CARIN Blue Button Framework and Common Payer Consumer Data

CARIN Blue Button Framework and Common Payer Consumer Data Set EMPOWERING CONSUMERS WITH THEIR HEALTH PLAN DATA

Our Template : The Argonaut Project Background: The Argonaut Project was formed in December 2014 as an implementation community comprising leading technology vendors and provider organizations to accelerate the use of FHIR and OAuth in health care information exchange. The Argonaut project is private-sector initiated and funded and works collaboratively with other FHIR initiatives to create open industry Implementation Guides in high priority use cases of importance to patients, providers and the industry as a whole. Deliverables: Focused on the ONC’s 2015 Edition Common Clinical Data Set (CCDS) to co-develop the SMART App Application Guide using the OAuth 2.0 profile for authorizing apps to access FHIR data and the Argonaut Data Query Implementation Guide (FHIR DSTU2). Timeline: As of October 2018: IG Publication – Mid 2016 (1 ½ years) 82% of all Hospitals using 2019 LEAVITT PARTNERS 2

Why do we need more ‘Argonaut-like’ efforts? Standards development process, by design, values comprehensiveness over speed-to market Market input is needed to make standards relevant and usable Identification of priority use cases to meet market needs Development of well-packaged implementation guides Facilitation of testing and implementation community Coupling with other standards or protocols needed for implementation (e.g., security) Implementers need to have greater input (i.e., deeper, earlier) into standards development Need to get as much collaboration as early as possible in the cycle to head off problems of heterogeneous implementations down the road Consumer platform companies have the ability to scale standards 2019 LEAVITT PARTNERS 3

CARIN Blue Button Framework Leverage the Argonaut Project as a best practice approach Common Payer Consumer Data Set (CPCDS) Includes key health data that should be accessible and available for exchange. Data must conform with specified vocabulary standards and code sets. CPCDS data elements can be stored and queried as profiled FHIR resources. Data Query Profiles Based on CPCDS, define the minimum mandatory elements, extensions and terminology requirements that must be present in the FHIR resource. Data Query Implementation Guide Collection of security specifications, profile definitions and supporting documentation. The guide satisfies use cases for member access to health plan data, ensuring the CPCDS elements are included and modeled in a standard format. Flat File Format Specification Representing CPCDS Data Elements Mapping From Flat File Format To FHIR Resource Profiles 2019 LEAVITT PARTNERS 4

Argonaut & CARIN Blue Button Framework Argonaut Project CARIN Blue Button Framework Logical Data Specification Common Clinical Data Set (CCDS) Common Payer Consumer Data Set (CPCDS) Physical Data Specification Using FHIR (Data Query) FHIR Resource Profiles Representing CCDS Data Elements FHIR Resource Profiles Representing CPCDS Data Elements Physical Data Specification Using Flat File None Flat File Format Specification Representing CPCDS Data Elements Document Query DocumentReference Profile Exposing Patient’s Existing Clinical Document None Flat File to FHIR Translation Not Applicable Mapping From Flat File Format To FHIR Resource Profiles Authorization SMART on FHIR SMART on FHIR/OAuth2 2019 LEAVITT PARTNERS 5

BB 2.0 API Using CARIN Blue Button Framework How can Plans leverage the CARIN Blue Button Framework? 1. Map directly to FHIR Profiles Create a direct mapping from the Claims SOR to FHIR Profiles. 2. Map to FHIR Profiles using Flat File as a bridge Generate Flat File extracts from the Claims SOR using existing ETL tools and processes. Leverage CARIN Framework’s common mapping from Flat File format to FHIR Profiles. Sharing and reuse of direct mappings from some Claims SORs in option 1 may be limited due to license restrictions or varying versions, configurations or hosting implementations. Option 2’s bridge mapping introduces additional step & 2019 LEAVITT PARTNERS 6

CARIN Blue Button Framework with CPCDS Consumer Apps Health Plan Covered Entities/BAs Health Plan A Clai Custo Health Plan B ms SOR1 m CSV Facet s v4 Data Hub A ClaiPlan C Health Multi-plan Data Warehouse ms SOR 2 Health Plan Face D Clai ts v3 ms SOR 3 CPCD S Flat File Format Mappings & Terminolo gies FHIR Extensions, Profiles & Implement ation Guides App A FHIR Server App B FHIR Profiles CARIN Blue Button Framework App Z ClaiPlan Z Health ms SOR 4 Medicare CC FHI W R RIF 2019 LEAVITT PARTNERS CPCDS – Common Payer Consumer Data Set (Claims, Eligibility, Benefits) Mapping Key Covere d Entity/B A SOR – System of Record CMS BB 2.0 HIPAA Individual Right of Access API 7

Deliverables 1. Define how to meet CMS Blue Button 2.0 a) Define the logical data set (similar to ONC 2015 Edition Common Clinical Data Set) that meets CMS Blue Button 2.0 API content – Common Payer Consumer Data Set (CPCDS) version 1.0 b) Define the FHIR Resource Profiles that map to CPCDS version 1.0 data elements 2. Define next versions that exceed CMS Blue Button 2.0 3. Define Flat File Bridge a) Define Flat File format specification representing logical CPCDS data elements b) Define mapping from Flat File format to FHIR Resource Profiles 4. Define the checklist for launching the CARIN Blue Button Framework a) Implementation Guide & Profiles b) Flat File specification & mapping c) Test harness 2019 LEAVITT PARTNERS 8

