Merge pull request #47 from Alvearie/HIWHC-2612--Add-Commercial,Opt-Drug

Hiwhc 2612  add commercial,opt drug

data/extensions/ClaimExtensions.fsh

@@ -1,7 +1,13 @@
+Extension:      AggregateClaimIndicator
+Id:             aggregate-claim-indicator
+Title:          "Aggregate Claim Indicator"
+Description:    "Indicator that identifies whether this claim record is included in the adjustment processing of the aggregate build logic for admissions, episodes or DCGs"
+* value[x] only string
+
 Extension:      CapitatedServiceIndicator
 Id:             capitated-service-indicator
 Title:          "Capitated Service Indicator"
-Description:    "An indicator that this service (encounter record) was capitated"
+Description:    "Indicator that this service (encounter record) was capitated"
 * value[x] only string
 
 Extension:      ClaimItemDetailClassification
@@ -13,32 +19,70 @@ Description:    "Classification of the information contained in this claim item
 Extension:      ClaimSnapshotProviderName
 Id:             claim-snapshot-provider-name
 Title:          "Claim Snapshot Provider Name"
-Description:    "The original provider name as reported on the claim"
+Description:    "Original provider name as reported on the claim"
 * value[x] only string
 
 Extension:      ClaimSnapshotProviderZipCode
 Id:             claim-snapshot-provider-zip-code
 Title:          "Claim Snapshot Provider Zip Code"
-Description:    "The original provider postal code, as reported on the claim"
+Description:    "Original provider postal code, as reported on the claim"
 * value[x] only string
 
-Extension:      CompanyCode
-Id:             company-code
-Title:          "Company Code"
-Description:    "The company code of the subscriber as reported on the claim"    
-* value[x] only CodeableConcept
-
 Extension:      CompoundCode
 Id:             compound-code
 Title:          "Compound Code"
 Description:    "Indicator of whether the product is a compound drug or not"    
 * value[x] only CodeableConcept
 
+Extension:      CrossoverIndicator
+Id:             crossover-indicator
+Title:          "Crossover Indicator"
+Description:    "Indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare"
+* value[x] only string
+
 Extension:      EmployeeBusinessUnit
 Id:             employee-business-unit
 Title:          "Employee Business Unit"
-Description:    "The business unit of the subscriber as reported on the claim"    
+Description:    "Business unit of the subscriber as reported on the claim"    
+* value[x] only CodeableConcept
+
+Extension:      Employer
+Id:             employer
+Title:          "Employer"
+Description:    "Customer-specific code for the employer as reported on the claim record"    
+* value[x] only CodeableConcept
+
+Extension:      FinancialSystem
+Id:             financial-system
+Title:          "Financial System"
+Description:    "Customer-specific code for the financial system"   
+* value[x] only CodeableConcept
+
+Extension:      FullyInsuredIndicator
+Id:             fully-insured-indicator
+Title:          "Fully Insured Indicator"
+Description:    "Indicator that the claim was for a fully insured plan"
+* value[x] only string
+
+Extension:      ClaimCategory
+Id:             claim-category
+Title:          "Claim Category"
+Description:    "Standard HIPAA code for the category of the claim status"   
+* value[x] only CodeableConcept
+* valueCodeableConcept from CLAIM-STATUS-CATEGORY (extensible)
+
+Extension:      ClaimStatus
+Id:             claim-status
+Title:          "Claim Status"
+Description:    "Standard HIPAA code for the status of an entire claim"   
 * value[x] only CodeableConcept
+* valueCodeableConcept from CLAIM-STATUS (extensible)
+
+Extension:      LastClaimIndicator
+Id:             last-claim-indicator
+Title:          "Last Claim Indicator"
+Description:    "Indicator that identifies whether this claim record is the last or most recent claim"   
+* value[x] only string
 
 Extension:      LocalNumberOfUnitsPerService
 Id:             local-number-of-units-per-service
@@ -59,6 +103,12 @@ Title:          "Network Id"
 Description:    "Customer-specific identifier of the patient provider network in which the member is enrolled"
 * value[x] only string
 
