E-Claims Domain Message Information Model Summary of Changes

E-CLAIMS DOMAIN MESSAGE INFORMATION MODEL SUMMARY OF CHANGES

DIM Changes v4.4 to 4.5 October 2, 2001

 Remove reference - Payment_request & Payment_intent cd: indication of “invoice control” now no reference  Invoice_element_summary cd: has no reference

DIM Changes v4.5 to v4.6 October 11, 2001

 AR_authorized_by connected to outer invoice element choice  AR_billing_for connected to outer invoice element choice  Delete Scoper for service_target (was E_Organization_Contact_Person)  Use same CMET for scoping Covered_party and Policy_holder  Add determiner_cd to living _subject  Added Recipient_contact role participating from Payment_request  Change AR_fulfils_request.type_cd from FLFL to FLFS  Change AR_fulfils_intent.type_cd from FLFL to FLFS  moved [confidentiality_cd = _ConfidentialityByAccessKind, "N"] from Payment_request to Invoice_element _summary

Invoice_element_summary  changed net_qty description

Invoice_element_summary  changed type_cd RSON to COMP & blocked target

Invoice_element_group  changed net_qty description

Incident  Change class_cd to INC (from JOBINC)  Change cd to specify if work place related, auto related, etc new vocab req'd

Adjucication_result  Remove Gross_qty

Coverage  Remove AR_required action, Required_act, AR_trigger, Act_criteria as these are not need for claims but rather coverage

Living_subject  Change id: to SET

Added Injury_coding_set & Injury_coding for Incident P_policy_author for Policy AR_previous_adjudication for Invoice_element_summary (COB) AR_required_act for Adjudication_result

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DIM Changes v4.6 to v4.7 October 31, 2001

Person/Group choice box  Renamed Living_subject in choice box to Person

Policy_holder  Change player relationship from deleted Person entity to Person (was Living_subject) entity in choice (for player Service_target and Covered_party)

Parent_or_Guardian (was Mother)  Renamed Role and Entity to allow for guardian or either parent to be specified for the Person playing the Service_target or Covered_party

Payment_request & Payment_intent  Removed cd – no use identified

Invoice_element_summary  Class_cd - removed INVE (is information item only)  Added reason_cd = _InvoiceReason

Invoice_element_group  Class_cd - removed INVE (is information item only)

Service_target  Removed id: use Person or Group id:

P_processed_by  Moved from Payment_intent to Adjudication_result

DIM Changes v4.6 to v4.7 November 01, 2001

Person/Group/Pet choice box  Added Pet entity (living_subject) in choice box

Coverage_confirmation_request  Added Coverage_confirmation_request act – entry point for Authorization Request message

Coverage_confirmation  Entry point for Authorization Response message  Added AR_fulfills Coverage_confirmation_request  Removed AR_fulfills_authorization  Added AR_related_service to list specific service codes associated with the specific codes authorization was requested for.

Invoice_element_detail  Added DEF to class_cd domain

Related_invoice_element  Added AR_related_service  Added Related_invoice_element act to list other related products or services that are also authorized by the payor along with the original one specified in the authorization request.

Authorization & Eligibility Request & Response Entry points  Combined the entry point references

Invoice, Cancel (& response), Pre-determination, Reassessment messages Entry point  Combined the entry point references

Adjudication, Invoice Query Messages Entry point  Combined the entry point references

Coverage_confirmation AR_covered_by  Added Act Relation to Policy (duplicate until re-drawn) to indicate the policy the covered party is eligible for coverage under

AR_fulfills_intent  Blocked target path (from Payment_intent to Payment)

Payment  Blocked target path (from Payment_intent to Payment)  Added reason_cd for payment reason if not based on a Payment_intent  Added P-subject participation if payment pertains to a specific provider (individual or organization)

Provider  Added Provider role played by a person or an Identified Organization that is the subject of a non-invoiced payment

Invoice_element_summary  Changed description/notes for cd attribute to indicate Benefit Group, from Invoice Type. Invoice Type (e.g. fee for service, contract) will be noted as a different message type.