Common Payer Consumer Data Set (CPCDS) v1.0 CMS Medic are Blue Button 2.0 API HCCI Healt h Plan #1 Healt h Plan #2 2019 LEAVITT PARTNERS Data Element Consensus CPCDS v1.0 Mee ts Exceeds In March 2018, CMS launched Blue Button 2.0, which provides secure beneficiary-directed data transport in a structured Fast Healthcare Interoperability Resources (FHIR) format that is developer-friendly. This will enable beneficiaries to connect their data to applications, services, and research programs they trust. Blue Button 2.0 uses open source code that is available for all plans at https://bluebutton.cms.gov/developers / . In February 2019, CMS issued the Interoperability and Patient Access Proposed Rule. Under this proposal, the scope and volume of the 9 information to be provided or made

Two Implementation Paths To Blue Button 2.0 API (FHIR Profiles) Health Plan/Data Holders Plan1 (SOR1 Claims Data Model) Plan2 (Facets v4 Claims Data Model) CARIN Blue Button Framework Common Payer Consumer Data Set (CPCDS) CARIN Flat File Implementation Guide CARIN Data Query Implementation Guide Plan1 SOR1 Data Query Implementation Guide Data Query FHIR Profiles Plan2 Facets Data Query Implementation Guide Plan2 Facets Flat File Implementation Guide Plan3 (SOR3 Claims Data Model) 2019 LEAVITT PARTNERS Plan3 SOR3 Flat File Implementation Guide CARIN Mapping Flat File (Bridge) Specification 10

Proposed Common Payer Consumer Data Set (CPCDS) v1.0 – Draft

Claim # CPCDS Element Reference CMS Medicare BB 2.0 Element 1 Claim service start date CLM FROM DT 2 Claim service end date CLM THRU DT 2019 LEAVITT PARTNERS Description [institutional] The first day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers From Date’). [non-institutional] Earliest of any of the line-item level dates. It is almost always the same as Claim Service End Date except for DME claims - where some services are billed in advance. [institutional] The last day on the billing statement covering services rendered to the beneficiary (i.e. 'Statement Covers Thru Date’) [non-institutional] The latest of any of the lineitem level dates # 3 4 CPCDS Element Claim paid date Claim received date Reference CMS Medicare BB 2.0 Element Description PD DT NCH WKLY PROC DT 5 Member admission date CLM ADMSN DT 6 Member discharge date NCH BENE DSCHRG DT [inpatient] The date corresponding with admission of the beneficiary to a facility and the onset of services. May precede the Claim Service Start Date if this claim is for a beneficiary who has been continuously under care. [inpatient] Date the beneficiary was discharged from the facility, or died. Matches the Claim Service End Date. When there is a discharge date, the Patient Discharge Status Code indicates the final disposition of the patient after discharge. 12

Claim # 7 8 9 10 11 12 13 14 15 16 17 CPCDS Element Patient account number Medical record number Claim unique identifier Claim adjusted from identifier Claim adjusted to identifier Claim diagnosis related group Reference CMS Medicare BB 2.0 Element Description Provider submitted information that can be included on the claim CPCDS Element 18 19 Claim processing status code Claim type code CLM ID prior replaced CLM DRG CD [inpatient] [inpatient] UB-04 Claim inpatient source Source of Admission admission code CLM SRC IP ADMSN CD code (FL-15) [inpatient] UB-04 Type Claim inpatient admission type of Admission/Visit (FLcode CLM IP ADMSN TYPE CD 14) UB-04 Type of Bill (FL-4) structure – Type of Claim bill facility type code CLM FAC TYPE CD facility Claim service classification type CLM SRVC CLSFCTN TYPE UB-04 Type of Bill (FL-4) code CD structure – Type of care UB-04 Type of Bill (FL-4) structure – Sequence in Claim frequency code CLM FREQ CD this episode of care 2019 LEAVITT PARTNERS # Claim sub type code 20 Patient discharge status code 21 22 Claim payment denial code Claim primary payer identifier 23 24 Claim payee type code Claim payee 25 Claim payment status code 26 Claim payer identifier Reference CMS Medicare BB 2.0 Element NCH CLM TYPE CD NCH NEAR LINE REC IDE NT CD Description active, cancelled Medical, vision, oral, etc [facility] The patient’s status as of the “Through” date of the PTNT DSCHRG STUS CD billing period The code on a noninstitutional claim indicating to whom payment was made or if the claim was denied / The reason that no payment is made for CARR CLM PMT DNL CD services on an / institutional claim. CLM MDCR NON PMT R (CARC/RARC, excd SN CD disallowed code) NCH PRMRY PYR CD Recipient of benefits payable Recipient reference paid, denied, partiallypaid Adjudicating payer that has generated this EOB 13

