectAuthorithyOvertype_cd*<= INDAUTH
LanguageCommunication(Language_communication)
language_cd*: [1..1] (HumanLanguage)mode_cd: [0..1] (LanguageAbilityMode)preference_ind: BL [1..1]
LanguageCommunication(Language_communication)
language_cd*: [1..1] (HumanLanguage)mode_cd: [0..1] (LanguageAbilityMode)preference_ind: BL [1..1]
Constraint:Each submitted invoiceelement must have 1EventAdjudicationResultsinstance
Constraint:cd: is only optional ineligibility messages
Constraint:DebitPayor must be for the rootInvoiceElementEventGrouping Act.CreditPayee is optional but may only beon the root InvoiceElementEventGrouping Act.
Constraint:DebitPayor must be for the rootFinancialTransactionEventPayment Act.CreditPayee may be specified for anyFinancialTransactionEventPayment.
Constraint:ReasonPaymentRequest may only be specifiedfor a leaf FinancialTransactionOrderPaymentRequest Actand it must enter the root InvoiceElementOrder first.
Constraint:AuthorInvoice and DebitPayor must befor the root FinancialTransactionOrderPaymentRequest Act.CreditPayee is optional but may only beon the root FinancialTransactionOrderPaymentRequest Act.
Constraint:All Relationships to the InvoiceElementOrderGroupcan only be associated with the root level instance
Constraint:Policy holder cannot be an animal
Constraint:ReferencePreviousAdjudication may only enterroot EventAdjudicationResults
Constraint:EventAdjudicationResults.cd mandatoryif target of ReasonAdjudicationSummary referencesnvoiceElementOrderDetail
Note:Can be used foridentification of aservice bureau
Net_amt must be positive or 0 forAdjudication Results messages
Net_amt must be negative or 0 forInvoice Cancel messages
Constraint:
CMET: (ACCT) A_Account[universal]
(COCT_MT110000)
Note:Payee is noted inA_Account CMET
0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
RoleRequestPayeeclass_cd <= ROLcd: <= PayeeRelationshipRoleType (payee relationship to covered party)
0..* participantSubjectPayeetype_cd*<= SBJ
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ACCT) A_Account[universal]
(COCT_MT110000) 0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ACCT) A_Account[universal]
(COCT_MT110000)
0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ACCT) A_Account[universal]
(COCT_MT110000)
Explanationof
Benefits(EOB)
PaymentIntent
Coverage(insurance)
InvoiceDetails
[lineitems]
Statement ofFinancial
Activity (SOFA)
Payment/Remittance Advice
FICR DMIMv5.7 - 02 Sep 20
1..1representedOrganizationAgentclass_cd <= AGNT
CMET: (ORG) E_Organization
[identified](COCT_MT150002)
Note:Required for Invoice Cancelsif the Invoice has already beenadjudicated. The Payment Intenton an Invoice Cancel indicates thenet effect of the cancel (reversal)
Note:Payee is noted inA_Account CMET
Note:RTO used to specify 15 pills (each)out of a bottle of 100 pills (each) toreflect billing for a portion of apackage (e.g. 0.15 of a bottle)
Note:For re-adjudicated invoices(e.g. audit purposes)
Note:Want sum of all adjudicationdetails (info & non-info) to equalwhat was submitted. For example,the reasons why you refused to paypart of the invoice
Note:Print form specified forEOB statement whenprovided to patient
Note:A_Invoice_element_group cannot be a leaf,A_Invoice_element_detail must be a leaf.
Note:Used to indicateconsent invoice againstpolicy or account.
Note:Can be a single patient, ananimal or a group of patientsand/or a group of animals.
