MEDRUC Medical resource usage and cost

TBG10 Healthcare

The MEDRUC message is sent from a party providing medical and related administrative services to a funding institution, allowing evaluation of the medical activity and justification for reimbursement. It can also be sent from a funding institution to another party in order to advise which reimbursements have been made.

The MEDRUC message can carry either initial specifications of used resources and costs, or modifications to specifications given in a previous message.

Typically, the MEDRUC message can be used between a healthcare service provider or an insurance company and another insurance company as well as between an insurance company and a healthcare service provider.

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Header

Position
Segment
Name
Max use

  1. A service segment starting and uniquely identifying a message. The message type code for the Medical resource usage and cost message is MEDRUC. Note: Medical resource usage and cost messages conforming to this document must contain the following data in segment UNH, composite S009: Data element 0065 MEDRUC 0052 D 0054 16A 0051 UN

    1. Data element S009/0057 is retained for upward compatibility. The use of
    S016 and/or S017 is encouraged in preference.
    2. The combination of the values carried in data elements 0062 and S009 shall
    be used to identify uniquely the message within its group (if used) or if
    not used, within its interchange, for the purpose of acknowledgement.

  2. A segment for unique identification of the message and specification of its function.

  3. A segment identifying the date/time of message generation and/or other date/times concerning the whole message.

  4. A segment specifying references to other related message(s) or batch(es), e.g. a previous message.

  5. A segment giving free text information, in coded or clear form, for specifying information about the whole message.

  6. A segment specifying the currency in which all the monetary amounts are expressed in the message.

  7. A segment specifying aggregate information concerning the whole message, e.g. number of claims, number of parties, number of patients, etc.

  8. Segment group 1
    Repeat 9

    1. A segment specifying total amounts for the whole reimbursement message.

    2. A segment specifying the tax type if relevant.

  9. Segment group 2
    Repeat 999

    1. A segment specifying the identity number and name of a party.

    2. A segment allocating a sequence number to the individual party allowing each party to be referenced from within the message.

    3. A segment specifying address(es) of the party.

    4. A segment identifying a person or department to whom contacts should be directed and their function.

    5. A segment giving communication type and number of the party.

    6. A segment specifying alternative identification numbers of the party. This segment also facilitates reference to another party if the current party is related to another party such as a department in a hospital, a physician in a department, etc.

    7. A segment specifying the relationship with another party.

    8. A segment specifying the nationalities of the party.

    9. A segment specifying the language used by the party.

    10. A segment specifying the type and (medical) speciality of an organisation.

    11. A segment specifying the type and (medical) speciality of a person as well as his/her position within an organisation.

    12. A segment specifying the professional (medical) qualifications of the party.

    13. A segment specifying validity dates or any other date related to the party.

    14. A segment specifying the status of involvement for the party (former, previous, current, next).

    15. A segment specifying administrative conditions of a party, such as the type of location from which a healthcare professional operates, (e.g. town, countryside, mountain area), identifier for agreement on reimbursement mode and tariff, or other statutory information.

    16. A segment specifying demographic information such as sex, marital status, and other demographic information.

    17. A segment identifying an account number and a financial institution related to the party.

  10. Segment group 3
    Repeat 999

    1. A segment identifying the type of the insurance contract.

    2. A segment allocating a sequence number to the individual contract allowing each contract to be referenced from within the message.

    3. A segment specifying certificate numbers and other references related to the contract. This segment is also used to hold a reference to administrative parties in the Parties Segment Group where the related insurance organisation or institution is identified.

    4. A segment specifying dates, times and periods related to the contract such as period of validity and period of specific coverage.

    5. Segment group 4
      Repeat 99

      1. A segment identifying the insurance scheme or product covering the patient.

      2. A segment with free text information, in coded or clear form, illustrating or justifying a particular term of the insurance scheme or product, specified in the ICD segment.

  11. Segment group 5
    Repeat 99

    1. A segment specifying the type and the name of a document.

    2. A segment specifying dates related to the document. (e.g. issuing date, validity date, etc.).

    3. Segment group 6
      Repeat 9

      1. A segment identifying the party.

      2. A segment specifying the address of the party.

      3. A segment specifying the involvement status of the party (former, previous, current, next).

      4. A segment specifying administrative conditions of a party such as the social sector it belongs to.

  12. Segment group 7
    Repeat 999

    1. A segment specifying whether reimbursement is due to the patient, to the healthcare service provider, or to a combination of both.

    2. A segment specifying the service type of the actual reimbursement claim, i.e. whether this is a new reimbursement claim, modification of a previous reimbursement claim, cancellation of a previous reimbursement claim or a complete replacement of a previous reimbursement claim.

    3. A segment specifying certificate numbers and other references related to the reimbursement claim. This segment may also be used to hold the reference to administrative, financial, and medical parties of the Parties Segment Group, insurance contracts of the Contract Segment Group and transport activities of the Transports Segment Group.