Claim # CPCDS Element Reference CMS Medicare BB 2.0 Element Description # CPCDS Element Drug 1 2 Days supply DAYS SUPLY NUM RX service reference number RX SRVC RFRNC NUM 3 DAW product selection code DAW PROD SLCTN CD 4 Refill number FILL NUM 5 Prescription origin code RX ORGN CD 2019 LEAVITT PARTNERS Number of days' supply of medication dispensed by the pharmacy Assigned by the pharmacy at the time the prescription is filled Prescriber's instruction regarding substitution of generic equivalents or order to dispense the specific prescribed medication The number fill of the current dispensed supply (0, 1, 2, etc) Whether the prescription was transmitted as an electronic prescription, by phone, by fax, or as a written paper copy 6 Plan reported brand-generic code 7 Pharmacy service type code 8 Patient residence code Reference CMS Medicare BB 2.0 Element Description Whether the plan adjudicated the claim as a brand or generic BRND GNRC CD drug Type of pharmacy that dispensed the PHRMCY SRVC TYPE CD prescription Where the beneficiary lived when the PTNT RSDNC CD prescription was filled 14

Claim # CPCDS Element Reference CMS Medicare BB 2.0 Element Description Provider 1 2 3 4 5 6 6 8 9 10 Claim billing provider NPI Claim billing provider network status CARR CLM BLG NPI NUM contracted noncontracted Physician who has overall responsibility for the beneficiary's care and treatment Claim attending provider NPI AT PHYSN NPI [institutional] Claim attending provider contracted nonnetwork status contracted The service location NPI will not be on the claim if it is the same CARR CLM SOS NPI NUM as the billing provider Claim site of service NPI , SRVC LOC NPI NUM NPI Claim site of service network contracted nonstatus contracted CARR CLM RFRNG PIN N Claim referring provider NPI UM Claim referring provider network contracted nonstatus contracted PRF PHYSN NPI, Rendering/servicing/ OP PHYSN NPI, operating/prescribing Claim performing provider NPI RNDRNG PHYSN NPI providerpharmacist Claim performing provider contracted nonnetwork status contracted 2019 LEAVITT PARTNERS # 11 CPCDS Element 12 Claim prescribing provider NPI Claim prescribing provider network status 13 Claim PCP NPI Reference CMS Medicare BB 2.0 Element Description Prescribing provider contracted noncontracted 15

Claim # CPCDS Element Reference CMS Medicare BB 2.0 Element Description Amounts 1 2 3 4 5 6 7 8 9 10 Submitted charge Claim total submitted amount CLM TOT CHRG AMT amount NCH CARR CLM ALOWD A Claim total allowed amount MT Includes all copayments, coinsurance, deductible, or other patient payment Amount paid by patient PTNT PAY AMT amounts [pharmacy] CARR CLM PRMRY PYR PD Claim amount paid to provider AMT Member reimbursement NCH CLM BENE PMT AMT Claim payment amount CLM PMT AMT By Payer Claim disallowed amount NCH IP NCVRD CHRG AMT Member paid deductible NCH BENE IP DDCTBL AMT NCH BENE PTA COINSRNC L Co-insurance liability amount BLTY AMT Copay amount 2019 LEAVITT PARTNERS # 11 12 CPCDS Element Member liability Claim primary payer paid amount Reference CMS Medicare BB 2.0 Element Description E.g. Non-contracted provider NCH PRMRY PYR CLM P D AMT 16

Claim Line # CPCDS Element Reference CMS Medicare BB 2.0 Element Description # Dispense/fill date (Rx) 8 9 Line Service Details 1 2 3 4 5 Service (from) date Line number Service to date Type of service Place of service code LINE 1ST EXPNS DT LINE NUM LINE LAST EXPNS DT LINE CMS TYPE SRVC CD LINE PLACE OF SRVC CD 6 Revenue center code REV CNTR 7 Number of units REV CNTR UNIT CNT 2019 LEAVITT PARTNERS The provider-assigned revenue code for each cost center for which a separate charge is billed (type of accommodation or ancillary) UB-04 Revenue Code (FL-42), Revenue Description (FL-43) Num of times service or procedure performed. UB-04 Units of Service (FL-46) CPCDS Element Allowed number of units National drug code 10 Compound code 11 Quantity dispensed 12 Quantity qualifier code Line network indicator benefit payment status Line claim payment denial code 13 14 Reference CMS Medicare BB 2.0 Element Description Maximum allowed number of units LINE NDC CD Whether or not the dispensed drug was CMPND CD compounded or mixed REV CNTR NDC QTY, Quantity dispensed for QTY DSPNSD NUM the drug The unit of REV CNTR NDC QTY QLFR measurement for the CD drug. (gram, ml, etc) in-network, out-ofnetwork, other 17

