Skip to content

Commit 6fa802a

Browse files
alex-dzedaalex-dzeda
authored
BFD-4229: Add Mapping + sample data for part D claims in v3 (#2766)
1 parent cf4d941 commit 6fa802a

23 files changed

Lines changed: 2260 additions & 70 deletions

‎apps/bfd-model/bfd-model-idr/StructureDefinitions/Source/ExplanationOfBenefit-Pharmacy.json‎

Lines changed: 558 additions & 0 deletions
Large diffs are not rendered by default.

‎apps/bfd-model/bfd-model-idr/StructureDefinitions/Source/LineItemComponent.json‎

Lines changed: 157 additions & 2 deletions
Original file line numberDiff line numberDiff line change
@@ -334,7 +334,8 @@
334334
{
335335
"id": "LineItemComponent.CLM_LINE_BENE_PD_AMT",
336336
"path": "LineItemComponent.CLM_LINE_BENE_PD_AMT",
337-
"label": "Claim Line Beneficiary Paid Amount",
337+
"label": "Beneficiary Paid Amount",
338+
"definition": "The amount paid by the beneficiary.",
338339
"min": 0,
339340
"max": "1",
340341
"type": [
@@ -439,6 +440,18 @@
439440
}
440441
]
441442
},
443+
{
444+
"id": "LineItemComponent.CLM_LINE_FROM_DT",
445+
"path": "LineItemComponent.CLM_LINE_FROM_DT",
446+
"label": "Line Item From Date",
447+
"min": 0,
448+
"max": "1",
449+
"type": [
450+
{
451+
"code": "date"
452+
}
453+
]
454+
},
442455
{
443456
"id": "LineItemComponent.CLM_LINE_ALOWD_CHRG_AMT",
444457
"path": "LineItemComponent.CLM_LINE_ALOWD_CHRG_AMT",
@@ -523,6 +536,19 @@
523536
}
524537
]
525538
},
539+
{
540+
"id": "LineItemComponent.CLM_LINE_GRS_ABOVE_THRSHLD_AMT",
541+
"path": "LineItemComponent.CLM_LINE_GRS_ABOVE_THRSHLD_AMT",
542+
"label": "Gross Drug Cost Above Out Of Pocket Threshold",
543+
"definition": "The gross drug cost amount that was covered by Part D's catastrophic coverage.",
544+
"min": 0,
545+
"max": "1",
546+
"type": [
547+
{
548+
"code": "string"
549+
}
550+
]
551+
},
526552
{
527553
"id": "LineItemComponent.CLM_LINE_ANSTHSA_UNIT_CNT",
528554
"path": "LineItemComponent.CLM_LINE_ANSTHSA_UNIT_CNT",
@@ -535,6 +561,19 @@
535561
}
536562
]
537563
},
564+
{
565+
"id": "LineItemComponent.CLM_LINE_GRS_BLW_THRSHLD_AMT",
566+
"path": "LineItemComponent.CLM_LINE_GRS_BLW_THRSHLD_AMT",
567+
"label": "Gross Drug Cost Below Out Of Pocket Threshold",
568+
"definition": "The gross drug cost amount that was not covered by Part D's catastrophic coverage.",
569+
"min": 0,
570+
"max": "1",
571+
"type": [
572+
{
573+
"code": "string"
574+
}
575+
]
576+
},
538577
{
539578
"id": "LineItemComponent.CLM_RNDRG_PRVDR_TAX_NUM",
540579
"path": "LineItemComponent.CLM_RNDRG_PRVDR_TAX_NUM",
@@ -547,6 +586,19 @@
547586
}
548587
]
549588
},
589+
{
590+
"id": "LineItemComponent.CLM_LINE_LIS_AMT",
591+
"path": "LineItemComponent.CLM_LINE_LIS_AMT",
592+
"label": "Low Income Cost Sharing Subsidy Amount",
593+
"definition": "The Low Income Cost Sharing Subsidy amount for the line item.",
594+
"min": 0,
595+
"max": "1",
596+
"type": [
597+
{
598+
"code": "string"
599+
}
600+
]
601+
},
550602
{
551603
"id": "LineItemComponent.CLM_RNDRG_PRVDR_NPI_NUM",
552604
"path": "LineItemComponent.CLM_RNDRG_PRVDR_NPI_NUM",
@@ -559,6 +611,19 @@
559611
}
560612
]
561613
},
614+
{
615+
"id": "LineItemComponent.CLM_LINE_TROOP_TOT_AMT",
616+
"path": "LineItemComponent.CLM_LINE_TROOP_TOT_AMT",
617+
"label": "Other True Out Of Pocket Paid Amount",
618+
"definition": "The Other True Out Of Pocket paid amount for the line item.",
619+
"min": 0,
620+
"max": "1",
621+
"type": [
622+
{
623+
"code": "string"
624+
}
625+
]
626+
},
562627
{
563628
"id": "LineItemComponent.providerSequence",
564629
"path": "LineItemComponent.providerSequence",
@@ -571,6 +636,19 @@
571636
}
572637
]
573638