Service target & Covered partymay be different people (e.g.pedestrian in auto-accident)
Note:Contact information is thru Ident_org CMET (not here)
Note:Class cd PAT(PatientRole) ismost generic codeavailable
Note:Used to attachdocuments, image, etc.required to support a health claim
Domain to be added in a subsequent release
Note:Subscriber Identifier;required for X12 837mapping
Note:Covered Person Identifier(Assigned by carrier - root of OID)= Subscriber+Dependents
Note:effective_time is from theperspective of the author
Note:"Please Pay"
Note:Need amount forcontract (maxallowable amount),not needed for e-Claims
Note:Limits included in the authorization such asmaximum dollar amounts, maximum quantities,date ranges, etc..
Note:"Please Adjudicate"
Note:Owner of the contract.
There are other participationsfor a contract, but we are notinterested in them for anInvoice.
Note:If Payment is not invoicedand pertains to a Provider,either a person or anOrganization
Note:"I Paid"
Note:"I Will Pay"
Note:Data centre andsequence numbermust be the samefor each completegroup anddetail hierarchy
Note:Carrier id
Note:Location of incident/accident(e.g. fixed address, sideof road, etc.)
Note:Specific adjudication observationswill be added here, such as DrugContraindications.
Note:This allows for root invoice elementgroup to be composed of invoiceelement groups and/or details. There must be one leaf detail
Note:This is where each benefit groupwill insert their billable act (e.g. PharmacyDispense Billable Act). Each Billable Act isa CMET, contained in the A_Billable_Act CMET.Refer to the CMET for more information.
The act will be in intent (INT) mood whenrequesting authorization
Note:Allows Payor to adj& pay on different policy
Note:id: = Coverage IdentifierAssigned by carrier identified by an OIDwith extension = Policy.Plan.Group.Contract.Division.Section.Version as agreed to byparticipants
0..* priorConfirmationOrderInFulfillmentOfCoverageRequesttype_cd*<= FLFS
0..1 priorActReplacementOftype_cd*<= RPLC
0..* justifiedFinancialTransactionIntent
0..* justifyingInvoiceElementEvent
Reasontype_cd*<= RSON
0..1 priorInvoiceAdjustmentEvent
OutcomeAdjudicatedtype_cd*<= OUTC
0..* limitingInvoiceElementEventCriterion
Limitationtype_cd*<= LIMIT
0..* summarizingInvoiceElementEvent
Summarytype_cd*<= SUMM
0..* priorFinancialTransactionIntentInFulfillmentOfPaymentIntenttype_cd*<= FLFS
0..* justifyingObservationEventReasonOverridetype_cd*<= RSON
0..* justifyingObservationEventReasonOverridetype_cd*<= RSON
0..1 invoiceElementEvent
0..* invoiceAdjustmentEventComponentGrouptype_cd*<= COMP
0..* accountEventCreditDeposittype_cd*<= CREDIT
0..* referedToInvoiceAdjustmentEventReferencePreviousAdjudicationtype_cd*<= REFR
0..* actOrderRequirestype_cd*<= RACTnegation_ind:
0..* justifiedConfirmationOrder
0..* justifyingInvoiceElementOrderReasonJustifiedtype_cd*<= RSON
0..* justifyingActReasonCoveragetype_cd*<= RSON
0..* accountDebitPayortype_cd*<= DEBIT
0..* subjectInvoiceElementEventCriterion
PertinentInformationCoverageCriteriatype_cd*<= PERT
0..* subjectAct
PertinentInformationtype_cd*<= PERT
0..* priorFinancialTransactionIntentInFulfillmentOfPaymentRequesttype_cd*<= FLFS
0..* pertinentObservationEvent
PertinentInformationInjuryCodingtype_cd*<= PERT
0..1 priorCoverageEvent
InFulfillmentOfPollicyOrAccounttype_cd*<= FLFSsequence_nbr*: [1..1] (COB priority as adjudicated primary, secondary, etc.) 0..* summarizingObservationEvent
SummaryRunningTotalstype_cd*<= SUMM
1..1 subjectConsentEvent
PertinentInformationConsenttype_cd*<= PERTnegation_ind:
0..* coverageDefinitionDefinitiontype_cd*<= INST
0..1 pertinentIncidentEventPertinentInformationIncidenttype_cd*<= PERT
0..* priorFinancialContractEventInFulfillmentOfContracttype_cd*<= FLFS
0..* pertinentObservationEventPertinentInformationAttachmenttype_cd*<= PERT
0..* coveringCoverageEventCoveragePolicyOrAccounttype_cd*<= COVBYsequence_nbr: [0..1] (COB priority as submitted. primary, secondary, etc.)