Invoice_element_group  Cd (Product/Service Code) is now CWE

Invoice_element_detail  Cd (Product/Service Code) is now CWE

Contract  Change class_cd to FCNTRCT from ACT  Added Payment_terms_cd with domain PaymentTerms and CWE (coded with exceptions)  Remove bold for Contract Id attribute – not required

Payment_request  Moved Payment_terms_cd to Contract (see above)

Payment  Changed description/notes for cd attribute to EFT, cheque, etc. from Type of Payment.

Invoice_element_detail  Add P_packaged_product participation joined to R-packaged_product role (with entity Product as both scoping and playing  Change net_qty to net_amt: MO (monetary amount data type)  Change item_nbr to unit_qty: PQ (physical quantity data type)  Change unit_qty to unit_price: RTO (Ratio data type)  Remove item_qualifier_cd as it is included in the unit_price

Invoice_element_group  Change net_qty to net_amt: MO (monetary amount data type)

Invoice_element_summary  Change net_qty to net_amt: MO (monetary amount data type)

Payment_request  Change net_qty to net_amt: MO (monetary amount data type)

Payment_intent  Change net_qty to net_amt: MO (monetary amount data type)

Adjudication_result  Change net_qty to net_amt: MO (monetary amount data type)  Change item_nbr to unit_qty: PQ (physical quantity data type)  Change unit_qty to unit_price: RTO (Ratio data type)

 Remove item_qualifier_cd as it is included in the unit_price

Payment  Change net_qty to net_amt: MO (monetary amount data type)

Adjudication_grouping  Change net_qty to net_amt: MO (monetary amount data type)

Entry points - Updated descriptions

DIM Changes v4.9 to v5.0 December 10, 2001

Validation updates – These changes do not change the model concepts but have it meet the tool requirements  Entry points - Shortened descriptions  Most Class names corrected for prefixes and capitals  Duplicate class names made unique  Syntax corrections for data types and domain names

P_Packaged_product  Participation changed from R-packaged_product role to R_Manufactured_product

R_Manufactured_product  Scoped by Ident_org CMET – manufacturer  Player E_Manufactured_product

E_package  Removed entity E_Package, replaced by E_Manufactured_product

R_Packaged_product  Added role R_Packaged_product scoper and player is E_Manufactured_product to specify packaging quantities

AR_Required_BY  Name changed from Required_action  Arrow direction revered to match new definition for type_cd RACT

P_Attention  Changed type_cd from ATT* to ATTN

P_Attention_confirmation  Changed type_cd from ATT* to ATTN

P_Payment_intent_limit  Added financial act to contain dollar limit for authorization

A_Coverage_confirmation_request  Added reason_cd for why ask for authorization

A_Attachment  Added ED data type to value:

A_Coverage_criteria  Removed effective_time, txt

 Added unit_qty, unit_price, net_amt to specify criteria information

AR_Justified_by  Change cardinality from [1..*] to [0..*]

AR_Invoice_compossed_of  Change cardinality from [1..*] to [0..*]

Added constraint for A_Invoice_element_group A_Invoice_element_detail choice to ensure group cannot be leaf level and detail must be leaf level.

A_Invoice_element_summary/Group  Type, was benefit group which is now represented by the message type.

A_Invoice_override  Added new act for previous A_Invoice_element_summary.reason_cd

A_Contract  Added cd: billing arrangement\

A_Payment_request  Added cd: for type of request i.e. standard, information only. Mandatory

AR_Fulfills_payment_request  Removed

Choice including invoice_elements was removed

Merge A_Invoice_element_summary A_Invoice_element_group with constraints for Act Relationships that connect to this object. Root group = summary

AR_Previous_adjudication  Link moved from outer choice to root group

AR_Authroized_by  Link moved from outer choice to root group

AR_Policy_components  Added to allow multiple policy components for compound identifiers

E_Group  Class_cd changed to LIV to allow for groups of animals

E_Animal  Renamed from E_Pet

R_Member  Player is choice of E_person or E_Animal

R_Service_target Player

A_Policy & A_Coverage  Remove cd: vocabulary

AR_Supported_by

 Cardinality changed to 0..1

A_Adjudication_result  effective_time: unbolded – optional

AR_Authorized_by  Blocked path from A_coverage_confirmation

A_Injury_code_set  Removed as set can be establish by InjuryCode CD data type

A_Injury_coding  Changed cd: data type to CD with domain InjuryCode with WCB Canada external code specification. The code will be the nature of injury while the body part and side of body are modifiers.

