Complex Mapping Rules FHIR-CPHA
DRAFT - WORK IN PROGRESS
This section itemizes mappings that are considered to be more complex. Some involve implementers to add specific coding. Others are considered to be complex simply because they are not straight field to field level mappings. Other mappings are not possible and therefore prohibited.
Claim Request
| Subject | CPHA ID | Field Name | FHIR Mapping rule |
|---|---|---|---|
| QJ Code | D.65.03 | Intervention/Exception | CPHA Code has been deprecated. QJ=deferred payment - patient to pay pharmacist can be derived using Payee Type = "subscriber" on the response message |
| DA and DBCode | D.65.03 | Intervention/Exception | CPHA Codes DA and DB have been deprecated. They are no longer required as the code meaning can be derived from the Claim Request, using the Prior Payor response(s)(FHIR: Claim.Insurance.ClaimResponse). The carrier and policy can be used to determine the type of coverage in prior claims and the DA/DB can be calculated by the adjudicator. THE FOLLOWING RULES ASSUME THE PRIOR PLANS ACCEPTED THE CLAIM (Response Code A or B). 1. If there is only a single plan for this claim (one instance of coverage in the FHIR message), DA/DB does not apply 2. When adjudicating a claim for the second plan, AND If the first plan was public (FHIR: Carrier + policy), * Assume DA code 3. If adjudicating a claim for the second plan, AND If the first plan was private (FHIR: Carrier+ policy), Assume a DB code 4. If adjudicating for YOU, third plan where 1-public + 2-private + 3-you, AND If the payor immediately before you was private(2), assume DB * If you are GreenShield, also assume DA in addition to DB 5. If adjudicating for YOU, third plan where (1-private + 2-public + 3-you) AND If the payor immediately before you was public(2), assume DA 6.. If plan is NIHB, the store is Ontario, the drug is an ODB Limited Use Product, and patient has ODB coverage, then * Assume DA 7. If the prior plan REJECTED the claim (response code R), and the pharmacy skipped the plan, then: * If you are NOT ESI, rejected plans are not taken into count when calculating DA/DB. Example: Public/private (rejected) then submitted to Private, neither the DA or DB would be apply to private * If you are ESI, then do not take into account the prior rejected plan if one of these error codes was included in the response: 'A6,C1,C4,C6,C8,CW,DX,EN,HA,HE,MW,MY,PA,QD,QJ,RW,SA', otherwise treat the rejected plan as a valid prior payor. |
| TransactionCode | A.03.03 & E.03.03 | Message.Header.event.code | The values are not a 1:1 mapping. Refer to Terminology for mapping rules - https://simplifier.net/guide/pharmacy-claims-standard/home/terminology-and-identifiers/event-transaction-code-for-review.page.md?version=current| |
| Single Claim over 10K | D.66.03 and others | Claim.item.detail.net.value | Claims over 10K must be managed as a 'feature', whereby the Pharmacy sending system understands whether the target adjudicator can accept a single claim over 10K. As CPHA3 supports a maximum drug cost of 9999.99, claims over this amount are split into two claims that together make up the entire drug cost. Special service codes are used to convey that the claim has been split. From a mapping perspective, this would mean that a single claim request would need to be split into two claims in the adjudicator engine if they do not natively support a single claim over 10K. The reverse situation is also true, whereby two claims being submitted by a PMS system must be mapped into a single claim. Neither of these two scenarios are feasible. Much further work is required to determine the implementation approach for this particular feature but at this point in time we beleive that it must be managed through capability tracking whereby the sending system knows what the adjudicator can support and aligns the request to meet that need. This will require coordination amongst implementersy. The SSCs that are used today are: R = partial claim, cost exceeds $9999.99. S = remainder of claim, cost exceeds $9999.99 FURTHER DISCUSSION REQUIRED |
| Intervention Codes | D.65.03 | Intervention/Exception | When an adjudicator maps from FHIR-CPHA, they may receive more than 2 codes (CPHA3 limit). In addition, some concepts that are intervention codes in CPHA3 will be replaced by FHIR data elements which will result in more than 2 codes. It may be necessary for the adjudicator to reject if there are more than 2 codes. Ideally, capability tracking will be used to advise the sending system to only send 2; however for the aforementioned reason, mapping could result in more than 2 codes |
