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 = 151 for both 51 & 54 | New Code for Proff=131 | Code =161 fore reversals |
| 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 Data Elements
Following are the key new data elements that have no mapping from CPHA3. Fields with a fixed value are not included in the list below
| New Data Element | Resource | Notes |
|---|---|---|
| Patient Paid Amount | ClaimResponse.payeeType.coding.code=subscriber | |
| Payee Type | ClaimResponse.payeeType | |
| Language code for Process Notes | ClaimResponse.processNote.language | Value is en, fr or unknown expressed as text |
| Process Note Directed To | ClaimResponse.processNote.directed To - extension | Value is patient, provider or both. Use a value of both if unknown |
| Process Note Number | ClaimResponse.processNote.number | Vendors must co-relate french and english notes by assigning the same processNote.number |
| Process Note Type | ClaimResponse.processNote.type | Values, display, print |
| Outcome Code | ClaimResponse.outcomeCode | derived from Response Status value = error or complete |
| Special Auth Total Quantity Dispense Accumulated | ClaimResponse.item.adjudication | |
| Special Auth Remaining Quantity | ClaimResponse.item.adjudication | |
| Special Auth Approved Days Supply | ClaimResponse.item.adjudication | |
| Special Auth reference | ClaimResponse.preAuthRef | |
| Special Auth Period | ClaimResponse.preAuthPeriod | |
| PaymentType | ClaimResponse.payment.type | Value of "partial" or "complete" must be derived |
| Coverage Program Type | ClaimResponse.subType - extension | Used in the Prior Claim Response, to be shared with other adjudicators; never displayed in Pharmacy applications |
| Claim Response Type | Claim Response Sub-type | value = "public" or "private", "patientAssistedCard" or "unknown |