A_Attachment  Added value: data type ED for attached content

DIM Changes v5.0 to v5.1 December 17 - 31, 2001

E_Product Renamed to E_Package

R_Maunfactured_product renamed to R_Product

R_Packaged_product renamed to R_Contains

A_Adjudication_result  Added cd domain specification CWE (coded with exception) as applies to external vocabulary

A_Adjudication_result  Added cd domains AdjudicationResult+ProductServiceBillableItem CWE

A_Adjudication_grouping  Added effective_time attribute to contain the date/time period the statement encompasses

A_Coverage_criteria_question  Added act to contain the coverage inquiry code

A_Invoice_element_group + A_Invoice_element_detail  Added descriptions and note to indicate how data center/sequence numbers are to be included for the invoice elements

A_Coverage_criteria  Added effective_date and txt attributes to accommodate the answers to the coverage inquiry questions (e.g. date of last eye exam, optional text to fully describe answer)

A_Billable_act Changes v5.0 to v5.1 December 17, 2001

Product references were removed

Location CMET has added note indicating that the location identifier is used for the Diagnostic Approval Number and the Claim Centre Number if required

DIM Changes v5.1 to v5.2 January 15 - 18, 2002

P_Attention, R_Recipient_contact Moved to right side of A_Payment_request

Constraint on A_Invoice_element_group changed to refer to all relationships from all act relationships

Constraint on AR_Invoice_element_covered_by added to ensure this relationship exists on the root act

AR_Covered_by removed from between A_Coverage_confirmation and A_Policy

A_Coverage_confirmation_request and associated classes moved to left side of the diagram

A_Coverage_confirmation_request joined to A_Billable_act by AR_Coverage_for

AR_Justified_by renamed to AR_Supported_by

A_Invoice_element_group mood_cd has added code value of INT when used in authorization request

A_Coverage_criteria attributes are extended to include the A_Related_invoice_element attributes which was then removed. The AR_Limited_by renamed to AR_Terms_conditions with type_cd PERT added. AR_Criteria_components was added to allow components of criteria or related products/services. AR_Payor added to A_Coverage_confirmation_request.

EntryPoint identifiers changed to FICR

A_Billable_act Changes v5.1 to v5.2 January 15 - 18, 2002

 Outstanding Questions (and Resolutions)

1.  Question Living subject Mother Role & Mother_subject

[CM 10/18] Resolved -unnecessary given the availability of Person.Mothers_Maiden_Name. It was noted that this element is not actually attributed to a person as mother of subject; rather it is a string used as one of several criteria to differentiate subject person's identity. Supposedly Canada, among others, may use a name part other than mother's maiden. It was suggested that a harmonization proposal may be in order to rename this element to more accurately reflect its use and possibly restructured it as a name-pair with qualifier type and string.

[MvC 10/19] Actually, it has been since clarified that we do in fact need Mother’s Name (not maiden name) for newborns. The use case is for First Nations newborns. They typically will not have an identifier, but are covered under their Mother’s coverage. They need to identify the Service_target (the newborn) and the name of the Mother when a claim is submitted. Not sure if there is a requirement for the Mother’s identifier, as well as name.

However, if one thinks outside the current use case, it is quite conceivable that we could identify other family members other than the mother. In Quebec, the father plays an equally important role to the mother when identifying children. Therefore, to make this generic to any familial relationship will be a good thing (leave it with me!).

Now, to the somewhat sticky point of Mothers_Maiden_Name in the RIM. Lloyd McKenzie has questioned this attribute (and I kinda agree with him) and suggests that this be modeled as a relationship (with Relationship.cd = “MTH”) to a person. I believe he is proposing to the next RIM harmonization meeting that this attribute be removed from the RIM. Let’s discuss at our next call.

