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)

The globally unique identifier for this instance of a Dispense Reimbursement Claim Rejection.

The Identifier Global datatype flavour is used to carry this information as follows:

the root attribute will contain a UUID

[1..1] effectiveTime (TS)

The date and timestamp of this message.

The date-timestamp must be given with the following precision:

YYYYMMDDHHMMSS

[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:

AgentOrg

Organization

id Organisation SDS identifier

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 an organisation

Fixed value: "ORG"

[1..1] participant [CMET: 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:

AgentOrg

Organization

id Organisation SDS identifier

name Name of organisation

[1..*] pertinentInformation

An act relationship 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)		The claim information pertinent to this rejection. 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

A link to the details of a rejected Medication Item and the reasons for its rejection.


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

[1..1] contextConductionInd (BL)		If "true", associations in the parent act are conducted across the ActRelationship to the child act. In this context the contextConductionInd defaults to "true".

[1..1] seperatableInd (BL)		This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act. If the source act is intended to be interpreted independently the value shall be "true" otherwise the value shall be "false". The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship. In this context the seperatableInd defaults to "false".

[1..1] pertinentMedicationItemInfo (MedicationItemInfo)		The medication item informatiom pertinent to the rejected claim. This information is mandatory

[1..1] pertinentInformation3

An link to 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] contextConductionInd (BL)		If "true", associations in the parent act are conducted across the ActRelationship to the child act. In this context the contextConductionInd defaults to "false".

[1..1] seperatableInd (BL)		This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act. If the source act is intended to be interpreted independently the value shall be "true" otherwise the value shall be "false". The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship. In this context the seperatableInd defaults to "false".

[1..1] pertinentReimbursmentClaimRef (ReimbursmentClaimRef)		Reference to the claim pertinent to this rejection. This information is mandatory

[1..1] pertinentInformation1

A link to the identity of the original prescription.


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

[1..1] contextConductionInd (BL)		If "true", associations in the parent act are conducted across the ActRelationship to the child act. In this context the contextConductionInd defaults to "true".

[1..1] seperatableInd (BL)		This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act. If the source act is intended to be interpreted independently the value shall be "true" otherwise the value shall be "false". The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship. In this context the seperatableInd defaults to "false".

[1..1] pertinentPrescriptionID (PrescriptionID)		The short form id of the prescription clinical event that is pertinent to this claim rejection.

MedicationItemInfo

Act identifying a supplied medication item and the reason(s) 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

A link to a reason used to reject the reimbursement for the supply of this medication item.


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

[1..1] contextConductionInd (BL)		If "true", associations in the parent act are conducted across the ActRelationship to the child act. In this context the contextConductionInd defaults to "true".

[1..1] seperatableInd (BL)		This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act. If the source act is intended to be interpreted independently the value shall be "true" otherwise the value shall be "false". The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship. In this context the seperatableInd defaults to "false".

[1..1] pertinentReimbursementRejectionReason (ReimbursementRejectionReason)		A reimbursement rejection reason pertinent to supply of this medication item.

[1..1] pertinentInformation2

A link to the identity of the supplied medication item.


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

[0..1] inversionInd (BL)		An indicator specifying that the ActRelationship.typeCode should be interpreted as if the roles of the source and target Acts were reversed. The inversion indicator is used when the meaning of ActRelationship.typeCode must be reversed. In this instance, the inversionInd defaults to "false".

[1..1] negationInd (BL)		When "true" allows the sender to specifically state that the relationship does not apply. In this context the negationInd defaults to "false".

[1..1] seperatableInd (BL)		This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act. If the source act is intended to be interpreted independently the value shall be "true" otherwise the value shall be "false". The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship. In this context the seperatableInd defaults to "true".

[1..1] pertinentSuppliedLineItemRef (SuppliedLineItemRef)		Reference to the medication item whose supply has caused this reimbursement to be rejected.

ReimbursmentClaimRef

Act identifying the rejected Dispense Reimbursement Claim.

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 Dispense Reimbursement Claim message.

The Identifier Global datatype flavour is used to carry this information as follows:

the root attribute will contain a UUID

PrescriptionID

Act identifying the original prescription using the Short Form Prescription Identifier.

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"

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

Indicates that this represents a Prescription Identifier

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

the code attribute will contain the fixed value "PID" from the list of codes in the PrescriptionAnnotation vocabulary;
the codeSystem attribute will contain the OID value referenced in the PrescriptionAnnotation vocabulary..

[1..1] value (II)

The Short Form Prescription Identifier.

The Identifier External datatype flavour is used to carry this information as follows:

the root attribute shall contain the value of the Short Form Prescription Identifier OID = 2.16.840.1.113883.2.1.3.2.4.18.8
the extension attribute shall contain the 18 character Short Form Prescription Identifier as described in the ETP Prescribing Systems Compliance Specification document (ref: NPFIT-ETP-EDB-0025.09).

ReimbursementRejectionReason

The reason for rejecting the 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 a Reimbursement Rejection Reason.

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

The code attribute will contain the fixed value "RJ" from the list of codes in the PrescriptionAnnotation vocabulary;
The codeSystem attribute will contain the OID value referenced in the PrescriptionAnnotation vocabulary.

[0..1] text (ST)

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

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

Coded information specifying the the reason for rejecting the reimbursement claim.

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

The medication item whose supply has caused the reimbursement to be 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 a promise of a service.

Fixed value: "PRMS"

[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.

The Identifier Global datatype flavour is used to carry this information as follows:

the root attribute will contain a UUID