0..* pertinentInvoiceElementEventCriterion
PertinentInformationTermsConditionstype_cd*<= PERTnegation_ind: (covered/not covered)
0..1 justifyingActReasonAdjudicationSummarytype_cd*<= RSON
0..* authorizingConfirmationEventAuthorizationtype_cd*<= AUTH
0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
0..* justifyingActReasonInvoiceElementtype_cd*<= RSON
0..* justifyingInvoiceElementOrder
ReasonPaymentRequesttype_cd*<= RSON
1..* act
ComponentInvoicetype_cd*<= COMPsequence_nbr:
InvoiceElementEventAdjudicatedclass_cd* <= INVE+INFINVEmood_cd* <= EVNid*: [1..1]cd: CWE <=ActProductServiceBillableItemCode (Product or service code that was adjudicatedand could include substituted codes - e.g. code Awas replaced by code B during adjudication)txt:net_amt: MOunit_qty: RTO<PQ,PQ>unit_price_amt: RTO<MO,PQ>factor_nbr:points_nbr:
IncidentEventclass_cd* <= INCmood_cd* <= EVNid:cd: CNE <= ActIncidentCode (work place related, auto related, etc.)txt:effective_time:
EventAdjudicationResultsclass_cd* <= ADJUDmood_cd* <= EVNid*: [1..1] (EOB identifier)cd: CNE <= ActAdjudicationCode (Summary of the adjudication processing - as submitted, w/ adjust, refuse)txt:status_cd: <= ActStatusreason_cd*: SET<CE> CWE [0..*] <= ActAdjudicationReason
CoverageEventPolicyOrAccountclass_cd* <= COVmood_cd* <= EVNid*: [1..1] (policy id, WCB claim #, auto claim #,HSA account)cd: <= ActPolicyCode (Policy Type)status_cd: <= ActStatuseffective_time:
ConfirmationEventCoverageclass_cd* <= CONFmood_cd* <= EVNid: (authorization/confirmation identifier)cd*: [1..1] <= ActCoverageConfirmationCode (eligible, not eligible, authorized, not authorized)txt:status_cd: [0..1] <= ActStatus (active, cancelled, etc.)effective_time: [0..1] (effective dates for confirmation - expiry)reason_cd: <= ActAdjudicationReason
FinancialContractEventclass_cd* <= FCNTRCTmood_cd* <= EVNid: (business arrangement identifier)cd: <= ActBillingArrangementCode (i.e. FFS, Block, Contract, Rostering, Capitation, etc.)txt:status_cd: <= ActStatuseffective_time:payment_terms_cd: CWE <= PaymentTerms
ObservationEventAttachmentclass_cd* <= OBSmood_cd* <= EVNid*: [1..1] (attachment identifier)cd*: [1..1] (Domain:ClaimsAttatchmentType)value: ED (content or reference)
InvoiceElementEventCriterionCoverageclass_cd* <= INVE+INFINVEmood_cd* <= EVN.CRTid: SET<II>cd: CWE <= ActCoverageLimitCodetxt:effective_time:net_amt:unit_qty:unit_price_amt:factor_nbr:points_nbr:
ObservationEventInvoiceOverrideclass_cd* <= OBSmood_cd* <= EVNcd: <= CNE ActInvoiceOverrideCode (override reason)txt:
ObservationEventInvoiceOverrideclass_cd* <= OBSmood_cd* <= EVNcd: <= CNE ActInvoiceOverrideCode (override reason)txt:
FinancialTransactionOrderPaymentRequestclass_cd* <= XACTmood_cd* <= ORDid*: SET<II> [1..*] (Item ID, Tracking #, etc.)net_amt: MO [0..1] (amount to be billed)
FinancialTransactionIntentPaymentclass_cd* <= XACTmood_cd* <= INTid*: SET<II> [1..1] (Item ID, Tracking #, etc.)txt:status_cd: <= ActStatuseffective_time: (time payor intends to perform transaction)net_amt*: MO [1..1] (amount to be paid for INV, GRP, ITM or ADJ)credit_exchange_rate_qty:debit_exchange_rate_qty:interest_rate_qty:
