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

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

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

3. Welcome & Introductions • Round the room

4. Quick Development Background How did we get here?

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

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

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

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

9. FM Life Cycle

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

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

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

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

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

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

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

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

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

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

20. Invoice Overview

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

22. Invoice & Adjudication Example

23. Coordination of Benefits (COB)

24. Billable Acts & Adjudication Observations

25. Deferred Adjudication

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

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

28. Upcoming FICR Projects What’s Next?

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

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