0. INTRODUCTION
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. SCOPE
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
Particularly, MEDRUC can be applied for all types of healthcare
service providers, funding institutions and healthcare systems.
1.3 Principles
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.
2. REFERENCES
See UNTDID, Part 4, Chapter 2.6 UN/ECE UNSM - General Introduction,
Section 1.
3. TERMS AND DEFINITIONS
3.1 Standard terms and definitions
See UNTDID, Part 4, Chapter 2.6 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 indicate mandatory, conditional and repeating
requirements.
0010 UNH, Message header
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 98B
0051 UN
0020 BGM, Beginning of message
A segment for unique identification of the message and
specification of its function.
0030 DTM, Date/time/period
A segment identifying the date/time of message generation
and/or other date/times concerning the whole message.
0040 RFF, Reference
A segment specifying references to other related message(s) or
batch(es), e.g. a previous message.
0050 FTX, Free text
A segment giving free text information, in coded or clear form,
for specifying information about the whole message.
0060 CNT, Control total
A segment specifying aggregate information concerning the whole
message, e.g. number of claims, number of parties, number of
patients, etc.
0070 Segment group 1: MOA-TAX
A group of segments giving total amounts for the whole
reimbursement message, and the relevant tax information if any.
0080 MOA, Monetary amount
A segment specifying total amounts for the whole
reimbursement message.
0090 TAX, Duty/tax/fee details
A segment specifying the tax type if relevant.
0100 Segment group 2: PNA-SEQ-ADR-CTA-COM-RFF-LAN-SPR-EMP-QUA-DTM-
RCS-FII
Parties Segment Group.
A group of segments giving information about involved
financial, administrative and medical parties such as
requester, payee, insurance organisations, insured family and
service providers, or their representatives.
0110 PNA, Party identification
A segment specifying the identity number and name of a
party.
0120 SEQ, Sequence details
A segment allocating a sequence number to the individual
party allowing each party to be referenced from within the
message.
0130 ADR, Address
A segment specifying address(es) of the party.
0140 CTA, Contact information
A segment identifying a person or department to whom
contacts should be directed and their function.
0150 COM, Communication contact
A segment giving communication type and number of the party.
0160 RFF, Reference
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.
0170 LAN, Language
A segment specifying the language used by the party.
0180 SPR, Organisation classification details
A segment specifying the type and (medical) speciality of an
organisation.
0190 EMP, Employment details
A segment specifying the type and (medical) speciality of a
person as well as his/her position within an organisation.
0200 QUA, Qualification
A segment specifying the professional (medical)
qualifications of the party.
0210 DTM, Date/time/period
A segment specifying validity dates or any other date
related to the party.
0220 RCS, Requirements and conditions
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.
0230 FII, Financial institution information
A segment identifying an account number and a financial
institution related to the party.
0240 Segment group 3: AGR-SEQ-RFF-DTM-SG4
Contracts Segment Group.
A group of segments related to the whole message, specifying
contracts between insured parties or between patients and
insurance institutions, and detailing insurance coverage.
0250 AGR, Agreement identification
A segment identifying the type of the insurance contract.
0260 SEQ, Sequence details
A segment allocating a sequence number to the individual
contract allowing each contract to be referenced from within
the message.
0270 RFF, Reference
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.
0280 DTM, Date/time/period
A segment specifying dates, times and periods related to the
contract such as period of validity and period of specific
coverage.
0290 Segment group 4: ICD-FTX
A group of segments specifying detailed information about
rights and insurance coverage.
0300 ICD, Insurance cover description
A segment identifying the insurance scheme or product
covering the patient.
0310 FTX, Free text
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.
0320 Segment group 5: FCA-GIS-RFF-DTM-FTX-AGR-SG6-SG7-SG8
This segment group provides information about a reimbursement
claim: identification of patient(s), and the healthcare
services provided to the patient(s).
The reimbursement claim specified in this segment group may be
related to any party specified in the Parties Segment Group,
any insurance coverage as specified in the Contracts Segment
Group or any transport activity as specified in the Transports
Segment Group.