ConfirmationOrderCoverageclass_cd* <= CONFmood_cd* <= ORDid: SET<II> (Tracking #, etc.)txt:reason_cd: <= ActAuthorizationReason
FinancialTransactionEventPaymentclass_cd* <= XACTmood_cd* <= EVNid*: SET<II> [1..*] (Cheque #, EFT #)cd*: [1..1] <= ActPaymentCode (e.g. EFT, cheque, etc.)txt:effective_time: (time transaction occurred)reason_cd: <= ActPaymentAdjustmentReason (reason for payment such as retroadjustment, fee deduction, etc. when not based on a Payment_intent)net_amt*: MO [1..1] (amount paid)credit_exchange_rate_qty:debit_exchange_rate_qty:
ConsentEventclass_cd* <= CONSmood_cd* <= EVNeffective_time:
InvoiceElementOrderGroupclass_cd* <= INVE+INFINVEmood_cd* <= ORD+INTid: SET<II> [0..*] (may include data centre and sequence numbers)cd: CS CNE [0..1] <= ActInvoiceCode (Invoice Type e.g. Healthcare Services, Rx Dispense, Rx Compound, Healthcare Goods, Preferred Accomodation)effective_time: IVL<TS> [0..1] (time period that invoice covers e.g. month of January)confidentiality_cd: <= ConfidentialityByAccessKindnet_amt: MO [0..1] (= sum of all immediate children Invoice_element_group.net_amt & Invoice_element_detail.net_amt where Class_cd = INVE)modifier_cd: SET<CS> CNE [0..*] <= ActInvoiceElementModifier
InvoiceElementEventCriterionQuestionclass_cd* <= INVEmood_cd* <= EVN.CRTcd: <= ActCoverageInquiryCode (type of criteria)effective_time:net_amt:unit_qty:unit_price_amt:
ObservationEventInjuryCodingclass_cd* <= OBSmood_cd* <= EVNcd: CD <= ActInjuryCode (- nature of injury, body part, side of body SAZ795)
AccountEventBankclass_cd* <= ACCTmood_cd* <= EVNid: SET<II> (Acount number, transit number, EFT#, bank number)
ActOrderRequiredclass_cd* <= ACTmood_cd* <= ORDcd: <= ActAdjudicationResultActionCode (e.g. print on EOB, allow override)txt:effective_time:
InvoiceElementOrderDetailclass_cd* <= INVE+INFINVEmood_cd* <= ORD+INTid*: SET<II> [1..1] (may include data centre and sequence numbers)cd: CD CNE [0..1] <= ActProductServiceBillableItemCode (Product/Service Code e.g. Office Visit ,Taxes, Markup, Dispense + Product/Service Code Modifier e.g. northern isolation, off hours specialty, on call)net_amt: MO [0..1] (= unit_qty * unit_price_amt * factor_nbr * points_nbr. E.g. $150 CAD)unit_qty: RTO<PQ,PQ> [0..1] (e.g. 3 {boxes})unit_price_amt: RTO<MO,PQ> [0..1] (e.g. $50 CAD/ 1 {box})factor_nbr: (multiplier, can be used for tax percentages)points_nbr: (multiplier)
ObservationEventSummaryclass_cd* <= OBSmood_cd* <= EVNcd*: [1..1] <= ActInvoiceElementSummaryCodevalue: (PQ or MO - Value of summary)
CoverageDefinitionclass_cd* <= COVmood_cd* <= DEFid*: [1..1] (plan id, group id)cd: <= ActCoverageCode (e.g. basic, extended, Plan G)effective_time:
InvoiceElementEventGroupingclass_cd* <= INVEmood_cd* <= EVNcd: CNE <= ActAdjudicationGroupCode (defines the 'categorization'. Only really relevant forsummaries.)effective_time*: [1..1] (summary period)
InvoiceElementEventCriterionclass_cd* <= INVE+INFINVEmood_cd* <= EVN.CRTid: SET<II>cd: CWE <= ActProductServiceBillableItemCodetxt:effective_time:
Predecessortype_cd*<= SUCC
0..* priorInvoiceElementEvent
