Claim Request & Reversal Messages - FHIR-CPHA
DRAFT -to be validated
Pharmacy Benefit Managers/Adjudicators and PMS vendors will need to map from the existing CPHA standard into FHIR. The table below provides field level mapping between standards. Some fields require more complex mapping rules that are identified in the section that follows within this guide.
FHIR fields that are new do not need to be mapped and therefore are not identified in the table below. They can be ignored on an inbound claim, though it is recommended that the FHIR message as a whole be stored for audit/reference purposes. Some additional FHIR information may be useful for auditing, such as compound ingredients and COB/prior payment data.
When mapping from CPHA to FHIR, it is imperative to understand the message structure which is made up of several FHIR resources (eg claim, dispense, medication, etc), and each has a corresponding FHIR profile. The FHIR profiles are used to constrain the base FHIR message and to provide specific constraints and implementation and usage rules. The FHIR-CPHA mappings are also specified within each FHIR profile, in the comments section for each data element/field.
The mappings apply to both the Medication Dispense Claim and the Professional services claim. Differences are noted below.
Claim Request - Dispense & Professional Services & Reversal Request
A. Message Destination, Purpose and Control Elements
| CPHA Field ID | Field Name | FHIR Dispense | Proff Services | Reversal Request |
|---|---|---|---|---|
| A.01.01 | IIN ( Issuer Identification Number) | MessageHeader.destination.target.identifier | Same | Same |
| A.02.03 | Version Number | Bundle.meta.tag.code | Same | Same |
| A.03.03 | Transaction Code | MessageHeader.eventID+Payee | Same field; different value | Same field; different value |
| A.04.03 | Provider Software ID | MessageHeader.source.software | Same | Same |
| A.05.03 | Provider Software Version | MessageHeader.source.version | Same | Same |
| A.07.03 | Active Device ID | TBD | Same | Same |
B.Provider Information
| CPHA Field ID | Field Name | FHIR Dispense | Profff Services | Reversal |
|---|---|---|---|---|
| B.21.03 | Pharmacy ID Code | Claim.Provider.Organization.identifier.value | Same | Same |
| B.22.03 | Provider Transaction Date | Claim.created | Same | Parmaeter: Provider Transaction date; same as the claim req |
| B.23.03 | Trace Number | Claim.identifier | Same | Parameter:Claim.identifier |
C. Beneficiary Information
| CPHA Field ID | Field Name | FHIR Dispense | FHIR Proff Services | Reversal |
|---|---|---|---|---|
| C.30.03 | Carrier ID | Coverage.payor.identifier where Claim.insurance.focal = true | Same | Same |
| C.31.03 | Group Number or Code | Coverage.contract.identifier where Claim.insurance.focal = true | Same | Same |
| C.32.03 | Client ID # or Code | Coverage.subscriberId | Same | Same |
| C.33.01 | Patient Code | Coverage.dependent. Note: String in FHIR | Same | Same |
| C.34.01 | Patient DOB | Patient.birthdate | Same | N/A |
| C.35.05 | Cardholder Identity | RelatedPerson.name.family | Same | N/A |
| C36.03 | Relationship | Coverage.relationship.coding.code | Same | N/A |
| C.37.01 | Patient First Name | Patient.name.given | Same | N/A |
| C.38.01 | Patient Last Name | Patient.name.family | Same | N/A |
| C.39.03 | Provincial Health Care ID Code | Patient.identifier: JursidictionalHealthNumber. value | Same | N/A |
| C.40.03 | Patient Gender | Patient.gender | Same | N/A |
D. Prescription and Professional Service Information
| CPHA Field ID | Field Name | FHIR Dispense | FHIR Proff Services | Reversal | |
|---|---|---|---|---|---|
| D.50.03 | Medical Reason Reference | Claim.diagnosis.diagnosis[x]. coding.system | N/A | N/A | |
| D.51.03 | Medical Condition / Reason for Use | Claim.diagnosis.diagnosis[x].coding.code | Required for Minor Ailment | N/A | |
| D.52.03 | New/Refill Code | MedicationDispense.type | N/A | N/A | |
| D.53.03 | Original Prescription Number | Claim.originalPrescription.identifier | Claim.identifier for the service | N/A | |
| D.54.03 | Refill Repeat Autho | N/Arizations | Claim.supportingInformation. RefillsRemaining | N/A | |
| D.55.03 | Current RX Number | MedicationRequest.identifier | Claim.identifier | Claim.identifier | |
| D.56.03 | DIN /GP# / PIN | DIN /Claim.item.productOrService, Medication.code | Proff service code | N/A | |
| D.57.03 | SSC | Not in dispense message | Claim.item.modifier.coding:SpecialServiceCode | N/A | |
| D.58.03 | Quantity | MedicationDispense.quantity | N/A | N/A | |
| D.59.02 | Days Supply | MedicationDispense.daysSupply | N/A | N/A | |
| D.60.03 | Prescriber ID Reference | MedicationRequest.requester.identifier | N/A | N/A | |
| D.61.03 | Prescriber ID | MedicationRequest.requester.identifier | N/A | N/A | |
| D.62.03 | Product Selection | MedicationDispense.substitution.reason.code | N/A | N/A | |
| D.63.03 | Unlisted Compound | Claim.item.productOrService AND Medication.code | N/A | N/A | |
| D.64.03 | Special Authorization Number or Code | Claim.insurance.preAuthRef | Same - provincial input; don't think it is required on claim for Proff | N/A | |
| D.65.03 | Intervention and Exception Codes | Claim.item.modifier.coding:InterventionCode | Same; may be used for coverage items | N/A | |
| D.66.03 | Drug Cost / Product Value | Claim.item.detail:DrugCost.net.value | Map from Claim.item.detail:ProfessionalFee | N/A | |
| D.67.03 | Cost Upcharge | Claim.item.detail:Upcharge.net.value | N/A | N/A | |
| D.68.03 | Professional Fee | Claim.item.detail:ProfessionalFee.net.value | Same | N/A | |
| D.70.03 | Compounding Charge | Claim.item.detail:CompoundingCharge.net.value | N/A | N/A | |
| D.71.03 | Compounding Time | Claim.item.detail:CompoundingTime.value | N/A | N/A | |
| D.72.03 | Special Service Fee | Claim.item.detail:SSF.net.value | N/A | N/A | |
| D.75.03 | Previously Paid | See Complex Mapping Rule Below | N/A | ||
| D.76.03 | Pharmacist ID | MedicationDispense.performer.identifier & Claim.provider.reference.organization.identifier | same | N/A | |
| D.77.03 | Adjudication Date | TBD Only Used on Reversals | Parameter:Adjudication Date |
Additional Data Required for Proff Services
The following fields are required in the Professional Services claim, but are not part of the Medication Dispense claim.
| New Field | Description | FHIR Message |
|---|---|---|
| Performer | could be a nurse, a pharmacist or other healthcare professional hired by the pharmacy to do the proff service. | Claim.careTeam.provider.identifier |
| Responsible Pharmacist | The pharmacist who is repsonsible for the service. The pharmacist may be both the performer and the Responsible Pharmacist | Claim.careTeam.provider |
| Service Reason | Usage: eg Refusal to Fill intervention codes, along with others - TBD | Claim.supportingInfo:Reason |
| Link to claim | Usage: The professional services claim will reference the dispense claim that it relates to | Claim.related |
| Claim.subType | Identifies a professional services fee versus a disepnse fee. Required for message validatio |