+Extension:      NursingHomeIndicator
+Id:             nursing-home-indicator
+Title:          "Nursing Home Indicator"
+Description:    "Indicator that the claim was for a nursing home patient"
+* value[x] only string
+
 Extension:      ProcedureGroup
 Id:             procedure-group
 Title:          "Procedure Group"
@@ -69,12 +119,23 @@ Description:    "Groups assigned to categorize related procedures"
 Extension:      ReferralIndicator
 Id:             referral-indicator
 Title:          "Referral Indicator"
-Description:    "An indicator signifying the service resulted from a referral"
+Description:    "Indicator signifying the service resulted from a referral"
 * value[x] only string
 
+Extension:      RxCount
+Id:             rx-count
+Title:          "RX Count"
+Description:    "Count of prescriptions for the drug claim"
+* value[x] only unsignedInt
+
+Extension:      SubmissionType
+Id:             submission-type
+Title:          "Submission Type"
+Description:    "Customer-specific code for the type of electronic submission"   
+* value[x] only CodeableConcept
+
 Extension:      WhPayerPcpResponsibilityIndicator
 Id:             wh-payer-pcp-responsibility-indicator
 Title:          "Health Data Connect PCP Responsibility Indicator"
-Description:    "An indicator signifying that the primary care physician is the physician considered either responsible or accountable for this claim"
+Description:    "Indicator signifying that the primary care physician is the physician considered either responsible or accountable for this claim"
 * value[x] only string
-

data/extensions/ClaimResponseExtensions.fsh

@@ -1,10 +1,22 @@
+Extension:   AdjudicationDate
+Id:          adjudication-date
+Title:       "Adjudication Date"
+Description: "Date on which the payment status of the claim was adjudicated" 
+* value[x] only date
+
 Extension:   ClaimAdjustmentType
 Id:          claim-adjustment-type
 Title:       "Claim Adjustment Type"
 Description: "The code for the claim's adjustment type" 
 * value[x] only CodeableConcept
 * valueCodeableConcept from WhPayerClaimAdjustmentTypeValueSet (extensible)
 
+Extension:   ClaimReceivedDate
+Id:          claim-received-date
+Title:       "Claim Received Date"
+Description: "Date the claim was received" 
+* value[x] only date
+
 Extension:   ClaimStatus
 Id:          claim-status
 Title:       "Claim Status"
@@ -39,5 +51,23 @@ Description: "Payment status of claim item"
 Extension:   ClaimResponseBenefitPlan
 Id:          claim-response-benefit-plan
 Title:       "Claim Response Benefit Plan"
-Description: "The Benefit Plan on the claim item."
+Description: "The benefit plan on the claim item"
 * value[x] only Reference(Coverage)
+
+Extension:   DispositionReason
+Id:          disposition-reason
+Title:       "Disposition Reason"
+Description: "Customer-specific code for the disposition reason, as related to how the claim was paid"
+* value[x] only CodeableConcept
+
+Extension:   SubmissionType
+Id:          submission-type
+Title:       "Submission Type"
+Description: "Customer-specific code for the type of electronic submission"
+* value[x] only CodeableConcept
+
+Extension:      UsualAndCustomaryAmount
+Id:             usual-and-customary-amount
+Title:          "Usual And Customary Amount"
+Description:    "Usual and customary amount on the drug claim"
+* value[x] only decimal

data/resources/claim/CDM_Claim.fsh

@@ -29,24 +29,56 @@ Description:    "A provider issued list of professional services and products wh
 * procedure.extension[procedureGroup]  ^definition      = "Groups assigned to categorize related procedures"
 
