FHIR Object's for payload - Valuesets and Systems

[angshu]

Dear All,
I have tried to compile the relevant valuesets in the spreadsheet.

These valuesets are structural in nature (e.g. Status, Category, ..) and not include valuesets for clinical terminologies (e.g. diagnosis, procedure etc) .

In the spreadsheet - primary we need to

1. Analyze and check the valuesets and their applicability in the affinity domain of HCX
2. We need to check the constraints and see the fitment in HCX context. As a guide - consider this

• "required" - strictly controlled and most likely fixed by FHIR (not a definitive rule, as everything can be overridden in FHIR)
• "preferred" - encouraged
• "extensible" - if not "covered", may be extended
• "example" - not encouraged, merely serve as example.
  You may check the FHIR website for more details here

3. We need to pay attention to the valusets that are marked as "extensible" and "example". identify what codes we are going to use.
4. We should also look at the "required" and "preferred" to see whether they fit, and if they require constraints (e.g. subset of values only). Again this is for guide only, if they dont fit - we can override.
5. If there are parallel or well established codes in health/insurance Indian context, lets use that.
6. Split the valuesets amongst ourselves and identify who is going to work on what, and propose ETA

I wish there was a better way to collaborate. I could have created a WIKI page on github and put in all the contents. If someone would like to do that, please lets do so. - it would be great, we can use PRs in that case. But I leave that to you all. Please propose if you think there. is a better way.

I wish I had more time to work on this, but unfortunately I may not be able to quickly. For some I have left some comments.

If you would like me to take you through and/or explain the payloads and how the valuesets fit, let me know - prefer later in the week.

[angshu]

Dear All,
The following are the valuesets that we need to sort out asap.

CoverageEligibilityRequest

• item.category > identify the general type of benefits under which products and services are provided.

CoverageEligibilityResponse

• insurance.item.category > identify the general type of benefits under which products and services are provided.
• error.code > An error code,from a specified code system, which details why the eligibility check could not be performed

Claim

• supportingInfo.category > class of the information supplied: information; exception; accident, employment; onset, etc.
• supportingInfo.code > specific information regarding special conditions relating to the setting, treatment or patient for which care is sought. This is used to identify the kind of additional information. This is marked as optional, so please provide argument is this is required in conjunction with "supportingInfo.category", or whether "category" alone is enough.
• item.category > Code to identify the general type of benefits under which products and services are provided.

ClaimResponse

• error.code > details why the claim could not be adjudicated.

There is also "Claim.item.productOrService" - but that will be most likely a value thats defined through the insurance plan details. However, if you have alternate thoughts, do share.

Note, in the above are "item.category" may seem like a common valuesets that can be used across different types - eligibility request/response, claim request/response. If you use different sets or opine that they ought to be different, please elaborate so.

Thanks in advance

[abhimail]

Dear All,

Wanted to bring to notice considerable work done by previous working group team on the identification/proposal of few of the potential value sets that may be useful in the claims context. Please find the complete list here.

Could we please review whether we can start with some of these as base/examples to built on? We may want to review following sheets for the immediate needs we have:

1. Sheet Denial Codes: As a base list claims response error.code
2. Sheet CD05.011: As a base list for item.category - Also useable in insurance.item.category and item.category
3. Sheet CD05.007 and CD05.0029: A base (may be a small subset) list for supportingInfo.category
4. Sheet CD05.101 - for PaymentReconciliation.detail.type
5. Sheet CD05.110 - Organisation Code/identifier for insurance orgs in India (could be use with Organisation references in multiple places)

Above list is mainly to address the immediate needs, community may want to review other sheets and opine on whether some of the identified codes/values could be used as base/example for other ValueSet requirements as mentioned in spreadsheet in the original post.

We may also need to look at harmonising the code naming system to create consistency and support machine+human readability.

In addition, another input on item.category and Claim.item.productOrService could be from the HBP-2.1 defined by NHA in the context of PMJAY. A potential mapping here (at least for PMJAY program use case) could be HBP 2.1 speciality <-> item.category and package+procedure <-> Claim.item.productOrService.

Kindly review and make suggestions.

[angshu]

@gopi-vitraya there would be overlap with the InsurancePlan declared supportingInfo here as you mentioned here?