},
639+
{
640+
"id": "LineItemComponent.CLM_LINE_PLRO_AMT",
641+
"path": "LineItemComponent.CLM_LINE_PLRO_AMT",
642+
"label": "Patient Liability Reduction Other Paid Amount",
643+
"definition": "The Patient Liability Reduction Other paid amount for the line item.",
644+
"min": 0,
645+
"max": "1",
646+
"type": [
647+
{
648+
"code": "string"
649+
}
650+
]
651+
},
574652
{
575653
"id": "LineItemComponent.CLM_LINE_RX_NUM",
576654
"path": "LineItemComponent.CLM_LINE_RX_NUM",
@@ -583,6 +661,19 @@
583661
}
584662
]
585663
},
664+
{
665+
"id": "LineItemComponent.CLM_RPTD_MFTR_DSCNT_AMT",
666+
"path": "LineItemComponent.CLM_RPTD_MFTR_DSCNT_AMT",
667+
"label": "Gap Discount Amount",
668+
"definition": "The reported manufacturer discount amount for the line item.",
669+
"min": 0,
670+
"max": "1",
671+
"type": [
672+
{
673+
"code": "string"
674+
}
675+
]
676+
},
586677
{
587678
"id": "LineItemComponent.CLM_LINE_FROM_DT",
588679
"path": "LineItemComponent.CLM_LINE_FROM_DT",
@@ -595,6 +686,19 @@
595686
}
596687
]
597688
},
689+
{
690+
"id": "LineItemComponent.CLM_LINE_INGRDNT_CST_AMT",
691+
"path": "LineItemComponent.CLM_LINE_INGRDNT_CST_AMT",
692+
"label": "Ingredient Cost Amount",
693+
"definition": "The ingredient cost amount for the pharmacy line item.",
694+
"min": 0,
695+
"max": "1",
696+
"type": [
697+
{
698+
"code": "string"
699+
}
700+
]
701+
},
598702
{
599703
"id": "LineItemComponent.CLM_LINE_MDCR_COINSRNC_AMT",
600704
"path": "LineItemComponent.CLM_LINE_MDCR_COINSRNC_AMT",
@@ -607,6 +711,19 @@
607711
}
608712
]
609713
},
714+
{
715+
"id": "LineItemComponent.CLM_LINE_SRVC_CST_AMT",
716+
"path": "LineItemComponent.CLM_LINE_SRVC_CST_AMT",
717+
"label": "Dispensing Fee",
718+
"definition": "The dispensing fee amount for the pharmacy line item.",
719+
"min": 0,
720+
"max": "1",
721+
"type": [
722+
{
723+
"code": "string"
724+
}
725+
]
726+
},
610727
{
611728
"id": "LineItemComponent.CLM_LINE_DGNS_CD",
612729
"path": "LineItemComponent.CLM_LINE_DGNS_CD",
@@ -619,6 +736,19 @@
619736
}
620737
]
621738
},
739+
{
740+
"id": "LineItemComponent.CLM_LINE_SLS_TAX_AMT",
741+
"path": "LineItemComponent.CLM_LINE_SLS_TAX_AMT",
742+
"label": "Sales Tax Amount",
743+
"definition": "The sales tax amount for the pharmacy line item.",
744+
"min": 0,
745+
"max": "1",
746+
"type": [
747+
{
748+
"code": "string"
749+
}
750+
]
751+
},
622752
{
623753
"id": "LineItemComponent.CLM_LINE_THRU_DT",
624754
"path": "LineItemComponent.CLM_LINE_THRU_DT",
@@ -631,6 +761,19 @@
631761
}
632762
]
633763
},
764+
{
765+
"id": "LineItemComponent.CLM_LINE_VCCN_ADMIN_FEE_AMT",
766+
"path": "LineItemComponent.CLM_LINE_VCCN_ADMIN_FEE_AMT",
767+
"label": "Vaccination Administration Fee",
768+
"definition": "The vaccination administration fee amount for the pharmacy line item.",
769+
"min": 0,
770+
"max": "1",
771+
"type": [
772+
{
773+
"code": "string"
774+
}
775+
]
776+
},
634777
{
635778
"id": "LineItemComponent.CLM_POS_CD",
636779
"path": "LineItemComponent.CLM_POS_CD",
@@ -643,6 +786,19 @@
643786
}
644787
]
645788
},
789+
{
790+
"id": "LineItemComponent.CLM_PRCNG_EXCPTN_CD",
791+
"path": "LineItemComponent.CLM_PRCNG_EXCPTN_CD",
792+
"label": "Pricing Exception Code",
793+
"definition": "The pricing exception code indicating network status.",
794+
"min": 0,
795+
"max": "1",
796+
"type": [
797+
{
798+
"code": "string"
799+
}
800+
]
801+
},
646802
{
647803
"id": "LineItemComponent.CLM_RNDRG_PRVDR_PRTCPTG_CD",
648804
"path": "LineItemComponent.CLM_RNDRG_PRVDR_PRTCPTG_CD",
@@ -835,7 +991,6 @@
835991
}
836992
]
837993
}
838-
839994
]
840995
}
841996
}

0 commit comments

Comments
 (0)