    4. A segment specifying dates, times and periods related to the reimbursement claim.

    5. A segment with free text information, in coded or clear form, for specifying information about the reimbursement claim.

    6. A segment identifying the type of the insurance contract related to the reimbursement claim.

    7. A segment specifying documents the reimbursement claim is referring to. This segment may also be used to hold a document reference of the external documents Segment Group.

    8. Segment group 8
      Repeat 99

      1. A segment specifying total amounts such as total amount to pay.

      2. A segment specifying relevant tax information.

    9. Segment group 9
      Repeat 99

      1. A segment specifying requirements and conditions concerning the reimbursement claim.

      2. A segment with free text information, in coded or clear form, illustrating or justifying a particular condition specified in the RCS segment.

    10. Segment group 10
      Repeat 999

      1. A segment identifying the patient, related person, or party identity number and name.

      2. A segment specifying the identification numbers of the person or other identification references such as card number. This segment may also be used to keep the reference to administrative, financial, and medical parties of the Parties Segment Group, and insurance contracts of the Contracts Segment Group.

      3. A segment specifying the details of the patient and related person(s) place of residence, or any other address or location related to the person, such as place of birth.

      4. A segment providing a telecommunication number for the person.

      5. A segment specifying relevant dates/times for the person such as date of birth, date of death or date identification card was issued.

      6. A segment specifying demographic information such as sex, marital status, and other demographic information.

      7. A segment specifying the result of a clinical examination, such as the height or weight of the patient.

      8. A segment specifying the nationality of a person.

      9. A segment specifying the language used by the person.

      10. A segment specifying confidentiality constraints on person data.

      11. A segment specifying the relationship between a related person and the patient. This relation can be an organ donor- receiver relationship, a mother-child relationship or any other family relationship.

    11. Segment group 11
      Repeat 999

      1. A segment specifying the type of medical activity provided such as hospitalisation or outpatient treatment.

      2. A segment specifying the service type for the medical activity: new activity, modification of a previous activity, cancellation of a previous activity or replacement of a previous activity.

      3. A segment specifying the activity status regarding its achievement (e.g. started, in progress, terminated) and/or payment (e.g. received, granted, paid).

      4. A segment identifying the actual medical activity, and allowing several alternative coding schemes depending on separately agreed criteria.

      5. A segment justifying the medical activity provided in terms of diagnosis or clinical observation.

      6. A segment specifying the identity number and name of any medical or administrative party related to the current activity, such as treatment provider or prescriber, diagnosis originator, etc.

      7. A segment specifying dates, times and periods related to the current medical activity such as date performed, date of prescription, date of sickness and date of medical authorisation.

      8. To specify a reference related to a treatment such as identification number of prescription or medical authorisation number. This segment may also be used to hold the reference to administrative, financial, and medical parties of the Parties Segment Group, insurance contracts of the Contracts Segment Group and transports of the Transports Segment Group.

      9. A segment with free text information, in coded or clear form, specifying information about the current medical activity.

      10. A segment providing quantities related to the medical activity such as number of units of service as identified in the IMD segment. If the service type of this medical activity is a modification then variations from the original quantities are given here.

      11. A segment specifying percentage used to calculate a share of a reimbursement. This information is useful when a party has already paid a certain amount, or more generally when several recipients are identified in the business scenario (e.g. 75% of a visit will be paid to the general practitioner and 25% to the patient).

      12. Segment group 12
        Repeat 99

        1. A segment specifying patient administrative information such as administrative status concerning current hospital stay or outpatient visit or ward stay related to the patient.

        2. A segment specifying the physical location of patient care in terms of ward, room, bed, etc.

        3. A segment specifying admission and/or discharge date and time or start and/or end date and time of a ward stay.

        4. This segment holds the reference of a healthcare party for specifying healthcare administrative information such as hospital, department, etc. where patient is admitted, located, etc.

      13. Segment group 13
        Repeat 99

        1. A segment specifying total amounts such as amount of fees.

        2. A segment specifying relevant tax information.

      14. Segment group 14
        Repeat 99

        1. A segment specifying requirements and conditions about the current medical activity.

        2. A segment with free text information, in coded or clear form, illustrating or justifying a particular condition specified in the RCS segment.

      15. Segment group 15
        Repeat 999

        1. A segment specifying a clinical intervention.

        2. A segment specifying the service type of the current detailed medical activity, i.e. whether this is a new detailed medical activity, modification of a previous detailed medical activity, cancellation of a previous detailed medical activity or a complete replacement of a previous detailed medical activity.

        3. A segment identifying the current detailed medical activity and allowing several alternative coding schemes depending on separately agreed criteria.

        4. A segment specifying the reason for applying the current detailed medical activity in terms of diagnosis or clinical observation.

        5. A segment specifying the identity number and name of any medical or administrative party related to the current activity, such as activity provider or prescriber, diagnosis originator, etc.

