Claim Request & Reversal Messages - FHIR-CPHA
Overivew
Pharmacy Benefit Managers/Adjudicators and PMS vendors will likely 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. These new fields can be ignored on an inbound claim request if mapping to CPHA3, though it is recommended that the FHIR message as a whole be stored for audit/reference/troubleshooting purposes. Some additional FHIR information may be useful for auditing, such as compound ingredients and COB/prior payment data, even if not consumed by the core adjudication systems.
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), each of which 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 | Notes |
|---|---|---|---|---|---|
| A.01.01 | IIN ( Issuer Identification Number) | MessageHeader.receiver.identifier | Same | Same | Direct mapping |
| A.02.03 | Version Number | No direct mapping and not relevant in FHIR | |||
| A.03.03 | Transaction Code | MessageHeader.eventID+Payee | Same field; different value | Same field; different value | Transformation required |
| A.04.03 | Provider Software ID | MessageHeader.source.software | Same | Same | Direct mapping |
| A.05.03 | Provider Software Version | MessageHeader.source.version | Same | Same | Direct Mapping |
| A.07.03 | Active Device ID | If required, MessageHeader.source.name | Same | Same | Direct Mapping |
B.Provider Information
| CPHA Field ID | Field Name | FHIR Dispense | Profff Services | Reversal | Notes |
|---|---|---|---|---|---|
| B.21.03 | Pharmacy ID Code | Claim.Provider.identifier.value | Same | Same | Direct Mapping; may also be specified if PharmacyOrganization resource is used |
| B.22.03 | Provider Transaction Date | Claim.created | Same | Parmaeter: Provider Transaction date; same as the claim req | Direct Mapping |
| B.23.03 | Trace Number | Claim.identifier | Same | Parameter:Claim.identifier | Direct mapping on value; must add system=http://pharmacyeclaims.ca/FHIR/CPHA-identifier/trace-number |
C. Beneficiary Information
| CPHA Field ID | Field Name | FHIR Dispense | FHIR Proff Services | Reversal | Notes |
|---|---|---|---|---|---|
| C.30.03 | Carrier ID | Coverage.payor.identifier where Claim.insurance.focal = true | Same | Same | Direct mapping to primary; New concept/no mapping to secondary payor in a primary claim |
| C.31.03 | Group Number or Code | Coverage.contract.identifier where Claim.insurance.focal = true | Same | Same | Direct mapping for primary |
| C.32.03 | Client ID # or Code | Coverage.subscriber.identifer | Same | Same | Direct mapping for primary |
| C.33.01 | Patient Code | Coverage.dependent Note: String in FHIR | Same | Same | Direct mapping for primary |
| C.34.01 | Patient DOB | Patient.birthdate | Same | N/A | Direct format; formatting change to FHIR YYYY-MM-DD |
| C.35.05 | Cardholder Identity | Coverage.subscriber.display | Same | N/A | Direct mapping for primary though full name should be sent |
| C36.03 | Relationship | Coverage.relationship.coding.code | Same | N/A | Transformation of codes required |
| C.37.01 | Patient First Name | Patient.name.given | Same | N/A | Direct Mapping |
| C.38.01 | Patient Last Name | Patient.name.family | Same | N/A | Direct Mapping |
| C.39.03 | Provincial Health Care ID Code | Patient.identifier: JursidictionalHealthNumber. value. AND Coverage.subscriber.identifier | Same | N/A | Direct mapping of value; must add the system associated with the JHN, and also the identifier.type=JHN |
| C.40.03 | Patient Gender | Patient.gender | Same | N/A | Transformation of codes is required |
D. Prescription and Professional Service Information
| CPHA Field ID | Field Name | FHIR Dispense | FHIR Proff Services | Reversal | Notes |
|---|---|---|---|---|---|
| D.50.03 | Medical Reason Reference | Claim.diagnosis.diagnosis[x]. coding.system | N/A | N/A | Direct mapping |
| D.51.03 | Medical Condition / Reason for Use | Claim.diagnosis.diagnosis[x].coding.code | Required for Minor Ailment | N/A | FHIR allows for both a code and text |
| D.52.03 | New/Refill Code | MedicationDispense.type | N/A | N/A | Transformation required |
| D.53.03 | Original Prescription Number | Claim.originalPrescription | Claim.identifier for the service | N/A | Direct Mapping |
| D.54.03 | Refill Repeat Autho | Claim.supportingInformation. RefillsRemaining |
N/A | N/A | Direct Mapping |
| D.55.03 | Current RX Number | Claim.identifier | Claim.identifier | Claim.identifier | Direct mapping |
| D.56.03 | DIN /GP# / PIN | DIN /Claim.item.productOrService, Medication.code |
Proff service code | N/A | Direct Mapping with addition of System ID to identify DIN versus CCDD, etc. |
| D.57.03 | SSC | Claim.item.modifier.coding: SpecialServiceCode |
Claim.item.modifier. coding:SpecialServiceCode Confirm use in DISPENSE CLAIM |
