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Content Format for Medical Claims

Content Format for Medical Claims

Blue Button files from health plans typically come from administrative claims databases, as well as potentially self-entered data on Personal Health Records.

Data made available to patients via Blue Button+ should be human-readable and formatted in a way that is “machine readable” for third party applications. This section includes recommended data elements and structure, and format options for providing that data to a patient.

To the extent that data holders already have useful and meaningful electronic health data for consumers' Blue Button files, including from administrative claims data, The followinging Data Fields are recommended for inclusion in the Blue Button+ files. The file should should be as consistent as possible – in both structure and content – with the Medicare Blue Button file (available here).

1. Sections

Text describing where these sections come from. Medicare data. X12 data.

Section Description Quick Link
Payer & Coverage Information ... Jump to Section
Patient Information ... Jump to Section
Claims ... Jump to Section

2. Breakdown of XML

Payer & Coverage Information {#payer}

Field Description Example
Name ... Medicare
Payer ID ... ...
Payer ID Type ... ...
Plan Name ... ...
Plan ID ... ...
Member Name ... ...
Member ID ... ...
Website ... ...

The following is the XML representation:

{% highlight xml %} Name of Insurance <payer_id>123456</payer_id> <payer_id_type>National Payer ID</payer_id_type> <plan_name>Name of Policy</plan_name> <plan_id>123456</plan_id> <member_id>W1234123456</member_id> <member_name>Name of Plan Member</member_name> http://yourinsurer.org {% endhighlight %}

Patient Information {#patient}

Field Description Example
Name ... Ellen Harrision Lu
Patient Identifier ... Member ID

The following is the XML representation:

{% highlight xml %} Ellen Harrison Lu <patient_identifier></patient_identifier> {% endhighlight %}

Claims Details {#claims}

There are two level of details for each claim.

  1. Summary of the claim
  2. Detailed breakdown of the claim

Summary of the Claim {#summary-of-claim}

Field Description Example
Claim Number ... ...
Type of Claim ... ...
Provider Details Name, Provider ID, Provider ID Type, Provider Billing Address ...
Date Start Date and End Date ...
Charges Price Billed, Insurance Approved, Insurance Paid, Patient Responsibility ...
Service Name of Service, Code System Name, Service Code ...
Diagnosis Name of Diagnosis, Code System Name, Diagnosis Code ...
Details See section below. ...

Claim Details {#claim-details}

The following is the XML representation:

Field Description Example
Start Date ... ...
End Date ... ...
Procedure Code ... ...
Procedure Description ... ...
Modifiers ... ...
Quantity ... ...
Price Billed ... ...
Insurance Approved ... ...
Patient Responsibility ... ...
Place of Service ... ...
Place of Service Code ... ...
Type of Service ... ...
Typer of Service Code ... ...
Rendering Provider Number ... ...
Rendering Provider NPI ... ...

{% highlight xml %} 0210336239290 Part B Inova Health Services <provider_id>123456789</provider_id> <provider_id_type>National Provider ID</provider_id_type> <provider_billing_address>601 OFFICE CENTER DRIVE FORT WASHINGTON, PA 19034</provider_billing_address> <start_date>20101102</start_date> <end_date>20101102</end_date> <price_billed>1022.5</price_billed> <insurance_approved>782.33</insurance_approved> <insurance_paid>625.86</insurance_paid> <patient_responsibility>156.47</patient_responsibility> Name of Service Provided <code_system_name>CPT</code_system_name> 28521 Name of Condition <code_system_name>CPT</code_system_name> 28521 Name of Condition <code_system_name>CPT</code_system_name> 5854

<start_date>20101102</start_date> <end_date>20101102</end_date> <procedure_code>A0428</procedure_code> <procedure_description>Description of Procedure</procedure_description> Additional details 1 <price_billed>275</price_billed> <insurance_approved>208.99</insurance_approved> <patient_responsibility>66.01</patient_responsibility> <place_of_service_code>41</place_of_service_code> <place_of_service>Ambulance - Land</place_of_service> <type_of_service_code>9</type_of_service_code> <type_of_service>Other Medical Services</type_of_service> <rendering_provider_number>Q335520003</rendering_provider_number> <rendering_provider_npi>1023062544</rendering_provider_npi>
<start_date>20101102</start_date> <end_date>20101102</end_date> <procedure_code>A0428</procedure_code> <procedure_description>Description of Procedure</procedure_description> Additional details 1 <price_billed>275</price_billed> <insurance_approved>208.99</insurance_approved> <patient_responsibility>66.01</patient_responsibility> <place_of_service_code>41</place_of_service_code> <place_of_service>Ambulance - Land</place_of_service> <type_of_service_code>9</type_of_service_code> <type_of_service>Other Medical Services</type_of_service> <rendering_provider_number>Q335520003</rendering_provider_number> <rendering_provider_npi>1023062544</rendering_provider_npi>
<start_date>20101102</start_date> <end_date>20101102</end_date> <procedure_code>A0425</procedure_code> <procedure_description>Description of Procedure</procedure_description> Additional details 44 <price_billed>472.5</price_billed> <insurance_approved>364.35</insurance_approved> <patient_responsibility>108.15</patient_responsibility> <place_of_service_code>41</place_of_service_code> <place_of_service>Ambulance - Land</place_of_service> <type_of_service_code>9</type_of_service_code> <type_of_service>Other Medical Services</type_of_service> <rendering_provider_number>Q335520003</rendering_provider_number> <rendering_provider_npi>1023062544</rendering_provider_npi>
{% endhighlight %}

Prescription Claims {#prescription-claim}

Claims for prescriptions.

Field Description Example
Claim ... ...
Type ... ...
Pharmacy Name, Provider ID, Provider ID Type, Provider Billing Address ...
Date ... ...
Drug Name, Code System Name, Code, Fill Number, Days Supply ...
Prescriber Identifier and Name ...

The following is the XML representation:

{% highlight xml %} 000000123456 Part D Costco Pharmacy <provider_id>1234567891</provider_id> <provider_id_type>National Provider ID</provider_id_type> <provider_billing_address>601 FIRST STREET, FORT WASHINGTON, PA 19034</provider_billing_address> 20071002 OXISTAT <code_system_name>RxNorm</code_system_name> 00462035860 <fill_number>0</fill_number> <days_supply>30</days_supply> 1111111111 Harvey, A. McGehee {% endhighlight %}