        6. A segment specifying dates, times and periods related to the current medical activity such as date performed, date of prescription, date of sickness and date of medical authorisation.

        7. To specify the reference related to a detailed medical activity such as identification number of prescription and medical authorisation number. This segment may also be used to hold the reference to administrative, financial, and medical parties of the Parties Segment Group, insurance contracts of the Contracts Segment Group, and transports of the Transports Segment Group.

        8. A segment with free text information, in coded or clear form, specifying information about the current detailed medical activity.

        9. A segment specifying quantities related to the detailed medical activity such as number of units of service as identified in the IMD segment. If the service type of this detailed medical activity is a modification then variations from the original quantities are given here.

        10. A segment specifying percentage used to calculate a share of a reimbursement. This information is useful when a party has already paid a certain amount, or more generally when several recipients are identified in the business scenario (e.g. 75% of a visit will be paid to the general practitioner and 25% to the patient).

        11. A segment specifying package and number of physical units for drugs or any other materials.

        12. Segment group 16
          Repeat 99

          1. A segment specifying total amounts such as amount of fees.

          2. A segment specifying relevant tax information.

        13. Segment group 17
          Repeat 99

          1. A segment specifying requirements and conditions concerning the current detailed medical activity.

          2. A segment with free text information, in coded or clear form, illustrating or justifying a particular condition specified in the RCS segment.

        14. Segment group 18
          Repeat 99

          1. A segment identifying the equipment used.

          2. A segment specifying the sequential number of the activity performed on the equipment.

  13. Segment group 19
    Repeat 999

    1. A segment specifying journey trip such as a journey from a hospital to a patient home.

    2. A segment allocating a sequence number to the transport activity, allowing each transport activity to be referenced from within the message.

    3. A segment specifying the service type of the transport activity: new transport activity, modification of a previous transport activity, cancellation of a previous transport activity or replacement for a previous transport activity.

    4. A segment with free text information, in coded or clear form, specifying information about the whole transport activity.

    5. Segment group 20
      Repeat 999

      1. A segment identifying the transport service provider, the kind of transportation used, and the vehicle.

        040 D5(040,030) If first, then all

      2. A segment specifying the service type of the actual transport phase: new transport phase, modification of a previous reported transport phase, cancellation of a previous reported transport phase and replacement for a previous reported transport phase.

      3. A segment identifying the current transport activity and allowing several alternative coding schemes depending on separately agreed criteria.

      4. A segment identifying the party transported and the transport service provider, such as a driver.

      5. A segment specifying references concerning the actual transport phase such as authorisation number. This segment may also be used to hold the reference to administrative, financial, and medical parties of the Parties Segment Group, and insurance contracts of Contracts Segment Group.

      6. A segment with free text information, in coded or clear form, specifying information about the current transport phase.

      7. A segment specifying the reason for the current transport phase in terms of diagnosis or clinical observation.

      8. A segment specifying quantities related to the transport phase, such as number of people transported.

      9. Segment group 21
        Repeat 99

        1. A segment specifying the address details of the transport phase such as location of departure and arrival.

        2. A segment specifying relevant dates and times for the transport phase such as date/time of departure, arrival and elapsed time.

      10. Segment group 22
        Repeat 99

        1. A segment specifying special circumstances affecting the current transport phase.

        2. A segment with free text information, in coded or clear form, illustrating or justifying a particular circumstance specified in the TSR segment.

      11. Segment group 23
        Repeat 999

        1. A segment specifying charges for a transport component.

        2. A segment specifying the service type of the actual transport component, i.e. whether this is a new transport component, modification of a previous transport component, cancellation of a previous transport component or a complete replacement of a previous transport component.

        3. A segment identifying the current transport component such as night trip, day trip, toll gate and highway.

        4. A segment specifying dates and times concerning the current transport component.

        5. To specify references of a transport component.

        6. A segment with free text information, in coded or clear form, illustrating or justifying the current transport component.

        7. A segment specifying quantities related to the transport component such as number of km.

        8. A segment specifying percentage used to calculate a share of a reimbursement. This information is useful when a party has already paid a certain amount, or more generally when several recipients are identified in the business scenario (e.g. 75% of a transport will be paid to the transport service provider and 25% to the patient).

        9. Segment group 24
          Repeat 99

          1. A segment specifying total amounts such as amount of fees.

          2. A segment specifying relevant tax information.

        10. Segment group 25
          Repeat 99

          1. A segment specifying special circumstances affecting the current transport component.

          2. A segment with free text information, in coded or clear form, illustrating or justifying a particular circumstance specified in the TSR segment.

  14. Segment group 26
    Repeat 9

    1. A segment specifying the result of an authentication procedure.

    2. A segment specifying dates and times of an authentication result.

  15. A service segment ending a message, giving the total number of segments in the message (including the UNH & UNT) and the control reference number of the message.

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