01-Claim Dispensed Med Request - New and Updated Fields

Under Construction

The following table provides a more detailed view of the key changes that implementers will see within the FHIR message itself. This describes what the changes are. The details of "how" these changes are realized in the FHIR messages can be found within the FHIR profiles.

Note: This list covers the vast majority of new fields; however some new fields in FHIR that contain fixed values or those that are structural in nature, or fields that are used in mapping may not be included as there is no business impact.

Claim for a Dispensed Medication

Feature	Details & Link to Profiles	POS - Sender Responsibility	Adjudicator - Receiver Responsibility
GENERAL
COMBINE MESSAGES Combine Pay Cardholder + Pay Provider Claim Request	Transactions that are separate in CPHA today will be combined into a single transactions that will specify the requested payee. This may be handled through mapping. The claim response will specify who the adjudicator will be paying.	MANDATORY	MANDATORY
NEW FUNCTIONALITY Claims over 10K in a single request	PCS FHIR allows claims to be submitted over 9999.99. As this is not mandatory, vendors must continue support for sending split claims in FHIR for those adjudicators until all adjudicators are capable of receiving claims over 10K BENEFITS: Reduced audit and clawbacks; more accurate/streamlined adjudication	RECOMMENDED - to be determined amongst implementation partners	RECOMMENDED - to be determined amongst implmentation partners
PATIENT	Patient Profile
NEW FIELD PMS Patient Identifier	Used when there is no JHN as the patient identifier BENEFIT: Addresses current challenge	Must be sent when known	May be consumed as required
COVERAGE	Prior Coverage Profile
NEW FIELD Coverage Type	Provides accurate plan type that the adjudicated claim was paid under. BENEFIT: Clear communication to pharmacy and to the downstream payors as this is included in downstream claim requests	MANDATORY - for downstream claims	OPTIONAL - downstream payors should consume when possible
DISPENSE INFORMATION	Medication Dispense Details Profile
NEW FIELD Units of measure for products	The quantity field will allow for a coded unit, eg unit, package, mL, L,g, kg FHIR: MedicationDispense.Quantity.Code	POS must include where value is known	Adjudicators may ignore initially; should support when possible
NEW FIELD Rendered Dosage - SIG	New field for pharmacies to submit the SIG as part of the claim request. Language may also be specified FHIR:MedicationDispense.extension:renderedDosageInstruction AND MedicationDispense.extension:languageIndicator BENEFIT: Will enhance adjudication /audit capability.	Sending system must include where known	Receiving system may ignore.
PRIOR PAYMENT DETAILS	Prior Claim Response Details Profile
NEW FIELDS COB -Prior Payment Details included in Downstream Claim request	New fields to support inclusion of adjudication details from previous payors in the claim request, including fiscal details as well as the claim type (eg public, private, etc). The prior adjudication results are included in downstream claim requests along with information about the prior payor (BIN, Amounts paid, Intervention codes, Response Codes, fiscal amounts, claim type) BENEFIT: More accurate adjudication; may reduce audit and clawbacks	MANDATORY: POS must map data received in the primary response to downstream claim requests	OPTIONAL: Receiving systems may ignore this data in the claim request and may support when possible
MEDICATION	Medication Details Profile
NEW FEATURE & FIELDS Compound ingredient Breakdown	New fields to allow a list of compound ingredients to be specified. New fields are: Product code (eg DIN) specified as code or text, quantity, Ingredient Percentage Total Cost, Flag to indicate Ingredient is Active BENEFIT: Will enhance adjudication /audit capability.	POS must include data when known	Adjudicators must minimally store data and fully support when capable.
NEW FIELD Medication code system	Add “Type” identifier on medication (eg DINS) to identify origin of pseudodins (NPN, Opinions,etc). BENEFIT: This helps adjudicators to choose the correct product for adjudication.	POS systems must send	Receivers may use the data when required
NEW FIELD Medication Code.Text	A new, optional text field to specify the name of the compound BENEFIT: Useful for audit purposes	Optional; should be specified when capable	May be consumed when desired
