Mapping Adjudicated Claims and Encounter Information

Health plans are required to map claims and clinical information for a member to US Core v3.1.1 FHIR Resources based on R4.

Mapping is also required when data is exchanged between systems. The Da Vinci Payer Data Exchange (PDex) exchanges are centered around Members/Patients. FHIR Platforms generate their own IDs when creating resources. Consequently, a Patient resource in one system can have a different FHIR Resource ID than a Patient in another system. When a bundle of resources is retrieved from a health plan’s FHIR API it will be necessary to map identifiers to determine whether a record in the target system needs to be updated or created.

Links to tables are provided in the following sections to assist implementers in mapping adjudicated claims data represented in the Consumer-Directed Payer Data Exchange IG (CARIN for Blue Button^®) to clinical resources that may be exchanged as part of workflows identified in the Da Vinci Payer Data Exchange IG (PDex). These tables identify the source profile element and the associated Common Payer Consumer Data Set (CPCDS) mapping.

The column definitions for these mapping tables are provided below.

US Core Element	MustSupport	Cardinality	CARIN-BB Element	CPCDS Element Mapping or Implementer Note
The Element name in the target Profile. e.g. Coverage.meta.lastUpdated	S indicates a Must Support Element	Defines the cardinality of the target element	The CARIN-BB source element name	The Mapping Element ID from the CARIN-BB CPCDS mapping document and the associated mapping element name [{“163”:”Coverage Last Updated Date”}]

Note: Regardless of the way in which payers store their administrative and clinical information, they will need to map it appropriately to these profiles.

The following links open various tables that provide these mappings from CARIN for Blue Button^® to fields in the respective clinical (US Core and PDex) profiles.

US Core CareTeam (4.3.3)

When a health plan has access to information about the CareTeam for a member, they need to make that information available using the United States Core Data for Interoperability (USCDI) CareTeam resource.

The CareTeam resource for the US Core identifies the care team members associated with a patient. It identifies which core elements, extensions, vocabularies, and value sets are present in the resource when using this profile.

• US Core CareTeam mapping

This profile supports searches using the combination of the patient and status search parameters, including support for composite OR search on status:

For example:

US Core Condition (4.3.4)

This profile sets minimum expectations for the Condition resource to record, search, and fetch a list of conditions associated with a patient. It identifies which core elements, extensions, vocabularies, and value sets are present in the resource when using the US Core Condition profile.

• US Core Condition mapping

This profile supports searches or all conditions including problems, health concerns, and encounter diagnosis for a patient using the patient search parameter. This search parameter is mandatory.

For example:

For a list of optional search parameters, see StructureDefinition-us-core-condition .

US Core Encounter (4.3.10)

This profile sets minimum expectations for the Encounter resource to record, search, and fetch basic encounter information for an individual patient. It identifies which core elements, extensions, vocabularies, and value sets are present in the resource when using the US Core Encounter profile.

The following search parameters and search parameter combinations are mandatory.

For a list of optional search parameters, see StructureDefinition-us-core-encounter .

US Core Patient (4.3.20)

The US Core Patient profile is used to express a member’s demographic information.

This profile sets minimum expectations for the Patient resource to record, search, and fetch basic demographics and other administrative information about an individual patient. It identifies which core elements, extensions, vocabularies, and value sets are present in the resource when using the US Core Patient profile.

The following search parameters and search parameter combinations are mandatory.

For a list of optional search parameters, see StructureDefinition-us-core-patient .

US Core Procedure (4.3.26)

This profile sets minimum expectations for the Procedure resource to record, search, and fetch procedures associated with a patient. It identifies which core elements, extensions, vocabularies, and value sets are present in the resource when using the US Core Procedure profile.

The following search parameters and search parameter combinations are mandatory.

For a list of optional search parameters, see StructureDefinition-us-core-procedure .

US Core Laboratory Result Observation (4.3.14)

This profile sets minimum expectations for the Observation resource to record, search, and fetch laboratory test results associated with a patient/member. It identifies which core elements, extensions, vocabularies, and value sets are present in the resource when using the US Core Laboratory Result Observation profile.

The following search parameters and search parameter combinations are mandatory.

Coverage (4.3.5)/HRexCoverage (9.15.1)

The Coverage resource is profiled in the Da Vinci Health Record Exchange (HRex) IG.

The HRexCoverage Profile defines the constraints for representing a member’s healthcare insurance information to the payer. Coverage instances complying with this profile, sometimes together with the Patient which this profile references via beneficiary, allows a payer to identify a member in their system.

The HRexCoverage structure is derived from the FHIR R4 Coverage resource.

• HRexCoverage Terminology Bindings (9.15.1.1.1)
• HRexCoverage Constraints (9.15.1.1.2)

Note: If the member identifier (using Coverage.identifier) is known, it should be sent, since this uniquely identifies a covered individual. If not known, the Coverage.subscriberId can be used together with demographic information found by resolving Coverage.beneficiary to identify the member.

PDex MedicationDispense (4.3.17)

The Da Vinci PDex MedicationDispense profile is used to record a member’s prescription drug claims.