0330 FCA, Financial charges allocation
A segment specifying whether reimbursement is due to the
patient, to the healthcare service provider, or to a
combination of both.
0340 GIS, General indicator
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.
0350 RFF, Reference
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.
0360 DTM, Date/time/period
A segment specifying dates, times and periods related to the
reimbursement claim.
0370 FTX, Free text
A segment with free text information, in coded or clear
form, for specifying information about the reimbursement
claim.
0380 AGR, Agreement identification
A segment identifying the type of the insurance contract
related to the reimbursement claim.
0390 Segment group 6: RCS-FTX
This segment group provides information about required
administrative conditions concerning the reimbursement
claim, such as risk identification (e.g. illness, maternity,
accident, industrial accident).
0400 RCS, Requirements and conditions
A segment specifying requirements and conditions
concerning the reimbursement claim.
0410 FTX, Free text
A segment with free text information, in coded or clear
form, illustrating or justifying a particular condition
specified in the RCS segment.
0420 Segment group 7: PNA-RFF-ADR-COM-DTM-PDI-NAT-LAN-HAN-REL
This segment group identifies the patient(s) to whom the
medical services of this actual reimbursement claim have
been provided and information about any related person, or
other name or identity of the patient.
This segment group may also be used to specify name and
identity of any other party related to the actual
reimbursement claim, and involved in the medical or
administrative process provided to the patient(s). In this
case, only the PNA segment is used.
0430 PNA, Party identification
A segment identifying the patient, related person, or
party identity number and name.
0440 RFF, Reference
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.
0450 ADR, Address
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.
0460 COM, Communication contact
A segment providing a telecommunication number for the
person.
0470 DTM, Date/time/period
A segment specifying relevant dates/times for the person
such as date of birth, date of death or date
identification card was issued.
0480 PDI, Person demographic information
A segment specifying demographic information such as sex,
marital status, and other demographic information.
0490 NAT, Nationality
A segment specifying the nationality of a person.
0500 LAN, Language
A segment specifying the language used by the person.
0510 HAN, Handling instructions
A segment specifying confidentiality constraints on
person data.
0520 REL, Relationship
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.
0530 Segment group 8: PRC-GIS-IMD-CIN-PNA-DTM-RFF-FTX-QTY-PCD-
SG9-SG10-SG11-SG12
A group of segments describing a medical activity. A medical
activity can be a collection of several detailed medical
activities which are all related to the same medical
treatment.
The medical activity specified in this segment group may
also be related to any party specified in the Parties
Segment Group, any insurance coverage description as
specified in the Contracts Segment Group or to any transport
activity as specified in the Transports Segment Group.
0540 PRC, Process identification
A segment specifying the type of medical activity
provided such as hospitalisation or outpatient treatment.
0550 GIS, General indicator
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.
0560 IMD, Item description
A segment identifying the actual medical activity, and
allowing several alternative coding schemes depending on
separately agreed criteria.
0570 CIN, Clinical information
A segment justifying the medical activity provided in
terms of diagnosis or clinical observation.
0580 PNA, Party identification
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.
0590 DTM, Date/time/period
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.
0600 RFF, Reference
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.
0610 FTX, Free text
A segment with free text information, in coded or clear
form, specifying information about the current medical
activity.
0620 QTY, Quantity
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.
0630 PCD, Percentage details
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).
0640 Segment group 9: PAS-LOC-DTM-RFF
A group of segments specifying healthcare administrative
information about the patient.
0650 PAS, Attendance
A segment specifying patient administrative
information such as administrative status concerning
current hospital stay or outpatient visit or ward stay
related to the patient.
0660 LOC, Place/location identification
A segment specifying the physical location of patient
care in terms of ward, room, bed, etc.
0670 DTM, Date/time/period
A segment specifying admission and/or discharge date
and time or start and/or end date and time of a ward
stay.
0680 RFF, Reference
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.
0690 Segment group 10:MOA-TAX
To specify total amounts, and the relevant duty/tax/fee
information about the current medical activity.
