This specification provides the definition of the Medical resource usage and cost message (MEDRUC) to be used in Electronic Data Interchange (EDI) between trading partners involved in administration, commerce and transport.
1.1 Functional definition
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.
1.2 Field of application
The Medical resource usage and cost message may be used for both national and international applications. It is based on universal practice related to administration, commerce and transport, and is not dependent on the type of business or industry.
Particularly, MEDRUC can be applied for all types of healthcare service providers, funding institutions and healthcare systems.
The MEDRUC message has a hierarchical structure:
- One message can carry one or more reimbursement claims.
- Each reimbursement claim concerns medical services provided to one or several patients.
- Each medical service gives information about service provided including amounts and price information (unit, prices, quantities, rates) as well as medical justification for the services provided (clinical information concerning diseases or interventions) and administrative justification for services provided according to insurance coverage.
- Each medical service can consist of none, one or many detailed medical activities.
- Each detailed medical activity can contain the same information elements as for a medical service.
Additional information can be attached to each level of the hierarchical structure using an internal reference mechanism.
This information may include:
- medical, administrative and financial parties involved.
- relevant insurance contracts and corresponding rights.
- description of patient or healthcare service provider transportation.
See UNTDID, Part 4, Chapter 2.3 UN/ECE UNSM - General Introduction, Section 1.
3. TERMS AND DEFINITIONS
3.1 Standard terms and definitions
See UNTDID, Part 4, Chapter 2.3 UN/ECE UNSM - General Introduction, Section 2.
4. MESSAGE DEFINITION
4.1 Data segment clarification
This section should be read in conjunction with the segment table which indicates mandatory, conditional and repeating requirements.