0. INTRODUCTION
1. SCOPE
   1. Functional definition
   2. Field of application
   3. Principles
2. REFERENCES
3. TERMS AND DEFINITIONS
   1. Standard terms and definitions
4. MESSAGE DEFINITION
   1. Data segment clarification
   2. Data segment index (alphabetical sequence)
   3. Message structure
      1. Segment table

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.

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.

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 2.6 UN/ECE UNSM - General Introduction, Section 1.

See UNTDID, Part 4, Chapter 2.6 UN/ECE UNSM - General Introduction, Section 2.

This section should be read in conjunction with the Segment Table which indicates 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:

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

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

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.