Adjustments

[Luke Roth]

Hey All, 

From a recent pull (our first and only pull so far) we received three ExplanationOfBenefit entities that all had the same Claim Group ID (ExplanationOfBenefit.identifier[N].value).  When we receive multiple ExplanationOfBenefit entities with the same Claim Group ID, how should we determine which entity is the current or active entity, and which are historical or inactive entities?  We were under the impression that we would only be receiving the active/most current EOB.

Also, should we be receiving a separate cancellation EOB when we receive an adjustment EOB, and what cost values would the cancellation EOB contain?

Lastly, in post Reg: Claim adjustment/cancellation handling it was mentioned that "Typically, new versions of a claim from adjustments or cancellations would be added as a separate EOB record."  What exceptions or atypical behavior should we expect?

[Beneficiary Claims Data API (BCDA) Community]

Hello,

Thanks for the question about cancelled and adjusted claims.

The initial claim and any adjustments to that claim will be represented as separate EOB resources sharing a Claim Group ID. Each of the EOB resources for a claim will share a Claim Group ID, but have a unique Claim ID. For each Claim Group ID, there should only be one EOB resource with status as "active".

When an adjustment is made, the EOB.status of the existing resource is updated from "active" to "canceled", and a new EOB resource becomes available to represent the adjustment. The new EOB resource will have a new unique Claim ID, and share the Claim Group ID with the original EOB resource.

New versions of a claim from adjustments or cancellations are added as a separate EOB record as described above. Please let us know if you find otherwise, and we can collect more information via email to troubleshoot.

Thanks,
The BCDA Team

[Samantha Tushaus]

To follow up on this - the CCLF information packet, section 5.2.1 Related Claims in the Part A Header File, states that a set of related claims with the same natural key might contain two original claims. In BCDA, would that manifest as two "active" status claims with the same Claim Group ID?

[Beneficiary Claims Data API (BCDA) Community]

Thanks for the question.

We need to add a clarification that our previous response applies only to professional and Part D claims. For each Claim Group ID, there should only be one EOB resource with a status of "active". Claim Group ID should be used for grouping multiple iterations/revisions of a single claim. The Claim Group ID can't be used to connect multiple related claims for these claim types.

For institutional claims, you're correct. The Claim Group ID would link multiple related claims and could manifest as multiple "active" status EOB resources with a shared Claim Group ID.

Thanks,
The BCDA Team