New Detailed Functionality PCS FHIR
From a business perspective, the FHIR standard will support the following additions .
| Key Problem Area | How addressed in the new standard |
|---|---|
| Professional Services | a) New claim type that specifically addresses professional services based on known business requirements. Example: In CPHA3, days supply needs to be specified for a minor ailment service; this is not part of the professional services message. b) Develop a national professional service code set |
| Coordination of Benefits | Additional information to support COB including: a) Prior Payor Adjudication details b) Specification of payee as the “subscriber” or “provider” c) Deprecate the use of DA/DB d) New field for adjudicator to specify the plan type |
| High Cost Drugs | a) Extend all pricing fields in request and response messages to allow claims a single claim over 10K (>9999.99 for cost, and >999.99 for fee) b) Continue to support submission of multiple claims until all implementers can support a single claim over 10K. |
| Improve Automation Capabilities | a) Ability to specify compound details b) Add Total Quantity Dispense Accumulated field, TBC c) Add Rendered Dosage Instruction (SIG) d) Support Days supply over 999 e) Increase number of Intervention codes f) Add units of measure to products g) Quantity field – increase decimal places h) Allow for multiple Diagnosis Codes to be specified i) Add Prior Payment Details from adjudicator to support downstream COB claims i) New Dispense Quantity Remaning field on claim request |
| Processing Improvements | a) Support additional error codes b) Support additional messages in the response and target the message to the right audience -> provider or patient c) Separate clinical messaging from fiscal messages d) Messaging in French, English or both e) Software Vendor pharmacy identifier f) Banner Pharmacy Identifier d) New special auth fields conveyed in the response |
| Support Legislative & Jurisdictional Requirements | a) New fields for Quebec pricing fields b) New Provincial Prescription number, to allow tracking of a prescription through its life cycle c) New PrescribeIT RX Number to allow provinces to track a prescription through its life cycle. |
| Modernization Items | a) Move to modern standards -> FHIR, JSON and REST b) Align with other relevant standards where possible c) Add code systems for DINs, quantity d) Add DIN code systems e) Streamline messaging by combining Pay Cardholder + Pay f) Streamline Network Totals g) Streamline Adjudication Details Query h) Deprecate codes and transactions that are no longer in scope i) Field to allow submission of CPHA formatted messages to support implementers with mapping & transformation during MVP |
New Functionality - Detailed View
The following list provides a more detailed view of the key changes that implementers will see within the FHIR message itself. Note: This list covers the vast majority of new fields; however some, such as new fields in FHIR that contain fixed values are not included in this list.
| No. | Topic | Details | Implementation Impact |
|---|---|---|---|
| Receive Additional Information | Receive additional information on claim requests (and response?), store and relay to other stakeholders, as required | Impacts are currently under review and currently considered as draft | |
| 1 | Units of measure for products | The quantity field will allow for units, eg unit, package, mL, L,g, kg | Sender must include where value is known; Receiving system may ignore initially |
| 2 | Additional COB data in Request Claim Request |
New fields to support inclusion of adjudication details from previous payors in the claim request. The prior adjudication results will be added to the claim request along with minimal information about the prior payor (BIN, Amount paid, Intervention codes) | Sending systems must map into FHIR; Receiving systems may ignore |
| 3 | Additional COB data in Response Response - Adjudication Details |
Add fields to claim response to indicate how much of cost/markup/fee cutbacks can be passed on to secondary third parties and to patient. This data can then be passed on in secondary/tertiary claims. Purpose is to help pharmacies obey terms insurer makes with clients. | Sender must include data; Receiving system (PMS) must include in downstream FHIR claims |
| 4 | Compound ingredient Breakdown | New fields to allow for compound ingredients will be added (DIN, quantity, fraction of total price) & indicator of active ingredient | Sending systems must include data when known; Receiving systems must minimally store data |
| 5 | Diagnosis, up to 5 optional | Allow up to 5 diagnosis codes. | Sending system must include where known; Receiving system may ignore?TBD |
| 6 | Rendered Dosage - SIG | Add a field for pharmacies to submit the SIG as part of the claim request. Included to enhance adjudication /audit capability. | Sending system must include where known; Receiving system may ignore. |
| 7 | Total Quantity Dispense Accumulated field | 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. | Sending system must include when known; Receiving system consume when possible |
| 8 | Expand response message capability - Target Patient or Pharmacist |
Add flag on response message to indicate if it targeted at the patient or pharmacist. Field length/list will be handled by default by changing to JSON. Drug engine/DIA can start populating longer messages whenever they are ready. Pharmacies don’t need this at all since they have other means of doing interaction checks, including DIS.??? to be discussed* Today, 3 of 40 characters; if extended | |
