Response Messages FHIR-CPHA

Claim Response

The following mappings are used in both the FHIR:Claim Response and also the FHIR:Prior Claim Response resource that is submitted as part of the secondary and tertiary claims to convey details of the prior adjudication results. The Prior Claim Response is a subset of the Claim Response.

A similar response is also used for Professional services and therefore the mappings from the Dispense Response to the Professional Services response are included below. The reversal response also demonstrates the data that is included in the Reversal, and where it is found in the dispense or professional services response.

Only the key data elements are included in the mapping table below

CPHA	FIELD NAME	FHIR Dispense Response	Proff Services Response	Reversal Response
E.01.03	Adjudication Date	ClaimResponse.created	Same	Parameters.parameter:AdjudicationDate
E.02.03	Trace Number	ClaimResponse.tracenumber	Same	Parameters.parameter:TraceNumber
E.03.03	Transaction Code	MessageHeader.event.code = 51 for both 51 & 54	New Code for Proff=31	Code =61, Same as CPHA
E.04. 03	Reference Number	ClaimResponse.identifier	Same	Parameters.parameter:ReferenceNumber
E.05.03	Response Status	ClaimResponse.disposition	Same	Parameters.parameter:ResponseStatus
E.06.03	Response Codes	ClaimResponse.item.adjudication:ResponseCodes	Same	Parameters.parameter:ResponseCodes
E.08.03	Drug Cost / Product Value	ClaimResponse.item.adjudication:DrugCost	N/A	N/A
E.09.03	Cost Upcharge	ClaimResponse.item.adjudication:Upcharge	N/A	N/A
E.10.03	Generic Incentive	ClaimResponse.item.adjudication:GenericIncentive	N/A	N/A
E.12.03	Professional Fee	ClaimResponse.item.adjudication:ProfessionalFee	Same	N/A
E.13.03	Compounding Charge	ClaimResponse.item.adjudication:CompoundingCharge	N/A	N/A
E.14.03	Special Services Fee	ClaimResponse.item.adjudication:SSF	N/A	N/A
E.15.03	Co-pay to Collect	ClaimResponse.item.adjudication:CoPayToCollect	Same	Same
E.16.03	Deductible to Collect	ClaimResponse.item.adjudication:DeductibleToCollect	Same	Same
E.17.03	Co-Insurance to Collect	ClaimResponse.item.adjudication:CoInsuranceToCollect	Same	Same
E.19.03	Plan Pays	ClaimResponse.payment.amount	Same	Same
E.20.03	Message Data Line	ClaimResponse.processNotes.text	Same	Parameters.parameter:ReversalRefusalReason
E.21.03	Message Data Line	ClaimResponse.processNotes.text	Same	Parameters.parameter:ReversalRefusalReason
E.22.03	Message Data Line	ClaimResponse.processNotes.text	Same	Parameters.parameter:ReversalRefusalReason

##New Concepts

|New|Patient Paid Amount|ClaimResponse.payeeType.coding.code=subscriber| |New| |New|Language code - Response messages|ClaimResponse.processNote.language| |New||ClaimResponse.outcomeCode|derived from Response Status value = error or complete|