New Features & Functions High Level View

Key Problem Areas - Overview

The following key problem areas have been identified and will be addressed by the new FHIR standard. The timing for each will vary across implementers and will be determined by each, based on their ROI, Priority and Product Roadmap.

Details of each of the new fields and functions can be found in the pages that follow, eg "Claim Request- FHIR Features".

Problem Area	Description	Benefits Identified
Professional Services	New, separate transaction specifically designed for Professional Services	The new separate message is streamlined 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
COB - Additional information	Prior Payor Adjudication details	Improve COB adjudication; increase number of claims processed Increase claims that can be processed electronically; reduce auditing and clawbacks.
High Cost Drugs -> over 10K	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) Continue to support submission of multiple claims until all implementers can support a single claim over 10K.	Addresses serious issues for Pharmacies today who have to split these claims. Reduced auditing and pharmacy clawbacks. This will result in reduced time and effort for both pharmacies and adjudicators.
Improve Automation Capabilities	Additional data to support improved adjudication, reduced auditing and clawbacks.	Compound ingredients, Patient Paid Amount, SIG, Days supply over 999
Processing Improvements	Examples are: 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	Improved user experience, and Support Troubleshooting. Improve communications with directed to patient or pharmacist, french or english indicator
Modernization Items	Examples Are: 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	Implement modern technology that is flexible and easily extendible.
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.	New fields will allow implementers to properly adhere to legislative requirements