Claim Line # CPCDS Element Reference CMS Medicare BB 2.0 Element Description # CPCDS Element Reference CMS Medicare BB 2.0 Element Line Amount Details 1 2 3 4 5 Amount related to a revenue center code for Line disallowed charged REV CNTR NCVRD CHRG A services that are not amount MT covered Payment (reimbursement) made to the beneficiary related to the line item service on the nonLine member reimbursement LINE BENE PMT AMT institutional claim Amount paid by the beneficiary to the provider for the line REV CNTR PTNT RSPNSBLTY item service Line amount paid by patient PMT (outpatient) Price paid for the drug Drug cost TOT RX CST AMT excluding mfr discounts Amount that Payer is responsible for reimbursing for the line item on the nonLine allowed payment amount LINE NCH PMT AMT institutional claim 2019 LEAVITT PARTNERS 6 7 8 9 10 Line amount paid to provider LINE PRVDR PMT AMT LINE BENE PTB DDCTBL A Line patient deductible MT Line primary payer paid LINE BENE PRMRY PYR PD amount AMT Line coinsurance amount LINE COINSRNC AMT Line submitted amount LINE SBMTD CHRG AMT Description Actual payment made by Payer to the provider for the line item service on the noninstitutional claim. Additional payments may have been made to the provider including beneficiary deductible and coinsurance amounts and/or other primary payer amounts Provider submitted charges for the line item service on the non-institutional claim 18

Claim Line # CPCDS Element 11 Line allowed amount 12 13 14 Line member liability Line copay amount Line discounted rate 2019 LEAVITT PARTNERS Reference CMS Medicare BB 2.0 Element LINE ALOWD CHRG AMT Description Allowed charges for the line item service on the noninstitutional claim. This charge is used to compute pay to providers or reimbursement to beneficiaries. The amount includes both the line-item Payer and beneficiary-paid amounts (i.e. deductible and coinsurance) E.g. Non-contracted provider 19

Diagnoses & Procedures # CPCDS Element Reference CMS Medicare BB 2.0 Element Description # CPCDS Element Diagnosis (0-n) 1 2 3 4 Diagnosis code Diagnosis description Present on admission Diagnosis code type 5 Diagnosis type 6 Is E code 2019 LEAVITT PARTNERS Primary, 1-25 ICD DGNS E CD1 Description Procedure (0-n) PRNCPAL DGNS CD, ICD DGNS CD(1-25) CLM POA IND SW(1-25) ICD DGNS VRSN CD(1-25) Reference CMS Medicare BB 2.0 Element ICD 9 or ICD 10 primary, secondary, discharge, etc. External cause of injury code. For hospital and emergency department visits, E-codes are used in addition to the diagnostic codes. They can be used as “other diagnosis”. 1 Procedure code ICD PRCDR CD(1-25) 2 Procedure description 3 Procedure date 4 Procedure code type 5 Procedure type 6 Modifier Code -1 HCPCS 1ST MDFR CD 7 Modifier Code -2 HCPCS 2ND MDFR CD 8 Modifier Code -3 HCPCS 3RD MDFR CD 9 Modifier Code -4 HCPCS 4TH MDFR CD PRCDR DT(1-25) CPT/HCPCS/ICD-PCS primary, secondary, discharge, etc. 20

Member # CPCDS Element Reference CMS Medicare BB 2.0 Element 1 Member id BENE ID 2 Date of birth DOB DT 3 Date of death 4 County BENE COUNTY CD 5 State BENE STATE CD 6 Country 7 Race code 8 Ethnicity 9 Gender code 10 Name 11 Zip code 12 Relationship to subscriber 13 Subscriber id 2019 LEAVITT PARTNERS Description Unique identifier to member BENE RACE CD GNDR CD BENE MLG CNTCT ZIP CD 21

Coverage # CPCDS Element 1 Subscriber id 2 Coverage type 3 Coverage status 4 Start date 5 End date 6 Group id 7 Group name 8 Plan 9 Payer 2019 LEAVITT PARTNERS Reference CMS Medicare BB 2.0 Element Description 22

CPCDS Data Dictionary & Resource Mapping

Claim # CPCDS Element R4 Resource Profile Element 1 Claim service start date ExplanationOfBenefit .billablePeriod.start 2 Claim service end date ExplanationOfBenefit .billablePeriod.end 3 Claim paid date ExplanationOfBenefit 4 Claim received date .payment.date .claimReceived (Extension) .supportingInfo. {category “clmrecvddate”, timingDate} 5 Member admission date 6 Member discharge date ExplanationOfBenefit [ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.valueReference(Encou [.billablePeriod.start], nter)] [.period] [ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.valueReference(Encou [.billablePeriod.end], nter)] [.period] 7 Patient account number Patient .identifier 8 Medical record number Patient .identifier 9 Claim unique identifier ExplanationOfBenefit .identifier 10 Claim adjusted from identifier ExplanationOfBenefit .related.{relationship “prior”, reference} 11 Claim adjusted to identifier ExplanationOfBenefit .related.{relationship “replaced”, reference} 12 Claim diagnosis related group 13 Claim inpatient source admission code 14 Claim inpatient admission type code ExplanationOfBenefit .supportingInfo.{category “ms-drg”, code} [ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.valueReference(Encou [.supportingInfo.{category “admsrc”, code}], nter)] [.hospitalization.admitSource] [ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.valueReference(Encou [.supportingInfo.{category “admtype”, code}], nter)] [.type] 2019 LEAVITT PARTNERS 24