 * item.extension contains CapitatedServiceIndicator named capitatedServiceIndicator 0..1
-* item.extension[capitatedServiceIndicator] ^short      = "An indicator that this service (encounter record) was capitated" 
-* item.extension[capitatedServiceIndicator] ^definition = "An indicator that this service (encounter record) was capitated" 
+* item.extension[capitatedServiceIndicator] ^short      = "Indicator that this service (encounter record) was capitated" 
+* item.extension[capitatedServiceIndicator] ^definition = "Indicator that this service (encounter record) was capitated" 
+
+* item.extension contains FullyInsuredIndicator named fullyInsuredIndicator 0..1
+* item.extension[fullyInsuredIndicator] ^short      = "Indicator that the claim was for a fully insured plan"
+* item.extension[fullyInsuredIndicator] ^definition = "Indicator that the claim was for a fully insured plan"
+
+* item.extension contains NursingHomeIndicator named nursingHomeIndicator 0..1
+* item.extension[nursingHomeIndicator] ^short      = "Indicator that the claim was for a nursing home patient"
+* item.extension[nursingHomeIndicator] ^definition = "Indicator that the claim was for a nursing home patient"
+
+* insurance.extension contains CrossoverIndicator named crossoverIndicator 0..1
+* insurance.extension[crossoverIndicator] ^short      = "Indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare"
+* insurance.extension[crossoverIndicator] ^definition = "Indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare"
+
+* extension contains AggregateClaimIndicator named aggregateClaimIndicator 0..1
+* extension[aggregateClaimIndicator] ^short      = "Indicator that identifies whether this claim record is included in the adjustment processing of the aggregate build logic for admissions, episodes or DCGs"
+* extension[aggregateClaimIndicator] ^definition = "Indicator that identifies whether this claim record is included in the adjustment processing of the aggregate build logic for admissions, episodes or DCGs"
 
 * extension contains ClaimSnapshotProviderName named claimSnapshotProviderName 0..1
-* extension[claimSnapshotProviderName] ^short      = "The original provider name as reported on the claim"
-* extension[claimSnapshotProviderName] ^definition = "The original provider name as reported on the claim"
+* extension[claimSnapshotProviderName] ^short      = "Original provider name as reported on the claim"
+* extension[claimSnapshotProviderName] ^definition = "Original provider name as reported on the claim"
 
 * extension contains ClaimSnapshotProviderZipCode named claimSnapshotProviderZipCode 0..1
-* extension[claimSnapshotProviderZipCode] ^short      = "The original provider postal code, as reported on the claim"
-* extension[claimSnapshotProviderZipCode] ^definition = "The original provider postal code, as reported on the claim"
-
-* item.extension contains CompanyCode named companyCode 0..1
-* item.extension[companyCode] ^short      = "The company code of the subscriber as reported on the claim"
-* item.extension[companyCode] ^definition = "The company code of the subscriber as reported on the claim"
+* extension[claimSnapshotProviderZipCode] ^short      = "Original provider postal code, as reported on the claim"
+* extension[claimSnapshotProviderZipCode] ^definition = "Original provider postal code, as reported on the claim"
 
 * extension contains EmployeeBusinessUnit named employeeBusinessUnit 0..1
-* extension[employeeBusinessUnit] ^short      = "The business unit of the subscriber as reported on the claim" 
-* extension[employeeBusinessUnit] ^definition = "The business unit of the subscriber as reported on the claim" 
+* extension[employeeBusinessUnit] ^short      = "Business unit of the subscriber as reported on the claim" 
+* extension[employeeBusinessUnit] ^definition = "Business unit of the subscriber as reported on the claim" 
+
+* extension contains Employer named employer 0..1
+* extension[employer] ^short      = "Customer-specific code for the employer as reported on the claim record"
+* extension[employer] ^definition = "Customer-specific code for the employer as reported on the claim record"
+
+* extension contains FinancialSystem named financialSystem 0..1
+* extension[financialSystem] ^short      = "Customer-specific code for the financial system"
+* extension[financialSystem] ^definition = "Customer-specific code for the financial system"
+
+* extension contains ClaimCategory named claimCategory 0..1
+* extension[claimCategory] ^short      = "Standard HIPAA code for the category of the claim status" 
+* extension[claimCategory] ^definition = "Standard HIPAA code for the category of the claim status" 
+
+* extension contains ClaimStatus named claimStatus 0..1
+* extension[claimStatus] ^short      = "Standard HIPAA code for the status of an entire claim"
+* extension[claimStatus] ^definition = "Standard HIPAA code for the status of an entire claim"
+
+* extension contains LastClaimIndicator named lastClaimIndicator 0..1
+* extension[lastClaimIndicator] ^short      = "Indicator that identifies whether this claim record is the last or most recent claim" 
+* extension[lastClaimIndicator] ^definition = "Indicator that identifies whether this claim record is the last or most recent claim"
 
