How an Appointment relates to a Coverage?

Hello,

Suppose an Appointment were scheduled to a Patient, only because the Patient itself has an active Coverage to that Organization.

Reading this appointment, How am I suppose to represent the appointment - coverage relationship (direct / indirect representation)?

  • Should I use an appointment extension?

  • Should I use another resource?

  • Should I use a custom Patient Identifier describing the Coverage itself (on the Appointment.actor reference attribute) ?

Thanks =)

The phrase “only because the Patient itself has an active Coverage to that Organization.” seem odd as the Coverage relates a Patient to their insurance not to a service provider - the party with whom the Patient has an appointment.

I’m also not sure why you are trying to relate from an appointment to a Coverage given that the Patient may have multiple appointments and multiple Coverages. Typically appointment and Coverage would both reference Patient and you could therefore search Coverages for those where Coverage.beneficiary = Appointment.actor where the actor is the Patient (from the examples it isn’t clear how to discern when the actor is the Patient).

If you want to send the Patient’s Coverages with an Appointment you could reference in the Appointment.supportingInformation.

If you need further help I suggest joining an HL7 Financial Management Work Group call on Tuesday mornings.

I’m not sure about this comment:

Typically appointment and Coverage would both reference Patient and you could therefore search Coverages for those where Coverage.beneficiary = Appointment.actor where the actor is the Patient (from the examples it isn’t clear how to discern when the actor is the Patient).

This isn’t wrong, it just doesn’t give you the coverage for the appointment. This would give you the list of coverages that could potentially be candidates for covering the services of an appointment, but it can’t tell you which one actually does. E.g. if the patient has two coverages 1) workers comp and 2) a commercial/personal, the pre-registration done as part of appointment scheduling will identify which of those two coverages is likely to apply to the appointment. The correct coverage would be confirmed (and updated as needed) at appointment check-in.

The way to represent this is by having Appointment reference an Account. And the Account would list the coverage(s) that apply to to the Appointment (pending verification at check-in, at which point the “final” coverages are documented on the Account referenced from Encounter.

Currently, Appointment does not have a reference to Account. I have submitted GF#54078 to add that reference.

Appointment.supportingInformation might(?) be an option if this is patient portal scheduling and the Coverage content is being submitted by the patient, to be verified before being considered as usable for billing.

Yes my example only gets you to the potential list of Coverages, but probably so is Account also going to relate to all possible Coverages, the exact suite of Coverages to use for the approintment, where there may be several applicable, will be an on site determinations for as you point out - it may or may not be work, and therefore worker compensation related.

If you believe it’s common for systems to capture coverage information on the basis of the Appointment (as opposed to just the patient record), you could submit a change proposal asking for a reference to Coverage to be added to Appointment - either as a core element or as a standard extension.

Hello,

First of all, I appreciate all the efforts spent to help me. :grinning:

Probably my question was a bit confusing. Let mt try to explain better:

Suppose a patient wants to schedule an appointment with a doctor.
In the pre-admission phase (phone, personal), this patient gives coverage information (where the payor is an Organization named “Master Health”) to the doctor’s secretary.

Once arrived at the ambulatory at the scheduled time, this coverage gets validated by the secretary on the organization, for financial issues.

I need to relate this Coverage to the Appointment, in such a way that I would be able to retrieve the list of appointments scheduled for the organization (“Master Health”).

Having said that:

  • [pknapp], Using Appointment.suportingInformation is a good choice, but I probably need to persist the reason for that Reference. If not, how could I determine if this reference is about the financial costs or by other reasons (Mothers coverage used on an appointment to her newborn child)?

  • [Cooper] If the Account resource list multiple coverages, I cannot explicitly determine which Coverage was used to schedule the Appointment and search by the organization latter.

  • [lloyd] It probably would be the most suitable scenario for me. Relating a Coverage to an Appointment for scheduling is a common practice here in my country (Brazil). I’m going to submit this proposal.

Thank you all.

The coverage wouldn’t point to the Appointment, but you could have the Appointment point to the Coverage. Typically you’d querying using the Patient, not the Coverage though.