Componenttype_cd*<= COMP
0..* invoiceElementEventA
sequence_nbr:
ComponentPaymentRequesttype_cd*<= COMP
0..* financialTransactionOrderA
sequence_nbr:
ReversalOfPaymentRequesttype_cd*<= REV
0..* priorFinancialTransactionOrder
ComponentCoveragetype_cd*<= COMP
0..*coverageDefinition
ComponentPolicytype_cd*<= COMP
0..* coverageEventA
ReferencePreviousPaymentRequesttype_cd*<= REFR
0..* referedToFinancialTransactionOrder
ComponentSummarizedtype_cd*<= COMP
0..* invoiceElementEventA
ReferencePaymenttype_cd*<= REFR
0..* referedToFinancialTransactionEvent
ComponentPaymenttype_cd*<= COMP
0..* financialTransactionEventA
sequence_nbr:
ReferencePaymentIntenttype_cd*<= REFR
0..* referedToFinancialTransactionIntent
ComponentPaymentIntenttype_cd*<= COMP
0..* financialTransactionIntentA
sequence_nbr:
PredecessorAtype_cd*<= SUCC
0..* priorInvoiceAdjustmentEvent
ManufacturedMaterialForm
class_cd* <= MMATdeterminer_cd* <= INSTANCEcd: <= FormType
EntityProvider
class_cd* <= ENTdeterminer_cd* <= INSTANCEnm:
Organization
class_cd* <= ORGdeterminer_cd* <= INSTANCEid: [0..*]nm: [0..*]
PersonInsured
class_cd* <= PSNdeterminer_cd* <= INSTANCEid: SET<II>nm:telecom:administrative_gender_cd: <= AdministrativeGenderbirth_time:deceased_time:multiple_birth_ind:birth_order_nbr:addr:
LivingSubjectInsuredAnimal
class_cd* <= LIVdeterminer_cd* <= INSTANCEnm:
PersonGuardianOrParent
class_cd* <= PSNdeterminer_cd* <= INSTANCEnm:
LivingSubjectGroup
class_cd* <= LIVdeterminer_cd* <= INSTANCEqty*: [1..1] (number in group)
PersonPatient
class_cd* <= PSNdeterminer_cd* <= INSTANCEnm:telecom:administrative_gender_cd: <= AdministrativeGenderbirth_time:deceased_time:multiple_birth_ind:birth_order_nbr:addr:
LivingSubjectAnimal
class_cd* <= LIVdeterminer_cd* <= INSTANCEnm:
OrganizationSchool
class_cd* <= ORGdeterminer_cd* <= INSTANCEid:nm:
RoleRequestPayeeclass_cd <= ROLcd: <= PayeeRelationshipRoleType (payee relationship to covered party)
0..1playingManufacturedMaterial
RoleEOBPrintFormclass_cd <= ROL
1..1player
RoleProviderclass_cd <= ROLid: [0..*]
0..1scopingOrganization
RoleStudentclass_cd <= ROL
0..* playedRole
1..1guardianPerson
GuardianOrParentclass_cd <= GUARD
0..* guardian
cd: <= PRN (parent - mother or father)id: (id of guardian or parent)
1..1contactPerson
ContactPartyRecipientclass_cd <= CONcd: <= AdministrativeContactRoleType
1..1underwritingOrganization
Underwriterclass_cd <= UNDWRTid*: [1..1]
1..1member
Memberclass_cd <= MBR
0..* memberid: (id within group, if known)
1..1policyHolder
0..1underwritingOrganization
PolicyHolderclass_cd <= POLHOLDid*: [1..1]
0..1coveredParty
0..1underwritingOrganization
CoveredPartyRoleclass_cd <= COVPTYid: (covered party in policy, member #)cd: CE <= CoverageRoleType (reason for being covered, including spouse, child, student, handicapped)
1..1patient
0..1providerOrganization
Patientclass_cd <= PATid: (patient and/or group identifier, if known)
1..1contactPerson
ContactPartyRecipientclass_cd <= CONcd: <= AdministrativeContactRoleType
0..* participantSubjectPayeetype_cd*<= SBJ
0..* participant
DirectTargetPrintOntype_cd*<= DIR
0..* participantLocationIncidenttype_cd*<= LOC