[gopi-vitraya]

No, benefit category and benefit type are different from specialty. @angshu

[vharish85]

@gopi-vitraya - item.category is the one in last meeting I picked right (@vharish85 ).

[gopi-vitraya]

@vharish85 - That's right. Also, I just posted the meeting notes here #20

[mayurilal]

@abhimail For CoverageEligibilityRequest.item.category I propose we consider values listed in sheet CD05.080 (Service Type) as base values instead of CD05.011 (Medical Specialty).

The "Reference Value" in CD05.080 are the value lists for CoverageEligibilityRequest.item.productOrService.

[mayurilal]

Need help on ValueSet: HCX Medical Speciality Provider
https://swasth-digital-health-foundation.github.io/standards/output/ValueSet-medical-specialty-provider.html

General Medicine is duplicated - Code 1 & Code 27.
Codes 37 & 64 refer to the same specialty - space between words needs to be managed.
Please advice if codes 24 & 36 are duplicates as well.

Thanks!

[gopi-vitraya]

@mayurilal
Hi. Thank you for joining the working group.

These valuesets were proposed by the previous working group, and some of them may have some issues. @abhimail is leading the "FHIR profiles and valuesets" workstream. You may just report issues, provide suggestions and tag him.

Also, see the comments by Angshuman and Abhishek. There are a few valuesets, for which we are looking for help. Some of them may need reviewing the valueset proposed by corresponding base FHIR profile, some of them may need a new set, some of them may need additional values. Please see if you could pick one of them and review/create/add the values and suggest the same to @abhimail .

Regards,
Gopi

[abhimail]

Thanks @gopi-vitraya

Hi @mayurilal,

Welcome to the community!

Many thanks for pointing out the inconsistencies. Will get them rectified and republished.

Best regards,
Abhishek

[nvirmani]

On CoverageEligibilityRequest -> item.category, @DrParveenKumar and I have been having a conversation and here's a suggested set of values for further discussion. It's still WIP, and we look forward to inputs.
https://docs.google.com/spreadsheets/d/1wqFWLcZO8CU_K2XT6H-72Swh13pVC0AtQKnsPnjycn0/edit#gid=0

[nvirmani]

It seems that CoverageEligibilityResponse.insurance.item.category should be similar to CoverageEligibilityRequest.item.category. Any additional perspectives on that? This thought emerged based on further conversations between @DrParveenKumar and I.

[gopi-g-dev]

@nvirmani @DrParveenKumar
Looks like there is a consensus emerging here. There is a discussion thread created particularily for this valueset.
Read this comment: https://github.com/Swasth-Digital-Health-Foundation/hcx-specs/discussions/22#discussioncomment-2329060

[nvirmani]

Question: CoverageEligibilityResponse.error.code - should this just contain why the system could not determine eligibility (request timed out) or also have reasons someone might not be eligible (e.g. not enough sum insured available)? Our sense is the former.

[gopi-g-dev]

@abhimail @krisaccessh

[gopi-g-dev]

Discussions on some of the valuesets are being done in separate threads. Please see:
Claim/bill item category - #22
SupportingInfo category - #35
Error codes - #36
SupportingInfo codes - #37

[gopi-g-dev]

@vrayulu
Valueset suggestions for Diagnostic Documents extension (Extension.extension:diagnosticDocumentCode.value[x]): https://docs.google.com/spreadsheets/d/1H-gjuvUFEykl60hO-3NYz4bb7AqDDYjBWbxHGLu6ZmE/edit?usp=sharing
Valuset suggestions for Informational Messages extension (Extension.extension:message.value[x]):
https://docs.google.com/spreadsheets/d/1toH5HdZlzIoJnbA9vvLy4_8E2vRnp5s2ubWXAaHqEJM/edit?usp=sharing

Both of them are from PMJAY. The binding strength is example.

[vrayulu]

Thanks @ggopi-dev . For POI, I will be using the values "Aadhaar, PAN, Driving License, Voter ID, Passport" as example in the IG. We can update later with more values and also change the binding from example to preferred. Please suggest if these are fine.

For POPR, I will use "Aadhaar verification XML, and Photograph". any other values that can be included for now?