Claim Request & Reversal Messages
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 Reversal
In CPHA3 today, the provider requests reversal of a claim and transmits the mandatory elements of Sections A, B, C, the current prescription number (Field D.55.03) from Section D, and the adjudication date (Field E.01.03) for the claim to be reversed.
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 | MH.Responsible.identifier | 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 and MedicationRequest.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 |
Claim.careTeam and MedRequest.requester.identifier | N/A | Direct mapping | |
| D.61.03 | Prescriber ID | MedicationRequest. requester.identifier |
Claim.careTeam and MedRequest.requester.identifier | N/A | Direct mapping plus optional assigner with current CPHAv3 | |
| D.62.03 | Product Selection | MedicationDispense.substitution. reason.code |
N/A | N/A | Direct Mapping of code; display optional. FHIR also has a mandatory flag/boolean for substitution. Reason is only provided when substitution boolean is indicated as true. System is mandatory; set value as Set value = http://pharmacyeclaims.ca/FHIR/CodeSystem/substitution-reason-codes | |
| 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 and Claim.item.detail.EligibleAmtProvincialPlan |
N/A | N/A | Direct Mapping in most cases. | |
| D.75.03 | Previously Paid | See Complex Mapping Rule Below |
N/A | See Complex Mapping below | ||
| D.76.03 | Pharmacist ID | MedicationDispense. performer.identifier |
Claim.careTeam.provider.identifier | N/A | Direct Mapping | |
| D.77.03 | Adjudication Date | N/A | *Only Used on Reversals *Parameter:Adjudication Date |
Direct Mapping for reversals |