[MvC 10/31] Fixed in v4.7. The relationship is still required, but to a Parent_or_Guardian role/entity, as it may be a mother, father or guardian that needs to be noted for a Patient (Living_subject) that is a baby who needs a parent or guardian for identification.

2.  Why Service_target id:

[MvC 10/31] Removed. Use Person (Living_subject) id for patient identifiers.

3.  Do we need cd for Payment_request & Payment_intent

[CM 10/18] We did identify the attribute in question and contend that it may be construed as redundant given the Act.class_cd. However, the RIM indicates that it serves to clarify or further define administrative acts in which case such redundancy is acceptable. It was observed that the Act.cd in this case might be used to define format variances by realm. For example, Payment_intent for healthcare services provided in the US must be in the form of an X12N 835 transaction. This is not the case in Canada or elsewhere.

[MvC 10/19] This CD should be used to identify the type of Payment_request or Payment_intent. I have yet to figure out how we could use this. I suggest we remove for now,as we need to identify a vocabulary if it is included :o)

[MvC 10/31] Removed. Can be added if a use case is identified for these elements.

4.  How specify item quantity, pricing and % adjustments in Invoice_element_detail

[MvC 10/31] Michael will bring this to the MnM list server, as this is a data type question.

[MvC 11/16] See RIM Proposal #2.

5.  Do we need only one of the two class_cd for Invoice_element_summary and Invoice_element_group (i.e. INVE or INFINVE)

[MvC 10/31] Invoice_element_summary and Invoice_element_group has only 1 class code, of INFINVE (Information Invoice Element), whereas the Invoice_element_detail can be an INVE (Invoice Element) or INFINVE.

6.  When would the covered_party player be a group?

Not required. Add

7.  How will we specify a benefit group? Either a suite of Message Types or Interaction Ids has been suggested.

[MvC 11/16] Benefit Group will be specified as Invoice_element_summary.cd. This attribute used to be Invoice Type (e.g. Fee for Service, Contract, Block, Information), which will now be manifested in different message types.

8.  What should we use for message routing? The Benefit Group can map to message control Attention_to.cd AND to Invoice_element_summary.cd. Message types can be for multiple benefit groups.

See TAG notes -

9.  What is the relationship between the patient (Service_target) and Insured (Covered_party) and/or Policy_holder? Currently, there are no formal relationships noted in the e-Claims DMIM. Should there be?

Not required.

RIM Harmonization Proposals

RIM Changes  C06_Nov_01: Remove Gross_qty from Invoice_element class  C06_Nov_02: Data type changes for Item_nbr & Item_qualifier_cd & unit_qty  C06_Nov_03: Remove Covered_party ROLE, as the attributes (handicap_cd, student_ind) are in the _CoverageReason vocabulary for Covered_party.cd  C06_Nov_04: Remove Payment_terms_cd in Financial_transaction (retain it in Financial_contract)

Vocabulary  New ParticipationType code “ATT” = attention. Note: could also use CBC – call back contact.

DEFINITION: A participation indicating the participant is a contact for a particular act.

 New ActRelationship code “SUMM” = summarized by.

DEFINITION: An act that contains summary values for a list or set of subordinate acts. For example, a summary of transactions for a particular accounting period.

 Add RoleClass code “WARR” = warranty.

DEFINITION: A role a product plays when a guarantee is given to the purchaser by a company stating that a product is reliable and free from known defects and that the seller will, without charge, repair or replace defective parts within a given time limit and under certain conditions.

 Add RoleClass code “GUARD” = guardian.

DEFINITION: One who is legally responsible for the care and management of the person or property of an incompetent or a minor.

 Add RoleClass code “MTH” = mother.

DEFINITION: A female parent of a child.

 Add RoleClass code “FTH” = father.

DEFINITION: A male parent of a child.

 Change domain for Adjudication_result.reason_cd = _AdjudicationResultReason + _AdjudicationResultInformationReason (remove plural) – hold for now, as this domain does not appear to be in the RIM(?)

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