Dispense Reimbursement Claim Rejection Tabular View

Dispense Reimbursement Claim Rejection - tabular view

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Coded With Extensions

Coded No Extensions

This message is used by the reimbursement organisation (the PPA in P1R2) to notify a dispensing contractor that a request for reimbursement for a dispensed prescription has been rejected, with reason(s) for the rejection.

Reference: W5 Section 3.4.7.1

Used by:

[1..1] classCode (CS {CNE:ADJUD} ){ Fixed="ADJUD " }

A code indicating that the ReimbursementClaimReject focal act is an Adjudication

Fixed value: "ADJUD"

[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

A code to indicate this is an event.

Fixed value: "EVN"

[1..1] id (II)

UUID identifying this instance of a service request. This identifier is universally unique across all records. It is in the form of a UUID.

This is the unique number of the event that identifies the payload of the message.

[1..1] effectiveTime (TS)

Date and time stamp for the Dispense Reimbursement Claim Rejection message.

[1..1] author

A participation used to link the focal act with the details of the organization that is rejecting the Reimbursement Claim


[1..1] typeCode (CS {CNE:AUT} ){ Fixed="AUT " }		Indicates that the role is the author of this rejection message. Fixed value: "AUT"

[1..1] participant [CMET: UKCT_MT120401UK02]		NPfIT CMET fulfilling the specific role of an organisation, in this instance the payor organisation (which may be the PPA) from whom the claim is rejected. Full details of the organisation and role profile are available from SDS. This information is mandatory. The following CMET data elements are required and must be provided: Organization.id (Organisation SDS identifier) Organization.name (Name of organisation)

[1..1] origin

A participation used to link the focal act with the details of the dispensing organization that originated the Reimbursement Claim


[1..1] typeCode (CS {CNE:ORG} ){ Fixed="ORG " }		A code to indicate the originating organisation Fixed value: "ORG"

[1..1] participant (UKCT_MT120401UK02)		NPfIT CMET fulfilling the specific role of an organisation, in this instance the dispenser organisation from whom the reimbursement claim originated. This information is mandatory. The following CMET data elements are required and must be provided: Organization.id (Organisation SDS identifier) Organization.name (Name of organisation)

[1..*] pertinentInformation

A participation used to link the focal act with the details of the Reimbursement Claim which it is rejecting


[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }		Indicates that this is pertinent information. Fixed value : "PERT"

[1..1] pertinentClaimInfo (ClaimInfo)		Indicates that the ClaimInfo is pertinent to the focal act. This information is mandatory

ClaimInfo

This act groups together the various information about the Claim that is being rejected.

Used by: ReimbursementClaimReject

[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

Indicates that this act is an observation

Fixed value: "OBS"

[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

Indicates that this is an event

Fixed value: "EVN"

[1..*] pertinentInformation2

An act relationship linking the details of the rejection of the various Medication Items and the reasons for doing so to the focal act


[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }		Indicates pertinent information. Fixed value: "PERT"

[1..1] pertinentMedicationItemInfo (MedicationItemInfo)		Indicates that the MedicationItemInfo is pertinent to the ClaimInfo. This information is mandatory

[1..1] pertinentInformation3

An act relationship linking the details of the Reimbursement Claim message that is being rejected


[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }		Indicates that this is pertinent information. Fixed value: "PERT"

[1..1] pertinentReimbursmentClaimRef (ReimbursmentClaimRef)		Indicates that the ReimbursementClaimRef is pertinent to the ClaimInfo. This information is mandatory

[1..1] pertinentInformation1

An act relationship linking the details of the original Prescription to the those of the reasons for rejection.


[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }		Indicates pertinent information. Fixed value: "PERT"

[1..1] pertinentPrescriptionRef (PrescriptionRef)		Indicates that the PrescriptionRef is pertinent to the ClaimInfo. This information is mandatory

MedicationItemInfo

Details of the medications that have been supplied and the reasons why the supply has caused a reimbursement rejection

Used by: ClaimInfo

[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

Indicates that this act is an observation

Fixed value: "OBS"

[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

Indicates that this is an event

Fixed value: "EVN"

[0..*] pertinentInformation1

An act relationship linking the details of the reason(s) used to reject the reimbursement for the supply of various Medication Items


[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }		Indicates that this is pertinent information. Fixed value: "PERT"

[1..1] pertinentReimbursementRejectionReason (ReimbursementRejectionReason)		A link to the details of the Reimbursement Rejection Reason.

[1..1] pertinentInformation2

An act relationship linking the details of the supplied line items to the reason(s) used to reject the reimbursement for their supply


[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }		Indicates that this is pertinent information. Fixed value: "PERT"

[1..1] pertinentSuppliedLineItemRef (SuppliedLineItemRef)		A link to the details of the identity of the Line Items whose supply has caused this reimbursement to be rejected

ReimbursmentClaimRef

Details of the Dispense Reimbursement Claim whose Reimbursement has been rejected

Used by: ClaimInfo

[1..1] classCode (CS {CNE:INFO} ){ Fixed="INFO " }

A code indicating that the ReimbursementClaim focal act is for information purposes only

Fixed value: "INFO"

[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

A code to indicate this is an event.

Fixed value: "EVN"

[1..1] id (II)

UUID identifying this instance of a service request. This identifier is universally unique across all records. It is in the form of a UUID.

In this instance, this is a unique number to identify the Reimbursement Claim Message.

PrescriptionRef

Details of the Prescription which resulted in the Dispense Reimbursement Claim that has been rejected

Used by: ClaimInfo

[1..1] classCode (CS {CNE:SBADM} ){ Fixed="SBADM " }

A code to indicate introducing or applying a substance to a subject.

Fixed value: "SBADM"

[1..1] moodCode (CS {CNE:RQO} ){ Fixed="RQO " }

Indicates that this is a request or order for a service.

Fixed value: "RQO" (Request or Order)

[1..1] id (II)

UUID identifying this instance of a service request. This identifier is universally unique across all records. It is in the form of a UUID.

In this instance, this is a unique number to identify the original Parent Prescription.

ReimbursementRejectionReason

Details of the Reason for the Rejection of the particular Dispense Reimbursement Claim

Used by: MedicationItemInfo

[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

Indicates that this act is an observation

Fixed value: "OBS"

[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

Indicates that this is an event

Fixed value: "EVN"

[1..1] code (CV {CNE:PrescriptionAnnotation} )

Indicates that this is the Reimbursement Rejection Reason

Fixed value: "RJ"

[0..1] text (ST)

Textual (human readable) form of the Reimbursement Rejection Reason.

[1..1] value (CV {CWE:ReimbursementRejectionReason} )

Coded information specifying the definiton used to authorize the protocol supply event.

The Coded with Code System datatype flavour is used to carry this information as follows:

The code attribute will contain a value from the list of codes in the ReimbursementRejectionReason vocabulary;
The codeSystem attribute will contain the OID value referenced in the ReimbursementRejectionReason vocabulary

SuppliedLineItemRef

Details of the Line Items whose supply has resulted in the Dispense Reimbursement Claim being rejected

Used by: MedicationItemInfo

[1..1] classCode (CS {CNE:SBADM} ){ Fixed="SBADM " }

A code to indicate introducing or applying a substance to a subject.

Fixed value: "SBADM"

[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

Indicates that this is an event

Fixed value: "EVN"

[1..1] id (II)

UUID identifying this instance of a service request. This identifier is universally unique across all records. It is in the form of a UUID.

In this instance, this is a unique number to identify the Supplied Line Item.