This page is part of the CARIN Blue Button Implementation Guide (v2.1.0-snapshot1: STU 2) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

Use Case

Page standards status: Informative

Terms and Concepts

Term	Definition
Subscriber	An individual or entity that selects benefits offered by an entity, such as an employer, government, or insurance company
Dependent	An individual, other than the subscriber, who has insurance coverage under the benefits selected by a subscriber
Member	Any individual covered by the benefits offered by an entity, such as an employer or insurance company
Beneficiary	Any individual that selects or is covered by benefits provided by government programs
Patient	An individual who has received, is receiving or intends to receive health care services. (Health care services as defined by federal and state regulations.)
Personal Representative	Per the HIPAA privacy regulations at 45 CFR 164.502(g), a personal-representative is someone authorized under state or other applicable law to act on behalf of the individual in making health care related decisions (such as a parent, guardian, or person with a medical power of attorney)
Coordination of Benefits	The process of determining which of two or more insurance policies will have the primary responsibility of processing/paying a claim and the extent to which the other policies will contribute
Payer	Public or private party which offers and/or administers health insurance plan(s) or coverage and/or pays claims directly or indirectly. Examples include: Insurance Company Health Maintenance Organization Medicare Third-party Administrator Repricer
Encounter data vs Claims	Encounter data means the information or data relating to the receipt of any item(s) or service(s) by an enrollee under a contract between a State and a managed care plan. Encounter data are conceptually equivalent to the paid claims records that state Medicaid agencies create when they pay providers on a FFS basis
EOB.careteam	The members of the team or organization who contributed to the service to the patient submitted on the claim by the billing provider to the payer
CareTeam Resource	The Care Team includes all the people and organizations who plan to participate in the coordination and delivery of care for a patient

Use Case - Consumer Access to their Claims Data

Background

Consumer-directed exchange occurs when a consumer or an authorized caregiver invokes their HIPAA Individual Right of Access (45 CFR 164.524) and requests their digital health information from a HIPAA covered entity (CE) via an application or other third-party data steward. 

Technical Workflow

Actors:

• Consumer (aka Subscriber, Beneficiary, Patient, or Personal Representative)
• Consumer App (aka digital third-party application selected by and primarily for the Consumer with a consumer-facing user interface)
• Health Plan API (aka Payer, Covered Entity)
• Health Plan’s Identity and Access Authorization server

Flow:

1. Consumer App presents a list of potential Payers / Health Plans that can be accessed by the Consumer.
2. Consumer selects the Payer / Health Plan.
3. Consumer App opens the link to the Health Plan's Identity and Access Authorization server.
4. Consumer enters the credentials.
5. Health Plan's Identity and Access Authorization server validates the credentials, generates and returns to the Consumer App an OIDC token with Consumer and authorized patient/beneficiary identities encoded.
6. Consumer App successfully links the user to the Payer / Health Plan and notifies the Consumer.
7. Consumer requests the Consumer App to fetch Explanation Of Benefit records.
8. Consumer App generates and sends to the Health Plan's CARIN IG for Blue Button® enabled FHIR API a request (which includes Patient ID, and token from the step #5) to fetch the Explanation Of Benefit (EOB) and supporting reference FHIR resources.
9. Health Plan's CARIN IG for Blue Button® enabled FHIR API responds with a bundle of the requested EOB and supporting reference FHIR resources.
10. Consumer App presents the EOB and supporting reference FHIR resources to the Consumer.

3.3 Use Case - Sharing of Non-Financial Claims Data

3.3.1 Background

The CMS Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P) requires Health Plans to adjudicated claims and encounter data (profiled in this IG available) for the Provider Access and Payer-to-Payer APIs. The data available via these APIs would be the information a Health Plan makes available to the member, with the exception that it excludes provider remittances and patient cost-sharing information.

This IG addresses consumer access to claims and encounter data and does not directly address these other APIs. It does, however, contain profiles structured in a way that may used by IGs that do define the requirements of these APIs, like the Payer Data Exchange (PDex) IG, to share this information.

The below diagram shows the structure of the profiles in this IG and how they are anticipated to be used by the PDex IG where the “Basis” profiles contain all of the requirements for each type of EOB without financial data requirements and the Full EOB profiles to be used for consumer access.