Claim # CPCDS Element R4 Resource 15 Claim bill facility type code ExplanationOfBenefit 16 Claim service classification type code ExplanationOfBenefit 17 Claim frequency code ExplanationOfBenefit .supportingInfo.{category “tob-typeoffacility”, code} .supportingInfo.{category “tob-billclassification ”, code} .supportingInfo.{category “tob-frequency”, code} 18 Claim processing status code ExplanationOfBenefit .status 19 Claim type code 20 Patient discharge status code 21 Claim payment denial code 22 Claim primary payer identifier ExplanationOfBenefit .type [ExplanationOfBenefit], [ExplanationOfBenefit.supportingInfo.valueReference(E [.supportingInfo.{category “discharge-status”, ncounter)] code}], [.hospitalization.dischargeDisposition] .adjudication.{category, ExplanationOfBenefit reason}.payment.adjustmentReason .insurance.{focal “false”, coverage(Coverage). ExplanationOfBenefit {payor(Organization).identifier, order 1}} 23 Claim payee type code ExplanationOfBenefit .payee.type 24 Claim payee ExplanationOfBenefit .payee.party 25 Claim payment status code ExplanationOfBenefit 26 Claim payer identifier ExplanationOfBenefit .payment.type .insurance.{focal “true”, coverage(Coverage). {payor(Organization).identifier, order 1 2}} 2019 LEAVITT PARTNERS Profile Element 25

Claim # CPCDS Element R4 Resource Profile Element Drug 1 Days supply 2 RX service reference number 3 DAW product selection code 4 Refill number 5 Prescription origin code 6 Plan reported brand-generic code 7 Pharmacy service type code 8 Patient residence code ExplanationOfBenefit.supportingInfo.{category, valueReference(MedicationDispense 1)} ExplanationOfBenefit.supportingInfo.{category, valueReference(MedicationDispense 1)} ExplanationOfBenefit.supportingInfo.{category, valueReference(MedicationDispense 1)} ExplanationOfBenefit.supportingInfo.{category, valueReference(MedicationDispense 1)} ExplanationOfBenefit.supportingInfo.{category, valueReference(MedicationDispense 1)} ExplanationOfBenefit.supportingInfo.{category, valueReference(MedicationDispense 1)} ExplanationOfBenefit.supportingInfo.{category, valueReference(MedicationDispense 1)} ExplanationOfBenefit.supportingInfo.{category, valueReference(MedicationDispense 1)} .daysSupply .identifier .substitution.{wasSubstituted, type, reason} .{type, quantity} ? .medicationReference(Medication3).isBrand .authorizingPrescription(MedicationRequest 2).di spenseRequest.performer(Organization).type .destination(Location) 1 – http://hl7.org/fhir/us/phcp/StructureDefinition/PhCP-MedicationDispense 2 – http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest 3 – http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication 2019 LEAVITT PARTNERS 26

Claim # CPCDS Element R4 Resource Profile Element Provider 1 Claim billing provider NPI ExplanationOfBenefit.entererprovider (PractitionerRoleOrganization) 2 Claim billing provider network status ExplanationOfBenefit 3 Claim attending provider NPI ExplanationOfBenefit 4 5 Claim attending provider network status Claim site of service NPI ExplanationOfBenefit ExplanationOfBenefit.facility(Location) 6 Claim site of service network status ExplanationOfBenefit 7 Claim referring provider NPI ExplanationOfBenefit 8 Claim referring provider network status ExplanationOfBenefit 9 Claim performing provider NPI ExplanationOfBenefit.provider(PractitionerRole) 10 11 Claim performing provider network status Claim prescribing provider NPI ExplanationOfBenefit ExplanationOfBenefit 12 Claim prescribing provider network status 13 PARTNERS Claim 2019 LEAVITT PCP NPI ExplanationOfBenefit ExplanationOfBenefit .identifier .supportingInfo. {category “billingnetworkcontractingstatus”, code} .careTeam.{sequence, provider(PractitionerRole).identifier, responsible “true”, role “supervising”} .supportingInfo. {category “attendingnetworkcontractingstatus” , code} .identifier .supportingInfo. {category “sitenetworkcontractingstatus”, code} .careTeam.{sequence, provider(PractitionerRole).identifier, role “referrer”} .supportingInfo. {category “referringnetworkcontractingstatus”, code} .careTeam.{sequence, provider(PractitionerRole).identifier, role “performing”} .supportingInfo. {category “performingnetworkcontractingstatu s”, code} .supportingInfo. {category “prescribingnetworkcontractingstatu s”, code} .careTeam.{sequence, provider(PractitionerRole).identifier, role “pcp”} 27

