ExplanationOfBenefit not conformant with FHIR R4?

[Brendan Keeler]

Hi there,

We are live in production and noticing that ExplanationOfBenefit payloads are failing FHIR validation.

ExplanationOfBenefit in FHIR R4 requires the provider element:

This is present in sample data, such as BB00001:

    "provider": {
      "reference": "#provider-org"
    },

However, it seems to be missing in production. Have others noticed this issue?

[Kirsten Hansen]

Hi Brendan,

Historically, eob.provider was missing from Part B claims. This was corrected in the beginning of this year (2023). Part B claims older than February 2023 may not have the information. All Part A and D claims should contain eob.provider.  We can look into your case further if you share the claim type and date range that is missing eob.provider data. 

As a reminder, please DO NOT share production claims data over email, just the claim type and date range or specific date of the claim. 

Thank you, 

Kirsten Hansen, Product Manager

The Blue Button 2.0 API Team

[Brendan Keeler]

Thanks Kirsten. So this means that Blue Button resources older than 2023 will be invalid FHIR? Does the CMS have any plans to correct this or are applications expected to normalize this?

Are there any recommended behaviors here? Should we add EOB.provider.reference.display = 'Unknown'? Should we copy the provider from a certain sequence or role in the EOB.careTeam?

[Kirsten Hansen]

Brendan,

We’ve talked with our upstream data source team (The Beneficiary FHIR Data Server) and they confirmed that data prior to the fix will not be present, as this data was not available from the upstream data source. However, we have put in a request to have the eob.provider field populated with ‘unknown’ or something similar, so that it will still be valid and return the field even if no data exists.  The default value population should be completed in the next couple weeks and we’ll confirm with you when it’s done. Thanks for bringing this to our attention and please keep the feedback and any bug reports coming.

Thanks, 

Kirsten Hansen, Product Manager

The Blue Button 2.0 API Team 

[Brendan Keeler]

Great, thanks Kirsten!

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Brendan Keeler

Flexpa | in | @ | Writing | c: 503-784-3456

[Kirsten Hansen]

Hi Brendan,

Wanted to update you that the work to have a default value for the EOB Carrier provider field has been completed. When data isn't present, it should populate with "UNKNOWN".

It will look like this when provider data doesn't exist:

... "provider" : { "identifier" : { "system" : "https://bluebutton.cms.gov/resources/variables/carr_clm_blg_npi_num", "value" : "UNKNOWN" } } ...

Kirsten Hansen

Product Manager

The Blue Button 2.0 API Team