0..1 underwriterAuthorPolicyAccounttype_cd*<= AUT
0..* contactPartyAttentiontype_cd*<= ATTN
0..* patientSubjectPatienttype_cd*<= SBJ
0..* assignedEntityAuthorContracttype_cd*<= AUT
0..1 agentAuthorInvoicetype_cd*<= AUTtime: TS (invoice date/time)
0..1 agentAuthorOverridetype_cd*<= AUT
0..1 agentAuthorOverridetype_cd*<= AUT
0..1 agentAuthorSummarytype_cd*<= AUTtime: (time calculation was made)
0..* agentPerformerProcessedtype_cd*<= PRFtime: (adjudication date/time)signature_txt: (security)
0..1 underwriterAuthorCoveragetype_cd*<= AUT
0..* policyHolder
ParticipantPolicyHoldertype_cd*<= HLD
CoveredPartytype_cd*<= COV
0..* coveredPartyBeneficiarytype_cd*<= BEN
0..* agent
AuthorConfirmationtype_cd*<= AUTtime: [0..1] (date confirmation was created)
0..* contactPartyAttentiontype_cd*<= ATTN
0..1 agentAuthorAuthorizationRequesttype_cd*<= AUTtime: (Request date/time)
0..* participantSubjectPaymenttype_cd*<= SBJ
0..1 agent
ResponsibleProviderGroupingtype_cd*<= RESPROV
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
CMET: (ACT) A_AdjudicationObservation
[universal](COCT_MT320000)
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ORG) Organization
[universal](COCT_MT150002)
CMET: (PSN) E_Person[contact]
(COCT_MT030203)
CMET: (ORG) Organization
[universal](COCT_MT150002)
CMET: (AGNT) R_ResponsibleDevice
[universal](COCT_MT040200)
CMET: (AGNT) R_Responsibility
[universal](COCT_MT040304)
0..*
CMET: (AGNT) R_Responsibility
[universal](COCT_MT040304)
0..*
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
CMET: (ORG) Organization
[universal](COCT_MT150001)
CMET: (ASSIGNED) R_AssignedPerson
[universal](COCT_MT090101)
CMET: (PSN) E_Person[contact]
(COCT_MT030203)
CMET: (ORG) Organization
[universal](COCT_MT150002)
CMET: (ROL) R_LocationServiceDelivery
[detailed](COCT_MT240001)
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (AGNT) R_Responsible
[universal](COCT_MT040000)
Invoice Re-Adjudication Request(FICR_RM000000)
Entry Point for Invoice Re-adjudication messages
CMET: (ACT) A_Billable[universal]
(COCT_MT280000)
Adjudication Result(FICR_RM000000)
Entry Point for adjudication results messages
Statement of Financial Activity(FICR_RM000000)
Entry point for Statement of Financial Activity messagesClaim Information(FICR_RM000000)
Entry Point for claim supportinformation messages
Eligibility, Authorization, Coverage Extn Results(FICR_RM000000)
Entry Point for Eligibility, Authorization and CoverageExtension Results messages
Invoice, Cancel, Query Requests & Query Results(FICR_RM000000)
Entry Point for Invoice, Cancel (& response), Query, Pre-determinationrequests & query results messages
Eligibility, Authorization, Coverage Extn(FICR_RM000000)
Entry Point for Eligibility, Authorization andCoverage Extension messages
Payment Advice(FICR_RM000000)
Entry point for payment remittance messages
ActChoice
EntityChoice
EntityChoicePatient
EntityChoiceA
0..*communicatesWith
0..*communicatesWith
0..* subordinateCoveredPartyIndirectAuthorithyOvertype_cd*<= INDAUTH
LanguageCommunication(Language_communication)