Claim # CPCDS Element R4 Resource Profile Element Amounts 1 Claim total submitted amount ExplanationOfBenefit .total.{category “submitted”} 2 Claim total allowed amount ExplanationOfBenefit .total.{category “eligible”} 3 Amount paid by patient ExplanationOfBenefit .total.{category “paidbypatient”} 4 Claim amount paid to provider ExplanationOfBenefit .total.{category “paidtoprovider”} 5 Member reimbursement ExplanationOfBenefit .total.{category “paidtopatient”} 6 Claim payment amount ExplanationOfBenefit .total.{category “benefit”} 7 Claim disallowed amount ExplanationOfBenefit .total.{category “noncovered”} 8 Member paid deductible ExplanationOfBenefit .total.{category “deductible”} 9 Co-insurance liability amount ExplanationOfBenefit .total.{category “coins”} 10 Copay amount ExplanationOfBenefit .total.{category “copay”} 11 Member liability ExplanationOfBenefit .total.{category “patientliability”} 12 Claim primary payer paid amount ExplanationOfBenefit .adjudication.{category “priorpayerbenefit”} 2019 LEAVITT PARTNERS 28

Claim Line # CPCDS Element R4 Resource Profile Element Line Service Details 1 Service (from) date ExplanationOfBenefit .item.servicedDate OR .item.servicedPeriod 2 Line number ExplanationOfBenefit .item.sequence 3 Service to date ExplanationOfBenefit .item.servicedPeriod 4 Type of service ExplanationOfBenefit .item.category 5 Place of service code ExplanationOfBenefit.item.locationReference(Location) .type 6 Revenue center code ExplanationOfBenefit .item.revenue 7 Number of units ExplanationOfBenefit 8 Allowed number of units ExplanationOfBenefit 9 National drug code ExplanationOfBenefit .item.quantity .item.adjudication.{category “units-allowed”, value} .item.productOrService OR .item.detail. productOrService 10 Compound code ExplanationOfBenefit .item.productOrService 11 Quantity dispensed ExplanationOfBenefit .item.detail.quantity 12 Quantity qualifier code ExplanationOfBenefit 13 Line benefit payment status ExplanationOfBenefit .item.detail.quantity .item.adjudication.{category “inoutnetwork”, reason} .item.adjudication.{category “denialreason”, 29 reason} 2019 LEAVITT PARTNERS 14 Line claim payment denial code ExplanationOfBenefit

Claim Line # CPCDS Element R4 Resource Profile Element Line Amount Details 1 Line disallowed amount ExplanationOfBenefit .item.adjudication.{category “noncovered”} 2 Line member reimbursement ExplanationOfBenefit .item.adjudication.{category “paidtopatient”} 3 Line amount paid by patient ExplanationOfBenefit .item.adjudication.{category “paidbypatient”} 4 Drug cost ExplanationOfBenefit .item.net 5 Line allowed payment amount ExplanationOfBenefit .item.adjudication.{category “benefit”} 6 Line amount paid to provider ExplanationOfBenefit .item.adjudication.{category “paidtoprovider”} 7 Line patient deductible ExplanationOfBenefit 8 Line primary payer paid amount ExplanationOfBenefit .item.adjudication.{category “deductible”} .item.adjudication. {category “priorpayerbenefit”} 9 Line coinsurance amount ExplanationOfBenefit .item.adjudication.{category “coins”} 10 Line submitted amount ExplanationOfBenefit .item.adjudication.{category “submitted”} 11 Line allowed amount ExplanationOfBenefit .item.adjudication.{category “eligible”} 12 Line member liability ExplanationOfBenefit .item.adjudication.{category “patientliability”} 13 Line copay amount ExplanationOfBenefit .item.adjudication.{category “copay”} ExplanationOfBenefit .item.adjudication.{category “discounted”} 2019 LEAVITT PARTNERS 14 Line discounted rate 30

Diagnoses # CPCDS Element R4 Resource Profile Element Diagnosis (0-n) ExplanationOfBenefit.diagnosis.diagnosisReference(Conditi on) ExplanationOfBenefit.diagnosis.diagnosisReference(Conditi on) .codediagnosis.diagnosisCodeableConcept.codin g.code .codediagnosis.diagnosisCodeableConcept.codin g.display 1 Diagnosis code 2 Diagnosis description 3 Present on admission 4 Diagnosis code type ExplanationOfBenefit .diagnosis.onAdmission ExplanationOfBenefit.diagnosis.diagnosisReference(Conditi .codediagnosis.diagnosisCodeableConcept.codin on) g.system 5 Diagnosis type ExplanationOfBenefit .diagnosis.type 6 Is E code ExplanationOfBenefit .diagnosis.type “external cause code” 2019 LEAVITT PARTNERS 31

Procedures # CPCDS Element R4 Resource Profile Element Procedure (0-n) 1 Procedure code 2 Procedure description 3 Procedure date 4 Procedure code type ExplanationOfBenefit.procedure.procedureReference(P rocedure) .code.coding.code ExplanationOfBenefit.procedure.procedureReference(P rocedure) .code.coding.display ExplanationOfBenefit.procedure.procedureReference(P rocedure) .performedPeriod ExplanationOfBenefit.procedure.procedureReference(P rocedure) .code.coding.system 5 Procedure type ExplanationOfBenefit .procedure.type 6 Modifier Code -1 ExplanationOfBenefit .item.modifier 7 Modifier Code -2 ExplanationOfBenefit .item.modifier 8 Modifier Code -3 ExplanationOfBenefit .item.modifier 9 Modifier Code -4 ExplanationOfBenefit .item.modifier 2019 LEAVITT PARTNERS 32