| 9 | Medication code system | Add “Type” identifier on medication (eg DINS) to identify origin of pseudodins (NPN, Opinions,etc). This helps adjudicators to choose the correct product for adjudication. | |
| 10 | Pharmacy ID Assigning Authority (static value) | OID to align with other standards; this is fully mappable | |
| 11 | Banner Pharmacy Identifier | Identifier assigned by Banner and will assist with troubleshooting. Optional use as determined by implementer Organization.identifier slice |
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| 12 | Software Vendor pharmacy identifier | Identifier assigned by vendor, used for troubleshooting. Optional use as determined by implementer MessageHeader.application.identifier Organization.identifier |
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| 13 | Special Auth Period | New field in the Claim Response to convey start and expiry dates of a special auth | |
| 14 | Special Auth Days Supply in the Claim Response | New field in the response to convey the authorized says supply | |
| 16 | Special Auth Remaining Quantity | New field in the Claim Response | |
| Enhance field formats | Enhance field formats in the legacy applications to accommodate for the changing health care landscape | ||
| 1 | Increase price fields | Increase allowed amounts on request and response message (>9999.99 for cost, and >999.99 for fee) | Capability tracking/coordination between implementers is required |
| 2 | Deferred - New field for dollar value paid to patient | 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 |
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| 3 | Quantity - Increase Decimal Places | Change quantity to include up to 3 decimal places. Added quantity unit, eg g, mg, ml, tablet, capsule, puffer etc. Aligns with PrescribeIT and DHDR looking for drug form** This will enhance adjudication capability |
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| 4 | Expand response "message data line" - |
Change response messages (text) to a list, and increase acceptable character count from 40 characters per message to 1000. TBD upper limit on list | |
| 5 | 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 |
| 6 | Combine Pay Cardholder + Pay Provider | Transactions that are separate in CPHA will be combined into a single transactions that will specify the requested payee. The claim response will specify who the adjudicator will be paying. FURTHER DISCUSSION AND EXAMPLES REQUIRED | |
| 7 | Increase Intervention Codes | Increase the number of intervention codes on claim request to 10. | Must be managed; receiver may reject if necessary (in the case of a mapping failure) or ignore additional codes Coordination between implmeenters may be required |
| 8 | Expand response message capability - Language |
Optional language code (english/french/not specified) to response messages. Allows vendor to display based on the user language. Adjudicators may specify blank if unknown (eg CPHA or don't support), and for FHIR, both english and french are expected if possible. FHIR responses will contain english + french combined | |
| 9 | Increase Error Codes | Increase the number of error codes on claim response to 10. | TBD whether additional error codes can be ignored for MVP |
| 10 | Network Totals | This query has been updated to streamline the number of queries supported | Mandatory when moving to FHIR |
| 11 | Get Adjudication Details | This query has been updated to streamline the number of queries supported | Mandatory when moving to FHIR |
| 12 | Source 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 |
| Fulfill legislative requirements | Fulfill legislative requirements or provincial requests | ||
| 1 | New Quebec Pricing Fields | Allows the Quebec Reference Price | Senders must send values in accordance with legislation Capability Tracking not required |
| 2 | Provincial Prescription Number | New Optional field used upon request from Jurisdiction | |
| 3 | PrescribeIT Prescription Number | New Optional field used upon request from Jurisdiction | |
| Modernize CPHA | Modernize CPhA from flat file to FHIR+JSON for future interoperability and ease of maintenance | ||
| 1 | FHIR & JSON format | Update from existing CPHA3 data format from fixed-width to JSON with UTF-8 encoding. Field mappings are one-to-one with CPHA3, but the structure is a FHIR JSON message. re minimum (i.e. tx number + date). | |
| 2 | Separate DUR messaging | Update the structure of the message so that clinical messaging is separated from the fiscal portion of the claim | Built into FHIR structure |
| 3 | Remove unnecessary fields | Remove fields that are not used in CPHA3. This includes reducing the number of fields required to cancel a prescription | |
| 4 | New Professional services message | A new transaction to support the Professional service. Mandatory support from onset; Adjudicator must determine fixed values that are in CPHA3 but not in FHIR when mapping request | |
| 5 | Terminology Mappings | In a few cases, FHIR terminology is mandatory and therefore must be mapped into current values. For example, gender codes must be mapped | |
| 6 | Deprecate Messages in CPHA that are not used | No impact on implementers | |
| 7 | Re-write Adjudication Details and Totals | These are completely new and steamlined, with mandatory support | These transactions are not mappable between CPHA3 and FHIR and therefore must be natively supported from in MVP |