| New Professional Service Claim | DIN | FHIR will include a separate message specifically designed for professional services. When mapping to CPHA3, this MessageHeader.event code (interaction) must be recognized and mapped into the CPHA 3 format. Refer to Terminology, Event Code listing for mapping detai | |
| Deferred - Trxn 04 Deprecated |
N/A | Deferred Payments | For payors that support pay patient claims (transaction type 04), these will no longer be supported and instead, the payee on the claim request will be used for this purpose. On the response, adjudicators must return the amount paid to the patient in the new field, and return 0 in the amount paid to the pharmacy field |
| Claim.Diagnosis | D.51.03 | Medical Condition / Reason for Use | CPHA limits this to a single code, 6 digits; FHIR will allow 0..*, with a practical limitation of 10. Implementers will determine the code system to be used |
| Claims over 9999.99 | Several | Dollar Amounts | FHIR extends the dollar limits to allow for a single claim over 10K. Currently, claims over this amount are mapped into multiple claims. It is not possible to map two inbound claims into a single claim for adjudication without serious risks; therefore, mapping will be prohibited and partnering systems must agree on timing and coordinate this during the implementation phase |
| Special Services Fee | D.72.03 | Claim Dispense Request | In CPHA this is being used by some to convey the remaining balance between what the provincial plan amount is and the total submission amount? It could also be used for the eligible amount from the provincial plan. We ahve added a field to the dispense claim to convey the eligible amount from the provincial plan. Adjudicators are using this value to drive some adjudication rules. More information is required in order to confirm the use of this field and where the POS vendor gets this information from. Do we need this for another purpose? Do we need this for professional services as well? |
| Special Services Code | Removed from the dispense message | Only present in the Professional Services Claim as it only applies to professional services. |
Response Mapping - FHIR to CPHA3
| Subject | CPHA ID | CPHA Name | Notes |
|---|---|---|---|
| Response Status - No mapping | E.05.03 | ClaimResponse.status | There is no direct mapping to these values but all can be derived A=accepted as transmitted - no adjustments B=accepted with Rx price adjustment C=claim captured for batch processing D=pay cardholder claim accepted R=rejected laim/reversal V=reversal accepted |
| Alert Codes - Clinical | E.06.03 | Response Codes | Clinical messaging will be split out from the fiscal response codes. Example: MA Avoidance of Alcohol Indicated There is no direct mapping to these values but all can be derived Mapping from FHIR Detected Issue resource will be required for vendors who support CPHA3 |
| Claim.item.detail.code | D.66.03 D.67.03 D.68.03 |
In CPHA3, there are distinct fields to specify the cost breakdown. In FHIR, these are represented as details, each with its own code. Mapping is straightforward, and only included here as mapping is not a field-field level mapping. Refer to the Terminology, Adjudication Category for full mapping details | |
| Patient Pays Amount | D.75.03 | Previously Paid | Derive from the ClaimResponse.payeeParty.type = subscriber. The ClaimResponse.total.amount.value will indicate the amount paid to patient (aka subscriber) |
Backward Compatibility Mapping
Vendor sends FHIR, Carrier accepts CPHA
Vendor sends CPHA, Carrier has moved to FHIR? to be discussed
| FHIR | Issue | CPHA Field | Approach |
|---|---|---|---|
| Claim.diagnosis | CPHA Allows for only 1; FHIR is 0..10 | Medical Condition | ODB only one using diagnosis code for LU products reject if more than one code submitted, or ignore |
| Medication.ingredient | Compound Ingredient breakdown not in CPHA | Ignore data; adjudicators store for audit purposes | |
| Intervention Code & Error Code | FHIR allows for 10, CPHA allows 3 | ||
| Response message (text) to list, character count from 40-1000 | This is a non-issue. CPHA adjudicators will maintain CPHA rules |