CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®)
1.0.0 - STU1

This page is part of the CARIN Blue Button Implementation Guide (v1.0.0: STU 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

Use Case

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.