Member # CPCDS Element R4 Resource Profile Element 1 Member id Patient .identifier 2 Date of birth Patient .birthDate 3 Date of death Patient .deceasedDateTime 4 County Patient .address 5 State Patient .address 6 Country Patient 7 Race code Patient 8 Ethnicity Patient .address .extension (http://hl7.org/fhir/us/core/StructureDefinition/ us-core-race) .extension (http://hl7.org/fhir/us/core/StructureDefinition/ us-core-ethnicity) 9 Gender code Patient .gender 10 Name Patient .name 11 Zip code Patient .address 12 Relationship to subscriber Patient ? 13 Subscriber id Patient .identifier 2019 LEAVITT PARTNERS 33

Coverage # CPCDS Element R4 Resource Profile Element 1 Subscriber id Coverage .subscriberId 2 Coverage type Coverage .type 3 Coverage status Coverage .status 4 Start date Coverage .period 5 End date Coverage .period 6 Group id Coverage .class 7 Group name Coverage .class 8 Plan Coverage .class 9 Payer Coverage .payor 2019 LEAVITT PARTNERS 34

Terminology Bindings

ExplanationOfBenefit (Elements) # R4 Profile Element 1 2 3 5 6 .related.relationship .status .type .diagnosis.type .supportingInfo.category 7 .supportingInfo.code 2019 LEAVITT PARTNERS Code System Notes, [CMS Medicare BB 2.0/ResDAC] http://terminology.hl7.org/CodeSystem/ex-relatedclaimrela tionship http://hl7.org/fhir/explanationofbenefit-status http://terminology.hl7.org/CodeSystem/claim-type http://terminology.hl7.org/CodeSystem/ex-diagnosistype http://terminology.hl7.org/CodeSystem/claiminformationca tegory http://example.org/fhir/CodeSystem/ms-drg (version 36), Example Required Extensible Example Example Required, [https://www.cms.gov/Medicare/Medicare-Feehttp://example.org/fhir/CodeSystem/typeofbill-facility-type for-Service-Payment/AcuteInpatientPPS/MSDRG-Classifications-and-Software.html (version 2007-03-01), version 36], http://example.org/fhir/CodeSystem/typeofbill-serviceclassi [https://www.cms.gov/Medicare/CMS-Forms/ fication-type CMS-Forms/CMS-Forms-Items/ (version 2007-03-01), http://example.org/fhir/CodeSystem/typeofbill-frequency CMS1196256.html version 2007-03-01] UB-04 Type of Bill (FL-4) (version 2007-03-01) 36

ExplanationOfBenefit (Code Systems) # Code Display Definition http://terminology.hl7.org/CodeSystem/claim-type (version 4.0.1) 1 inpatient-facility 2 outpatient-facility 3 4 professional-nonclinician Professional or Non-clinician pharmacy Pharmacy 5 6 vision oral 2019 LEAVITT PARTNERS Vision Oral Claims generated for clinics, hospitals, skilled nursing facilities, and other institutions for inpatient services, including the use of equipment and supplies, laboratory services, radiology services, and other charges (CMS1450/UB-04 or 837-I). Claims generated for clinics, hospitals, skilled nursing facilities, and other institutions for outpatient services, including the use of equipment and supplies, laboratory services, radiology services, and other charges (CMS1450/UB-04 or 837-I). Claims generated for physicians, suppliers, and other non-institutional providers for both outpatient and inpatient services (CMS-1500 or 837-P) or claims with Level II HCPCS codes representing non-physician services like ambulance rides, wheelchairs, walkers, other durable medical equipment, and other medical services that are not identified by CPT-4/HCPCS Level I codes. Pharmacy claims for goods and services. Vision claims for professional services and products such as glasses and contact lenses. Dental, Denture and Hygiene claims. 37

ExplanationOfBenefit (Code Systems) # Code Display Definition http://terminology.hl7.org/CodeSystem/claiminformationcategory (version 4.0.1) cms-drg CMS DRGs CMS DRGs ms-drg Medicare Severity DRGs Medicare Severity DRGs r-drg Refined DRGs Refined DRGs ap-drg All Patient DRGs All Patient DRGs s-drg Severity DRGs Severity DRGs aps-drg All Patient, Severity-Adjusted DRGs All Patient, Severity-Adjusted DRGs apr-drg All Patient Refined DRGs All Patient Refined DRGs ir-drg International-Refined DRGs International-Refined DRGs 2 clmrecvddate Claim Received Date Claim received date 3 admsrc Source of Admission Source of Admission 4 admtype Type of Admission/Visit 5 tob-typeoffacility Type of Bill – Type of facility 10 tob-billclassification Type of Bill – Type of service provided to the beneficiary Type of Admission/Visit The first character from the three-digit code located on the CMS 1450/UB-04 claim form (FL-4) that describes the type of bill a provider is submitting to a payer The second character from the three-digit code located on the CMS 1450/UB04 claim form (FL-4) that describes the type of bill a provider is submitting to a payer The third character (i.e. sequence in this episode of care) from the three-digit code located on the CMS 1450/UB-04 claim form (FL-4) that describes the 38 1 2019 LEAVITT PARTNERS