language_cd*: [1..1] (HumanLanguage)mode_cd: [0..1] (LanguageAbilityMode)preference_ind: BL [1..1]
LanguageCommunication(Language_communication)
language_cd*: [1..1] (HumanLanguage)mode_cd: [0..1] (LanguageAbilityMode)preference_ind: BL [1..1]
Constraint:Each submitted invoiceelement must have 1EventAdjudicationResultsinstance
Constraint:cd: is only optional ineligibility messages
Constraint:DebitPayor must be for the rootInvoiceElementEventGrouping Act.CreditPayee is optional but may only beon the root InvoiceElementEventGrouping Act.
Constraint:DebitPayor must be for the rootFinancialTransactionEventPayment Act.CreditPayee may be specified for anyFinancialTransactionEventPayment.
Constraint:ReasonPaymentRequest may only be specifiedfor a leaf FinancialTransactionOrderPaymentRequest Actand it must enter the root InvoiceElementOrder first.
Constraint:AuthorInvoice and DebitPayor must befor the root FinancialTransactionOrderPaymentRequest Act.CreditPayee is optional but may only beon the root FinancialTransactionOrderPaymentRequest Act.
Constraint:All Relationships to the InvoiceElementOrderGroupcan only be associated with the root level instance
Constraint:Policy holder cannot be an animal
Constraint:ReferencePreviousAdjudication may only enterroot EventAdjudicationResults
Constraint:EventAdjudicationResults.cd mandatoryif target of ReasonAdjudicationSummary referencesnvoiceElementOrderDetail
Note:Can be used foridentification of aservice bureau
Net_amt must be positive or 0 forAdjudication Results messages
Net_amt must be negative or 0 forInvoice Cancel messages
Constraint:
CMET: (ACCT) A_Account[universal]
(COCT_MT110000)
Note:Payee is noted inA_Account CMET
0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
RoleRequestPayeeclass_cd <= ROLcd: <= PayeeRelationshipRoleType (payee relationship to covered party)
0..* participantSubjectPayeetype_cd*<= SBJ
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ACCT) A_Account[universal]
(COCT_MT110000) 0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ACCT) A_Account[universal]
(COCT_MT110000)
0..1 accountDebitPayortype_cd*<= DEBIT
0..1 accountCreditPayeetype_cd*<= CREDIT
CMET: (ACCT) A_Account[universal]
(COCT_MT110002)
CMET: (ACCT) A_Account[universal]
(COCT_MT110000)
RemittanceAdvice
Explanationof
Benefits(EOB)
PaymentIntent
Statement ofFinancial
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
InvoiceElementDetail
InvoiceElementGroup
InvoiceElementDetail
InvoiceElementDetail
InvoiceElementGroup
Root InvoiceElement Group
PaymentRequest
AdjudicationTransform
Adjudicate as: Submitted with Adjustment Refuse
+ Reason Codes
InvoiceElementDetail
InvoiceElementGroup
InvoiceElementDetail
InvoiceElementDetail
InvoiceElementGroup
Root InvoiceElement Group
PaymentIntent
Invoice & Adjudication Example
• Pharmacy invoice of $26.001. $20.00 for the drug cost
2. $6.00 for the professional fee
• Payor adjudicates to $11.081. Reduce the drug cost to $15.00
2. Accepts professional fee of $6.00
3. Indicates a deductible of -$5.00
4. Patient copay is -$4.92
5. Indicates patient is nearing their limit of $1000
Invoice & Adjudication Example
InvoiceAmt.