 * item.quantity.extension contains LocalNumberOfUnitsPerService named localNumberOfUnitsPerService 0..1
 * item.quantity.extension[localNumberOfUnitsPerService] ^short      = "Customer-specific quantity of either services or units"
@@ -56,10 +88,13 @@ Description:    "A provider issued list of professional services and products wh
 * extension[snapshotAgeInYears] ^short      = "The age of the patient in years at the date of service"
 * extension[snapshotAgeInYears] ^definition = "The age of the patient in years at the date of service"
 
+* extension contains SubmissionType named submissionType 0..1
+* extension[submissionType] ^short      = "Customer-specific code for the type of electronic submission"
+* extension[submissionType] ^definition = "Customer-specific code for the type of electronic submission"
+
 * extension contains WhPayerPcpResponsibilityIndicator named whPayerPcpResponsibilityIndicator 0..1
-* extension[whPayerPcpResponsibilityIndicator] ^short      =  "An indicator signifying that the primary care physician is the physician considered either responsible or accountable for this claim"
-* extension[whPayerPcpResponsibilityIndicator] ^definition =  "An indicator signifying that the primary care physician is the physician considered either responsible or accountable for this claim"
+* extension[whPayerPcpResponsibilityIndicator] ^short      =  "Indicator signifying that the primary care physician is the physician considered either responsible or accountable for this claim"
+* extension[whPayerPcpResponsibilityIndicator] ^definition =  "Indicator signifying that the primary care physician is the physician considered either responsible or accountable for this claim"
 
 //Business rule to ensure the correct position of a provider on claim item against the CareTeam sequence
 * careTeam.sequence obeys claim-careteam-sequence-check
-

data/resources/claim/CDM_ClaimResponse.fsh

@@ -13,7 +13,15 @@ Description:     "This resource provides the adjudication details from the proce
 * identifier.value 1..1
 * identifier.type  from IdentifierTypeValueSet (extensible)
 
-* type             from ClaimTypeValueSet (extensible)
+* adjudication.extension contains AdjudicationDate named adjudicationDate 0..1
+* adjudication.extension[adjudicationDate] ^short      = "Date on which the payment status of the claim was adjudicated"
+* adjudication.extension[adjudicationDate] ^definition = "Date on which the payment status of the claim was adjudicated"
+
+* type  from ClaimTypeValueSet (extensible)
+
+* extension contains ClaimReceivedDate named claimReceivedDate 0..1
+* extension[claimReceivedDate] ^short      = "Date the claim was received" 
+* extension[claimReceivedDate] ^definition = "Date the claim was received" 
 
 * extension contains ClaimStatus named claimStatus 0..1
 * extension[claimStatus] ^short      = "Custom code for the claim status"
@@ -23,6 +31,10 @@ Description:     "This resource provides the adjudication details from the proce
 * payment.extension[claimAdjustmentType] ^short      = "The code for the type of adjustment for the claim"
 * payment.extension[claimAdjustmentType] ^definition = "The code for the type of adjustment for the claim"
 
+* payment.extension contains DispositionReason named dispositionReason 0..*
+* payment.extension[dispositionReason] ^short      = "Customer-specific code for the disposition reason, as related to how the claim was paid"
+* payment.extension[dispositionReason] ^definition = "Customer-specific code for the disposition reason, as related to how the claim was paid"
+
 * item.adjudication.category from AdjudicationCategoryValueSet (example)
 
 //Extension for claim status at item level

data/resources/claim/CDM_ClaimResponse_Drug.fsh

@@ -4,6 +4,10 @@ Id:             cdm-claim-response-drug
 Title:          "CDM Claim Response Drug"
 Description:    "This resource provides the adjudication details from the processing of a Claim resource. The CDMClaimResponseDrug profile extends the CDMClaimResponse resource with additional adjudication details that are specific to pharmacy claims."
 
+* item.extension contains UsualAndCustomaryAmount named usualAndCustomaryAmount 0..1
+* item.extension[usualAndCustomaryAmount] ^short      = "Usual and customary amount on the drug claim"
+* item.extension[usualAndCustomaryAmount] ^definition = "Usual and customary amount on the drug claim"
+
 * item.extension contains RxFormularyIndicator named rxFormularyIndicator 0..1
 * item.extension[rxFormularyIndicator] ^short      = "An indicator that the prescription drug is included in the formulary"
 * item.extension[rxFormularyIndicator] ^definition = "An indicator that the prescription drug is included in the formulary"