"active" vs "cancelled" EOBs

[Jason Turan]

I have a question about the "status" field at the root of each EOB resource. From a claims payment perspective, can any EOB with a status of "cancelled" be ignored? For many of these cancelled EOBs, I still see an amount in the payment -> amount -> value section, so I'm a bit confused on if that's an amount that was actually paid, or if it would be the amount paid had the claim not been cancelled.

Assuming these EOBs can be ignored, do they represent rejected/denied claims? I see examples where a claim has been adjusted by CMS, so the original claim has a status of "cancelled" and the adjusted claim has a status of "active". I want to ensure I'm not double-counting certain claims and amounts in a patient's data.

Thanks,

Jason

[Jillian Theil]

Hi  Jason,

Thanks for your question. We are consulting with our upstream data provider and will get back to you with an answer as soon as possible.

Thanks,
Jillian Theil
- The Blue Button 2.0 Team

On Mon, Apr 1, 2024 at 4:18 PM Jillian Theil <jillia...@navapbc.com> wrote:

Hi Jason -

EOB claims are loaded into our upstream data provider, as a record of the fact that a claim is processed.  Given this, an application could interpret that when EOB.status = canceled, the payment element should be ignored even if there is a value, since the claim did not go out at all. 

Thanks,
Jillian Theil
-The Blue Button 2.0 API Team

--
You received this message because you are subscribed to the Google Groups "Developer Group for CMS Blue Button API" group.
To unsubscribe from this group and stop receiving emails from it, send an email to developer-group-for-cms-b...@googlegroups.com.
To view this discussion on the web visit https://groups.google.com/d/msgid/developer-group-for-cms-blue-button-api/563f7217-0def-4e9b-9403-022c052c6e7cn%40googlegroups.com.

[Jillian Theil]

Hi Jason,  

Apologies for the delayed reply and also for some issues we are having with the Google Group UI.  
 
To answer the first part of your question: “Can these claims be ignored?” Yes, these claims can be ignored if you are trying to just capture finalized claims at a given point in time (and it sounds like you are calculating costs as well, so in that case those costs can be ignored).
 
The second part of your question is a bit more complex. You asked “do they represent rejected/denied claims”? Not exactly. It would be more accurate to say that any claim with a ‘canceled’ status has been updated and that entry is no longer accurate for that claim. For most claims with a ‘canceled’ status in BB2.0, there will be another claim that has an ‘active’ status which is the current version of that claim.
 
The FHIR spec offers a set list of eob statuses that we are able to use, and we try to map those as close as possible to ‘active’ and ‘canceled’. However, for a technical definition from our upstream data provider, the CMS definitions are as follows:  
 
- Active claim = claim has a status of Final action and the claim is not voided
 
- Canceled claim = Subsequent adjustments to the claim exist or the final action was to void the claim
 
We hope that answers your question, let us know if you need more clarifications

Best,
Jillian Theil
- The Blue Button 2.0 API Team