CLAIM INFORMATION	Claim Dispense Details Profile
NEW FIELD Pharmacy ID Assigning Authority (static value)	OID to align with other standards; this is fully mappable	POS systems must map and send	Receivers may use the data if deemed necessary
UPDATE FIELDS Increase price fields to support Claims over 10K	Increase all dollar amounts on request and response message (eg >9999.99 for cost, and >999.99 for fee, special service fee)	Each POS vendor will determine timing of support for Claims over 10K in accordance with the adjudicators schedules and partner agreements. Capability tracking and coordination between implementers is required	Each implementer will determine timing and whether in scope for initial rollout/MVP. Capability tracking and coordination with POS vendors is required
UPDATE FIELD Quantity - Increase Decimal Places	Change quantity to include up to 3 decimal places. Quantity unit, eg g, mg, ml, tablet, capsule, puffer etc. BENEFIT: More precise specification of quantity. Aligns with PrescribeIT and DHDR looking for drug form** This will enhance adjudication capability	Optional; should be specified when capable	Optional; should consume when capable
NEW FIELD Related Claim Reference	New field to co-relate a claim to a professional service BENEFIT: Adjudicators can establish a clear link between claims using this definitive field.	POS systems must send as Professional services claims are supported from the onset	Adjudicators should consume this data when possible
UPDATE FIELD Extend Diagnosis, up to 5 optional	Allow up to 5 diagnosis codes.	Sending system must include where known	Receiving system may ignore?TBD
UPDATE FIELD Days supply - Increase	Extended to allow specification of a larger duration. It is currently limited to 999 days, but some products (eg IUD's) may last for up to 5 years.	Sender must increase where possible; Receiving systems may map anything over 999 to 999
UPDATE FIELD Increase Intervention Codes	Increase the number of intervention codes on claim request to 10. BENEFIT: Allows for more precise adjudication	OPTIONAL	OPTIONAL Receiver may reject if necessary (eg mapping failure) or ignore additional codes Coordination between implementers may be required
NEW FIELDS New Quebec Pricing Fields	Quebec Professional Fee, Quebec Wholesale Price,Quebec Guaranteed Selling Price	Must send values in accordance with legislation	Consume when required
NEW FIELD EligibleAmtProvincialPlan	New Optional field to capture the Eligible Amount (total cost and fee) for a given medication for a provincial plan. This is used by adjudicators to drive specific adjudication rules. CPHA Mapping: Special Services Fee(s) BENEFIT: This provides a discrete field specifically for the intended purpose	Mandatory: POS vendors must send as this is mappable	Mandatory; consume when required as this is mappable
UPDATED FIELD Refills Remaining Increase to 3 decimals	This field will allow up to 999 to be specified. BENEFIT: The extension meets today's requirements as some prescriptions allow over 99 refills. Allows for more precise adjudicationa nd may reduce auditing	Must send when possible	Consume when possible
NEW FUNCTIONALITY Multiple Coverages may be specified	All claims will incldue all known instances of insurance BENEFIT: Upon receipt of a claim, the adjudicator may examine other coIf the pharmacists purchased the medication directly from the manufacturer, there would not be any wholesaler's profit margin
PRESCRIPTION INFORMATION	Prescription Profile
NEW FIELD Jurisdictional Prescription ID	Generated by EMR or PMS; this optional element is important to provinces who may track a prescription through its life cycle	MedicationRequest.identifier	Optional; at the request of the Adjudicator	Optional support as required
NEW FIELD PrescribeIT Prescription Number	Optional. Upon request from Jurisdiction or may send when known	Consume if required
MESSAGE HEADER PROFILE	Message Header Profile
NEW FIELD Banner Pharmacy Identifier	Identifier assigned by Banner and will assist with troubleshooting. Optional use as determined by implementer Sender Organization.identifier may be used for this purpose or the Source contact.	POS systems must send if requested by an implementer	Adjudicators will use the data if desired
NEW FIELD Software Vendor Pharmacy identifier	Software vendor client name is conveyed in the Sender.Identifier. This may be assigned by vendor, used for troubleshooting.	Optional use as determined by implementer	Consume when capable

Message Structure