N/A | Direct mapping of code; addition of system=http://pharmacyeclaims.ca/FHIR/CodeSystem/special-service-codes to uniquely identify SSC versus another modifier |
| D.58.03 | Quantity | MedicationDispense.quantity | N/A | N/A | Direct map + units of measure |
| D.59.02 | Days Supply | MedicationDispense.daysSupply | N/A | N/A | Direct map; FHIR allows 4 characters and specification of "days" |
| D.60.03 | Prescriber ID Reference | MedicationRequest. requester.identifier |
N/A | N/A | Direct mapping |
| D.61.03 | Prescriber ID | MedicationRequest. requester.identifier |
N/A | N/A | Direct mapping plus optional assigner with current CPHA v |
| D.62.03 | Product Selection | MedicationDispense.substitution. reason.code |
N/A | N/A | Direct Mapping of code; display optional. System is mandatory; set value as Set value = http://pharmacyeclaims.ca/FHIR/CodeSystem/substitution-reason-codes Must also specify a substitution flag (true/false) |
| D.63.03 | Unlisted Compound | Claim.item. productOrService AND Medication.code |
N/A | N/A | Medication.code.coding.system=http://pharmacyeclaims.ca/FHIR/CodeSystem/unlisted-compound-codes AND Medication.code is direct mapping. Medication.code.codeableConcept.text may contain the name of the compound. Ingredients may also be specified in Medication resource |
| D.64.03 | Special Authorization Number or Code | Claim.supportingInfo: SpecialAuthNumber.value |
TBD provincial input required; may not be required on claim for Proff |
N/A | DirectMapping |
| D.65.03 | Intervention and Exception Codes | Claim.item.modifier.coding: InterventionCode |
Same; may be used for coverage items |
N/A | Direct Mapping; though 10 codes supported in FHIR versus 2 in CPHA3 |
| D.66.03 | Drug Cost / Product Value | Claim.item.detail:DrugCost.net.value | Map from Claim.item.detail:DrugCost | N/A | Direct Mapping |
| D.67.03 | Cost Upcharge | Claim.item.detail:Upcharge.net.value | N/A | N/A | Direct Mapping |
| D.68.03 | Professional Fee | Claim.item.detail: ProfessionalFee.net.value |
Same | N/A | Direct Mapping |
| D.70.03 | Compounding Charge | Claim.item.detail: CompoundingCharge.net.value |
N/A | N/A | Direct Mapping |
| D.71.03 | Compounding Time | Claim.item.detail: CompoundingTime.value |
N/A | N/A | Direct Mapping; unit is new |
| D.72.03 | Special Service Fee | Claim.item.detail: SSF.net.value |
N/A | N/A | Direct Mapping |
| D.75.03 | Previously Paid | See Complex Mapping Rule Below |
N/A | See Complex Mapping below | |
| D.76.03 | Pharmacist ID | MedicationDispense. performer.identifier |
same | N/A | Direct Mapping |
| D.77.03 | Adjudication Date | N/A | *Only Used on Reversals *Parameter:Adjudication Date |
Direct Mapping for reversals |
New Fields- No Mapping from FHIR-CPHA3
Following is a listing of the "key" new data elements/fields that have been added to the PCS FHIR specification. These do not exist today in CPHA and therefore there is no direct mapping. Refer to the FHIR Profiles and message examples for further details. Note: FHIR fields with a fixed value are not included in the list below though there is no maping to/from CPHA. Any new fields can be managed with simple transformation rules to set the fixed values.
| New Field | FHIR Message | Notes |
|---|---|---|
| RenderedDosage | Claim.extension | Textual field to capture the rendered dosage |
| Link to/from Dispense claim to Professional services claim | Claim.Related | |
| Disepnse Quantity Remaining | Claim.supportingInfo | |
| Medication Dispense Quantity Unit Code | MedicationDispense.Quantity.Unit.Code | Usage: Most common are tabs, pack, mg, grams, kg, ml, litres Rationale: Allows for validation in pricing where necessary. Reduces auditing as pricing be verified and must be supplied when known |
| PresribeIT Identifier | MedicationRequest.identifier | Only used upon request |
| Jurisdictional Prescription Number | MedicationRequest.identifier | Only used upon request |
| Claim Created Date | Claim.created | This may be different than the dispense date; mandatory in FHIR |
| DetectedIssue Details | MedicationDispense.detectedIssue | Future - may be used to provide further details regarding managed issues & drug interactions |
| Prior Payment Details | Claim Request (secondary) and Adjudication Response | only the paid amount can be mapped; all other fields are new and cannot be mapped |
Additional Fields 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 validation | |
| Claim.related | Usage Note: This is a new field in the claim for the dispense. It is a reference to a related dispense claim identifier to allow adjudicators to formally relate the professional claim to the claim for the medication dispense and vice versa. Usage Note: If known to the pharmacy, this link should be provided. CPHA Map: None - this is a new data element |