New Fields & Functionality
DRAFT - For review
This standard is based upon version 4.0.1. The following outlines the new fields and changes from the existing CPHA Standard. Updates to the new standard may include a) New Fields, not in CPHA, b)Technical Updates such as the movement from a fixed format to JSON, c) changes to Conformance Rules, such as a field becoming mandatory versus optional or vice versa or d) data type upgrades to enhance clarity on existing CPHA fields. Fields that are not used in CPHA may also be removed in the new standard.
From a business perspective, the FHIR standard will address the following key problem areas:
| Key Problem Area | How addressed in the new standard |
|---|---|
| Professional Services | New claim type that specifically addresses professional services based on known business requirements (They don’t fit nicely in the standard today, eg there is no days supply on a minor ailment service) |
| Coordination of Benefits | Additional information to support COB including:-Prior Payor Adjudication details -Specification of payee as the “subscriber” or “provider” -Deprecate use of DA/DB |
| High Cost Drugs | 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) |
| Improve Automation Capabilities | Add Compound details Add Prior Payment Details Add Total Quantity Dispense Accumulated field Add Rendered Dosage Instruction (SIG) Days supply over 999 Increase number of Intervention codes Add units of measure to products Quantity field – increase decimal places Allow for multiple Diagnosis Codes to be specified |
| Processing Improvements | Support additional error codes Support additional messages in the response and target the message to the right audience -> provider or patient Separate clinical messaging from fiscal messages Messaging in French, English or both Software Vendor pharmacy identifier Banner Pharmacy Identifier |
| Support Legislative & Jurisdictional Requirements | New fields for Quebec pricing fields Identifier sharing - Provincial Prescription number and PrescribeIT RX Number to allow provinces to track a prescription through its life cycle. |
| Modernization Items | Move to modern standards -> FHIR, JSON and REST Align with other relevant standards where possible Add code systems for DINs, quantity Add DIN code systems Streamline messaging by combining Pay Cardholder + Pay Streamline Network Totals Streamline Adjudication Details Query Deprecate codes/transactions that are no longer in scope |
Changes in FHIR - Detailed View
The following provides a more detailed view of the key changes that implementers will see within the FHIR message itself.
| Number | Topic | Category & Details | Implementation Impact |
|---|---|---|---|
| Receive Additional Information | Receive additional information on claim requests (and response?), store and relay to other stakeholders, as required | ||
| 1 | Add 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 No capability tracking/coordination required |
| 2 | Additional COB data 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 No capability tracking/coordination required |
| 3 | Additional COB data 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 No capability tracking/coordination required |
| 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 No capability tracking/coordination required |
| 5 | Diagnosis, up to 5 optional | Allow up to 5 diagnosis codes. | Sending system must include where known; Receiving system may ignore?TBD No Capability tracking/coordiantion required |
| 6 | Add 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. No Capability tracking/coordiantion required |
| 7 | Add Total Quantity Dispense Accumulated field | Additional field to enhance adjudication | Sending system must include when known; Receiving system may ignore No capability tracking/coordination required |
| 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 | No capability tracking required |
| 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 | No capability tracking required |
| 11 | Provincial Prescription Number | Optional, only used when requested in future by province, where known MedicationRequest.identifier |
No capability tracking required |
| 12 | Banner Pharmacy Identifier | Identifier assigned by Banner and will assist with troubleshooting. Organization.identifier slice |
No capability tracking required |
| 13 | Software Vendor pharmacy identifier | Identifier assigned by vendor, used for troubleshooting MessageHeader.application.identifier Organization.identifier slice |
No capability tracking required |
| Enhance field formats | Enhance field formats in the legacy applications to accommodate for the changing health care landscape | ||
| 9 | Increase price fields | Increase allowed amounts on request and response message (>9999.99 for cost, and >999.99 for fee) | Capability tracking/coordination required- refer to Complex mapping rules |
| 10 | 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 |
|
| 11 | 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 |
|
| 12 | Expand response "message data line" - List |
Change response messages (text) to a list, and increase acceptable character count from 40 characters per message to 1000. TBD upper limit on list | TBD |
| 13 | 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 Capability tracking not required |
| 14 | 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 | |
| 15 | 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 Capability tracking is required |
| 16 | Expand response message capability - Language |
Add language code (english/french/not specified) to response messages. This cannot be at the bundle level; could be english + french translation and vendor will display based on the user language. Adjudicators should be able to specify blank if unknown (eg CPHA or don't support), and for FHIR, both english and french are expected if possible. Need blank language code for Backwards compability. FHIR responses will contain english + french combined | No Capability tracking/coordination |
| 17 | Increase Error Codes | Increase the number of error codes on claim response to 10. | Capability tracking may be required |
| 18 | Network Totals | This query has been updated to streamline the number of queries supported | No capability tracking is required if mandatory when moving to FHIR |
| 19 | Adjudication Details | This query has been updated to streamline the number of queries supported | No capability tracking is required if mandatory when moving to FHIR |
| 8 | 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 | ||
| 18 | Add Quebec Pricing Fields | Allows the Quebec Reference Price | Senders must send value in accordance with legislation Capability Tracking not required |
| Modernize CPHA | Modernize CPhA from flat file to FHIR+JSON for future interoperability and ease of maintenance | ||
| 19 | FHIR & JSON format | hanged 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). | Capability tracking/coordination required |
| 20 | Separate DUR messaging | Update the structure of the message so that this clinical messaging is separated from the fiscal portion of the claim | Capability Tracking/coordination not required |
| 21 | Remove unnecessary fields | Remove fields that are not used in CPHA3. This includes reducing the number of fields required to cancel a prescription to the ba | |
| 26 | Professional services message | A new transaction to support the Professional service. Must be present prior to implementation and must be mappable |