0700 MOA, Monetary amount
A segment specifying total amounts such as amount of
fees.
0710 TAX, Duty/tax/fee details
A segment specifying relevant tax information.
0720 Segment group 11:RCS-FTX
This segment group provides information about required
medical and administrative conditions concerning the
current medical activity.
0730 RCS, Requirements and conditions
A segment specifying requirements and conditions about
the current medical activity.
0740 FTX, Free text
A segment with free text information, in coded or
clear form, illustrating or justifying a particular
condition specified in the RCS segment.
0750 Segment group 12:CLI-GIS-IMD-CIN-PNA-DTM-RFF-FTX-QTY-PCD-
PAC-SG13-SG14-SG15
A group of segments describing a detailed medical
activity.
The detailed medical activity specified in this segment
group may also be related to any party specified in the
Parties Segment Group, any insurance coverage description
as specified in the Contracts Segment Group or to any
transport activity as specified in the Transports Segment
Group.
0760 CLI, Clinical intervention
A segment specifying a clinical intervention.
0770 GIS, General indicator
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.
0780 IMD, Item description
A segment identifying the current detailed medical
activity and allowing several alternative coding
schemes depending on separately agreed criteria.
0790 CIN, Clinical information
A segment specifying the reason for applying the
current detailed medical activity in terms of
diagnosis or clinical observation.
0800 PNA, Party identification
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.
0810 DTM, Date/time/period
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.
0820 RFF, Reference
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.
0830 FTX, Free text
A segment with free text information, in coded or
clear form, specifying information about the current
detailed medical activity.
0840 QTY, Quantity
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.
0850 PCD, Percentage details
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).
0860 PAC, Package
A segment specifying package and number of physical
units for drugs or any other materials.
0870 Segment group 13:MOA-TAX
To specify total amounts, and the relevant
duty/tax/fee information about the detailed medical
activity.
0880 MOA, Monetary amount
A segment specifying total amounts such as amount
of fees.
0890 TAX, Duty/tax/fee details
A segment specifying relevant tax information.
0900 Segment group 14:RCS-FTX
This segment group provides information about required
administrative conditions about the reimbursement
claim, such as risk identification (e.g. illness,
maternity, accident, industrial accident).
0910 RCS, Requirements and conditions
A segment specifying requirements and conditions
concerning the current detailed medical activity.
0920 FTX, Free text
A segment with free text information, in coded or
clear form, illustrating or justifying a particular
condition specified in the RCS segment.
0930 Segment group 15:EQD-SEQ
A group of segments providing information about the
equipment used to provide the current detailed medical
activity.
0940 EQD, Equipment details
A segment identifying the equipment used.
0950 SEQ, Sequence details
A segment specifying the sequential number of the
activity performed on the equipment.
0960 Segment group 16:TMD-SEQ-GIS-FTX-SG17
Transports Segment Group.
A group of segments specifying a transport activity related to
the provision of a medical service. A transport activity
comprises of several transport phases, each transport phase can
be made up of several detailed transport activities.
0970 TMD, Transport movement details
A segment specifying journey trip such as a journey from a
hospital to a patient home.
0980 SEQ, Sequence details
A segment allocating a sequence number to the transport
activity, allowing each transport activity to be referenced
from within the message.
0990 GIS, General indicator
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.
1000 FTX, Free text
A segment with free text information, in coded or clear
form, specifying information about the whole transport
activity.
1010 Segment group 17:TDT-GIS-IMD-PNA-RFF-FTX-CIN-QTY-SG18-SG19-
SG20
A group of segments specifying one transport phase. A new
phase can result from vehicle changes, crew changes,
different stages, different numbers of people transported,
different rates, etc.
The transport activity specified in this segment group may
also be related to any party specified in the Parties
Segment Group such as transport service provider.
1020 TDT, Details of transport
A segment identifying the transport service provider, the
kind of transportation used, and the vehicle.
1030 GIS, General indicator
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.
1040 IMD, Item description
A segment identifying the current transport activity and
allowing several alternative coding schemes depending on
separately agreed criteria.
