Hello all, this is my first time requesting vocab modifications (but it does tie back to some previous forum conversations, linked below), so I apologize if I’m missed anything, posted in the wrong place, etc. Please see below and advise on next steps.
My goal:
- Annotate records with provenance showing that they are from a particular claim type and include the “open”/“closed” adjudication status. As an example, a specific record may come from a “closed professional claim line” or an “open dental claim line”.
The issue:
- This is not currently possible in the OMOP schema using standard vocabularies. The standard vocabulary Type Concept provides the ability to delineate claim type (id:
32871“Professional claim”, id:32844“Facility claim”, id:32816“Dental claim”, etc.). That same vocabulary also has records for id:32875“Payer System” and id:32867“Primary Provider System” which can roughly translate to “open” pre-adjudicated claims or “closed” adjudicated claims. The trouble is that there aren’t any vocabulary entities that combine this information.
Why is it important to retain this information?
- Claim type (Professional, Facility, Dental, etc.)
- Provide researchers with a general understanding of provenance
- Understanding claim type is critical for researching things like policy interventions, utilization patterns, etc.
- Adjudication status
- Post-adjudication (“Closed”) claims are generally viewed as higher quality for most use cases. They represent completed transactions that have been thoroughly reviewed, with any discrepancies resolved.
- Pre-adjudication (“Open”) claims frequently have more data, but also missing claims and duplicates which affect research findings if not properly understood and managed.
Also, adjudication status is critical for the cost table to work correctly, which is something Vojtech pointed out in the other post.
My Proposal:
I am requesting that OMOP modify their standard type vocabulary to include additional entities that can create a hierarchical relationship grouping by claim adjudication status.
This picks up on an exchange I originally had with several others on the forum, including @Vojtech_Huser . I believe the below captures what Vojtek advised at the end of this post.
Also, for quick reference, here is the existing standard vocab list for aall type concepts with “Claim” in the name is here.
An example of the new members I am requesting is below, with new entities labeled with a *
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Dental claim
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Approved dental claim*
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Rejected dental claim*
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Pre-adjudicated dental claim*
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Facility claim
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Approved facility claim*
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Rejected facility claim*
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Pre-adjudicated facility claim*
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Inpatient claim
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Approved inpatient claim*
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Rejected inpatient claim*
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Pre-adjudicated inpatient claim*
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-
Outpatient claim
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Approved outpatient claim*
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Rejected outpatient claim*
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Pre-adjudicated outpatient claim*
-
-
Pharmacy claim
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Approved pharmacy claim*
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Rejected pharmacy claim*
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Pre-adjudicated pharmacy claim*
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-
Professional claim
-
Approved pharmacy claim*
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Rejected pharmacy claim*
-
Pre-adjudicated pharmacy claim*
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The leaf-level new members shown above would also roll up to existing members in a separate hierarchy, shown below:
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Adjudicated Approved Claims*
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Approved dental claim *
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Approved facility claim *
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Approved inpatient claim *
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Approved outpatient claim *
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Approved pharmacy claim *
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Approved professional claim *
-
-
Adjudicated Rejected Claims*
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Rejected dental claim
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Rejected facility claim *
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Rejected inpatient claim *
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Rejected outpatient claim *
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Rejected pharmacy claim *
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Rejected professional claim *
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-
Pre-Adjudicated Claims*
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Pre-Adjudicated dental claim *
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Pre-Adjudicated facility claim *
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Pre-Adjudicated inpatient claim *
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Pre-Adjudicated outpatient claim *
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Pre-Adjudicated professional claim *
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Pre-Adjudicated pharmacy claim *
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