51 & 52 -Claim Responses - New and Updated Fields

Overview

This Claim response message is used two purposes: Message event type = 51 is used for a Response to a Claim for Dispensed Medication. Message event type = 52 is used for Responses to a Claim for Professional Services. Otherwise, the responses are identical.

Also, of note: The Claim Response conveyes adjudication details, as does the Prior Claim Response. As such, their structure is the same and many of the new fields are in both.

The following table contains details on new fields and functionalities. Field that can be manaaged with mappings between CPHA3 and FHIR are not included. Implementers should consult the mapping section for further details.

Under Construction

Feature or Field	Details	Sender Responsibility	Receiver Responsibility
CLAIM RESPONSE	Claim Response
NEW FUNCTIONALITY Specify Payee as Provider or Patient	As there is a single claim request used for both Pay Provider and Pay Patient claims, the Payee field in FHIR will indicate whether the Provider or Patient will be paid	MANDATORY Adjudicator must indicate	MANDATORY Data must be consumed so it is clear who is to be paid
NEW FIELDS & FUNCTIONALITY Separate clinical data from fiscal data	DUR messages will be separated from fiscal information. BENEFIT: Once implemented, DUR data will be more easily identified	OPTIONAL - Must support when possible; DUR messaging to be split and should not appear in Process Notes, once this capability exists	MANDATORY - vendors must look for DUR information in Process Notes and in DUR fields until all adjudicators can support new DUR fields
NEW FIELD Special Auth Approved Days Supply	New field in the response to convey the authorized says supply. The Special Authorized days supply for this prescription is independent of where it is dispensed. Today may be used for LU codes in Ontario BENEFIT: Supports Pharmacist decision making	OPTIONAL Will be supported only by Adjudicators who require this	OPTIONAL POS should accept this value when possible
NEW FIELD Special Auth Remaining Quantity	New field in the Claim Response. Total quantity remaining on a prescription special authorization after this dispense. Recognizing that the quantity is relating to the unit and the strength of the product, this may also be specified. eg 10 tabs of 5mg strength is equivalent to 20 tabs and 2.5 mg. Limits may vary and may depend on the indication; sometimes the patient requires 2 strengths of tablets. Some SAs can cover multiple DINs; there will be support for text as well in the specificaton. BENEFIT: Supports Pharmacist decision making	OPTIONAL Adjudicators Conformance Rule: When codified, the quantity remaining must be based upon the DIN strength in the claim request. For more complex limits (eg multiple DINs), text should be used. Adjudicators should send when applicable	OPTIONAL . Pharmacy vendors should consume when possible. Conformance Rule: When codified, the quantity remaining must be based upon the DIN strength in the claim request. For more complex limits (eg multiple DINs), text should be used.
NEW FIELD Special Auth Total Quantity Dispense Accumulated	The total number of pills "adjudicated" for a special auth number. An Adjudicator authorizes the number of pills against a special auth number; the dispenses may occur across several pharmacies. This accumulated total is returned as part of the adjudication result as informational data. Used in NFLD today and may be used by other provinces. BENEFIT: Supports Pharmacist decision making	OPTIONAL Send when possible and applicable	OPTIONAL Consume when possible
NEW FIELD Special Auth Period	New field in the Claim Response to convey start and expiry dates of a special authbr> BENEFIT: Supports Pharmacist decision making	OPTIONAL POS must sender when applicable	OPTIONAL Receivers will use the data as required
Increase Response/Error Codes to 10	Increase the number of error codes on claim response to. BENEFIT: Supports Pharmacist decision making	OPTIONAL Adjudicators may send additional codes when ready and should understand if POS can handle the increase	MANDATORY POS must support from the onset
NEW FIELD Response Code System	New field to specify the response code system, eg CPHA, BC, RAMQ, etc. These are fixed values. BENEFIT: Allows downstream adjudicators and POS applications to clearly understand what system the response code belongs to, which ensures there is no duplication across systems	OPTIONAL- should support when possible	OPTIONAL
NEW FIELD Target Audience Indicator (Patient or Pharmacist) on Message	New field on response message to indicate if it targeted at the patient or pharmacist. BENEFIT: Supports Pharmacist decision making in conveying information to the patient	OPTIONAL Support as soon as feasible.	OPTIONAL Consume data as soon as feasible
NEW FIELD Print or Display Message	Indicates whether the message should be printed on the receipt for the patient	OPTIONAL	OPTIONAL
Extend Message Line Length	This allows adjudicators to send more meaningful messages to the Pharmacist. The Field length will be handled by default by changing to JSON in the FHIR message. This becomes a list, each with an increase from 40 characters per message to 1000 BENEFIT: Further details about adjudicated result can be conveyed	OPTIONAL Adjudicators may start populating longer messages whenever they are ready. In CPHA, there are 3 lines of 40 characters that will be extended.	OPTIONAL POS vendors will accept the new maximum length
Support Language on Message Lines Returned-	Optional language code (english/french/not specified) to response messages. BENEFIT: Allows vendor to display based on the user language. This is not static as a single prescription/dispense may be viewed & managed by users of both languages over the lifetime of a prescription Adjudicators may specify blank if unknown (eg CPHA3 mappings scenario), and for FHIR, both english and french are expected if possible. FHIR responses will contain english + french combined	OPTIONAL	OPTIONAL
NEW FIELD Payee Deferred - Clearly deliniates the dollar value paid to patient	BENEFIT: The response message will be enhanced for deferred payments (insurer pays patient). This will enable COB, and responses for delayed adjudication. There is logic in the PMS today CPHA3 that blocks COB if a code QJ is returned because vendors do not know the amount to be paid to the patient and therefore vendors cannot properly calculate and submit the previously paid amount on claims to subsequent payors. In FHIR standard, the pay to patient amount will be included which will be shared when sending the claim to subsequent payors. This will prevent subsequent payors from overpaying the claim. The QJ code will be deprecated as it is not necessary to indicate a deferred payment because we will have a specific field to indicate the dollar value paid to the patient. Vendors will be able to remove the COB restriction because they know the amount. For payors that support pay patient claims (transaction type 04), return the amount paid to the patient in the new field, and return 0 in the amount paid to the pharmacy field. Transaction 04 will be deprecated	MANDATORY	MANDATORY
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
Prior Payment Results
NEW FIELDS Additional COB data in Response- Adjudication Details	New fields sent with the intention of providing downstream payors with details about prior adjudication results. Fields will indicate cost/markup/fee cutbacks. A coverage type used for adjudication (eg private/public) is also included. This data is passed on in downstream/secondary claims and may contain a digital signature. BENEFIT: Improves adjudication, reduce audits and cutbacks. The policy type allows more claims to be submitted as it is definitive information from the source	MANDATORY Adjudicator must include data in the response	MANDATORY POS must include this resource, as is in downstream FHIR claims
Digital Signature	Provenance Profile
NEW FUNCTIONALITY Digital Signature on Prior Claim Results	A provenance resource is optionally included in the Claim Response message with a Digitial signature. The digital signature applies only to the Prior Claim response BENEFIT: Provides assurance to downstream payors that the prior claim results have not been inadvertently modified/tampered with	MANDATORY. Mapping only, eg if provenance supplied in Claim Response it must be included in downstream claim requests. Further information is available in the Technical section of this specification.	Adjudicators may support when possible. Further information is available in the Technical section of this specification.
COVERAGE	Prior Coverage
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	OPTIONAL - should consume when possible