$26.00
Prof Fee$6.00
Drug$20.00
Total Due$26.00
Drug$15.00
Adjud w/Adjust
Prof Fee$6.00
Adjud asSubmit
NearingMax
$1000
InformationItem
Adjud w/Adjust
InvoiceAmt.
$11.08
TotalPayable$11.08
Deduct.-$5.00
CoPay-$4.92
PayorAdjustments
Coordination of Benefits (COB)
InvoiceAmt.
$26.00
Prof Fee$6.00
Drug$20.00
Total Due$26.00
Drug$15.00
Adjud w/Adjust
Prof Fee$6.00
Adjud asSubmit
Deduct.-$5.00
CoPay-$4.92
PayorAdjustments
NearingMax $1000
InformationItem
Adjud w/Adjust
Invoice Amt.$11.08
Explanation of Benefits(EOB)
To Payor 2
Drug$15.00
Adjud w/Adjust
Prof Fee$6.00
Adjud asSubmit
Deduct.-$5.00
CoPay-$4.92
PayorAdjustments
NearingMax $1000
InformationItem
Adjud w/Adjust
Invoice Amt.$11.08
Explanation of Benefits(EOB)
To Payor 3
To Payor 3
Billable Acts & Adjudication Observations
InvoiceAmt.
$26.00
Prof Fee$6.00
Drug$20.00
Total Due$26.00
Product Service
RxDispense
PrefAccom
Billable Acts
DrugInteraction
AdjudicationObservations
Drug$15.00
Adjud w/Adjust
Prof Fee$6.00
Adjud asSubmit
Adjud w/Adjust
InvoiceAmt.
$21.00
TotalPayable$21.00
Deferred Adjudication
Referencesto submitted
invoice(not shown)Drug
$15.00Adjud w/Adjust
Prof Fee$6.00
Adjud asSubmit
Deduct.-$5.00
CoPay-$4.92
PayorAdjustments
NearingMax $1000
InformationItem
Adjud w/Adjust
Invoice Amt.$11.08
Explanation ofBenefits (EOB)
Invoice #1 - $11.08
Invoice Amt.$26.00
Prof Fee$6.00
Drug$20.00
Total Due$26.00
Invoice #1 - $26.00 Send Invoice toPayor for Payment
Payor sends backacknowledgementand will respondwith completed
adjudication resultslater
Invoice Amt.$36.00
Prof Fee$4.00
Drug$30.00
Total Due$36.00
Invoice #2 - $36.00
Upcharge$2.00
Send Invoice toPayor for Payment
Payor sends backacknowledgementand will respondwith completed
adjudication resultslater
Referencesto submitted
invoice(not shown)
Drug$30.00
Adjud asSubmit
Prof Fee$4.00
Adjud asSubmit
Adjud asSubmit
Invoice Amt.$36.00
Explanation of Benefits(EOB)
Invoice #2 - $36.00
Upcharge$2.00
Adjud asSubmit
Total Payable$47.08
Other Concepts
• Statement of Financial Activity (SOFA)– Can be included on adjudication results
• Number/amount of submitted, adjudicated, paid invoices
• Used to help keep Provider and Payor systems synchronized
– Queries for SOFA summary & details• Summary of counts and amounts ($) 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
What’s 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?