1050 PNA, Party identification
A segment identifying the party transported and the
transport service provider, such as a driver.
1060 RFF, Reference
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.
1070 FTX, Free text
A segment with free text information, in coded or clear
form, specifying information about the current transport
phase.
1080 CIN, Clinical information
A segment specifying the reason for the current transport
phase in terms of diagnosis or clinical observation.
1090 QTY, Quantity
A segment specifying quantities related to the transport
phase, such as number of people transported.
1100 Segment group 18:ADR-DTM
A group of segments specifying the transport legs and
relevant dates and times.
1110 ADR, Address
A segment specifying the address details of the
transport phase such as location of departure and
arrival.
1120 DTM, Date/time/period
A segment specifying relevant dates and times for the
transport phase such as date/time of departure,
arrival and elapsed time.
1130 Segment group 19:TSR-FTX
This segment group provides information about special
circumstances affecting the transport phase.
1140 TSR, Transport service requirements
A segment specifying special circumstances affecting
the current transport phase.
1150 FTX, Free text
A segment with free text information, in coded or
clear form, illustrating or justifying a particular
circumstance specified in the TSR segment.
1160 Segment group 20:TCC-GIS-IMD-DTM-RFF-FTX-QTY-PCD-SG21-
SG22
A group of segments providing information about each
transport phase specifying the transport components to be
used for financial calculation.
1170 TCC, Transport charge/rate calculations
A segment specifying charges for a transport
component.
1180 GIS, General indicator
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.
1190 IMD, Item description
A segment identifying the current transport component
such as night trip, day trip, toll gate and highway.
1200 DTM, Date/time/period
A segment specifying dates and times concerning the
current transport component.
1210 RFF, Reference
To specify references of a transport component.
1220 FTX, Free text
A segment with free text information, in coded or
clear form, illustrating or justifying the current
transport component.
1230 QTY, Quantity
A segment specifying quantities related to the
transport component such as number of km.
1240 PCD, Percentage details
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).
1250 Segment group 21:MOA-TAX
To specify total amounts and the relevant duty/tax/fee
information.
1260 MOA, Monetary amount
A segment specifying total amounts such as amount
of fees.
1270 TAX, Duty/tax/fee details
A segment specifying relevant tax information.
1280 Segment group 22:TSR-FTX
This segment group provides information about special
circumstances affecting the current transport
component.
1290 TSR, Transport service requirements
A segment specifying special circumstances
affecting the current transport component.
1300 FTX, Free text
A segment with free text information, in coded or
clear form, illustrating or justifying a particular
circumstance specified in the TSR segment.
1310 Segment group 23:AUT-DTM
A group of segments providing an authentication result for the
message.
This segment group can also be used for authentication results
of message sender or receiver.
1320 AUT, Authentication result
A segment specifying the result of an authentication
procedure.
1330 DTM, Date/time/period
A segment specifying dates and times of an authentication
result.
1340 UNT, Message trailer
A service segment ending a message, giving the total number of
segments in the message and the control reference number of the
message.
4.2 Data segment index (Alphabetical sequence by tag)
ADR Address
AGR Agreement identification
AUT Authentication result
BGM Beginning of message
CIN Clinical information
CLI Clinical intervention
CNT Control total
COM Communication contact
CTA Contact information
DTM Date/time/period
EMP Employment details
EQD Equipment details
FCA Financial charges allocation
FII Financial institution information
FTX Free text
GIS General indicator
HAN Handling instructions
ICD Insurance cover description
IMD Item description
LAN Language
LOC Place/location identification
MOA Monetary amount
NAT Nationality
PAC Package
PAS Attendance
PCD Percentage details
PDI Person demographic information
PNA Party identification
PRC Process identification
QTY Quantity
QUA Qualification
RCS Requirements and conditions
REL Relationship
RFF Reference
SEQ Sequence details
SPR Organisation classification details
TAX Duty/tax/fee details
TCC Transport charge/rate calculations
TDT Details of transport
TMD Transport movement details
TSR Transport service requirements
UNH Message header
UNT Message trailer
Contents of MEDRUC