PS Reimbursement Rejection Tabular View

PS Reimbursement 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 protocol supply has been rejected, with reason(s) for the rejection.

Reference: W5 Section 13.4.8.1

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 PS Reimbursement 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

This participation provides a link to the (payor) organisation that has rejected 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) to whom the claim was presented to. 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] primaryInformationRecipient

This participation provides a link to the dispensing organisation (claimant) that submitted the reimbursement claim.

[1..1] typeCode (CS {CNE:PRCP} ){ Fixed="PRCP" }

A code indicating that the receiving organisation is the primary recipient

Fixed value: "PRCP"

[1..1] participant [CMET: UKCT_MT120401UK02]

NPfIT CMET fulfilling the specific role of an organisation, in this instance the claiming organisation (which is the dispensing organisation) that presented the reimbursement claim. 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

[0..*] pertinentInformation3

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] 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".

[0..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] pertinentRejectionReason (RejectionReason)		A rejection reason pertinent to the reimbursement claim. This is information is mandatory.

[1..1] pertinentInformation1

An act relationship to identify the original PS Notification with Claim Information or PS Notification message for which the claim is being rejected.


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

[1..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".

[0..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] pertinentPSNotificationRef (PSNotificationRef)		Reference to the PS Norification pertinent to this rejection. This information is mandatory

[1..1] pertinentInformation2

An act relationship to identify the original PS Notification with Claim Information or the PS Claim Information message for which is being rejected.


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

[1..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] pertinentSupplyHeaderRef (SupplyHeaderRef)		A reference to the protocol supply event that is pertinent to this PS Reimbursement Claim Rejection. This information is mandatory

RejectionReason

Reason supporting the Reimbursement Claim Rejection. Reference: NPFIT-ETP-PZ-0159-v1.2 Table 12.

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

Code representation for prescription charge exemption status.

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)

A human readable description of the description of the reason for rejection.

[1..1] value (CV {CNE: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

PSNotificationRef

Reference to the original PS Notification with Claim Information or PS Notification message for which the claim is being rejected.

Used by: ReimbursementClaimReject

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

A code indicating that the PS Notification 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)

The unique identifier of the target act being referred to. This shall be a DCE UUID carried in the root attribute of the id element.

In this instance, this is a link to the original PS notification.

SupplyHeaderRef

Details of the original PS Notification with Claim Information message or the PS Claim Information message that has now been rejected.

Used by: ReimbursementClaimReject

[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" }

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 the unique number to identify the PS Notification with Claim Information or PS Claim Information message.