ExplanationOfBenefit (Code Systems) # Code Display Definition http://example.org/fhir/CodeSystem/rx-origin-code (version 4.0.1) 1 0 Not Specified Not Specified 2 1 Written Written 3 2 Telephone Telephone 4 3 Electronic Electronic 5 4 Facsimile Facsimile 6 5 Pharmacy Pharmacy 2019 LEAVITT PARTNERS 39

Encounter (Elements) # R4 Profile Element 1 .hospitalization.admitSource.coding.code 2 .type.coding.code 3 .hospitalization.dischargeDisposition.coding.code 2019 LEAVITT PARTNERS Code System Notes, [CMS Medicare BB 2.0/ResDAC] Preferred, [https://www.cms.gov/Medicare/CMS-Forms/C MS-Forms/CMS-Forms-Items/ CMS1196256.html, version 2007-03-01] UB-04 http://terminology.hl7.org/CodeSystem/admit-source Source of Admission code (FL-15) Example, [https://www.cms.gov/Medicare/CMSForms/CMS-Forms/CMS-Forms-Items/ CMS1196256.html, version 2007-03-01] UB-04 http://terminology.hl7.org/CodeSystem/encounter-type Type of Admission/Visit (FL-14) Example, [https://www.cms.gov/Medicare/CMS-Forms/ CMS-Forms/CMS-Forms-Items/ CMS1196256.html, version 2007-03-01] UB-04 http://terminology.hl7.org/CodeSystem/discharge-dispositi Patient Status (FL-17) on 40

Encounter (Code Systems) # Code Display Definition http://example.org/fhir/CodeSystem/typeofbill-facility-type (version 2007-03-01) 2019 LEAVITT PARTNERS 41

MedicationDispense # R4 Profile Element Code System Notes, [CMS Medicare BB 2.0/ResDAC] 1 .substitution.type.coding.code http://hl7.org/fhir/v3/substanceAdminSubstitution Example 2 .substitution.reason.coding.code http://hl7.org/fhir/v3/ActReason Example 3 .type.coding.code http://hl7.org/fhir/v3/ActCode Example 2019 LEAVITT PARTNERS 42

Location # 1 R4 Profile Element .type.coding.code 2019 LEAVITT PARTNERS Code System http://terminology.hl7.org/CodeSystem/v3-RoleCode Notes, [CMS Medicare BB 2.0/ResDAC] Extensible, [https://bluebutton.cms.gov/resources/variables /clm fac type cd/] 43

Smart on Value @rryanhowells [email protected] @carinalliance www.carinalliance.com Offices in Salt Lake City, Chicago, and Washington, D.C. 801-538-5082 www.leavittpartners.com @LeavittPartners

Appendix 45

Health Plan Claims Extracts Health Plans send Claims data to their vendors and business associates under several use cases (care coordination, utilization management, predictive analytics) using a variety of custom, one-off, flat file extracts. No industry wide standard exists for Health Plans to send (adjudicated) Claims data to either Covered or Non-covered Entities. EDI X12 standards for Claims only exist for Providers’ HIPAAcovered transactions with Health Plans (i.e. Claim Submission – 837, Claim Acknowledgement – 277CA, and Payment/Remittance Advice – 835) Most Health Plans generate the flat file Claims extracts from their Claims System of Record (SOR) i.e. Claims Adjudication 2019 LEAVITT PARTNERS 46

EDI X12 and CPCDS Covered Entities/BAs Health Plan A Facets Provider A Provider B 27 0 837-I/CMS1450/ 837-P/CMS1500 UB04 EDI Clearinghouse v4 (EOB) Health Plan B Claims SOR1 (EOB) 27 1 99 277C 9 A 83 5 Data Hub A Multi-plan Data Warehouse (EOB) Health Plan Facets C v3 CPCD S FHIR Server CARIN Blue Button IG (FHIR Profiles) CARIN Blue Button Framework (EOB) Claims SOR2 (EOB) Health Plan D Claims SOR3 (EOB) 270 Eligibility & Benefits Inquiry 270 Eligibility & Benefits Response 837 Claims Submission 999 Claims Submission 277CA Individual Claim Acknowledgement 835 Electronic Remittance Acknowledgement Advice 2019 LEAVITT PARTNERS Key Covere d Entity/B A SOR Record EDI X12 Mappings Transactions System of 47

2019 LEAVITT PARTNERS CPCDS Comprehensive/Generic Oral Vision Pharmacy Professional/Non-Clinician Outpatient Facility Inpatient Facility EOB Optio n1 Oral Vision Pharmacy Professional/NonClinician Outpatient Facility Inpatient Facility CARIN BB IG Proposed EOB Profile Options Optio n2 Comprehensive/Generic CPCDS 48