Claim Request - Dispense
A single FHIR message structure will support both the Pay Provider Claim (01) and the Pay Cardholder Claim (04). the Message Header.event.code will identify whether this is an "01" or an "04", however, this will also be identified in the Claim.payee data elements. The "01" and "04" are only retained for backward compatibility and efficiency for systems who are mapping between FHIR and CPHA.
Pay Provider Claim. (01)
The diagram below depicts the structure of a FHIR Claim Request. Below the diagram, there are links to all FHIR profiles and each profile has details with respect to mandatory and optional fields and conformance rules as well as links to the field values (aka terminology). The diagram highlight the mappings from FHIR to CPHA, shown in bolded capital letters.
Pay Cardholder Claim (04)
The provider sends a single claim, as it is dispensed, containing the information described in the Model Below. This message structure is identical to the Pay Provider Claim Request. There will be two differences in the way it is populated:
The claim is for a patient who has a reimbursement program. The processor acknowledges receipt of the claim immediately, but the results of the adjudication and the payment will be forwarded to the cardholder.
**This is a draft, to be fully reviewed by the TWG before it is finalized**.
Profile Summary
| Profile Name | Profile Link |
|---|---|
| Bundle | Bundle Profile |
| MessageHeaderRequest | Profile for MessageHeaderRequest |
| eRX ClaimRequest | Profile Claim Dispense |
| Dispense | Profile-Dispense |
| Prescription | Profile for Prescription |
| Medication | Profile for Medication |
| Patient | Profile for Patient |
| Pharmacy | Profile for Pharmacy |
| Coverage | Profile for Coverage |
| Prior Coverage | Profile for Prior Coverage |
| Clinical Issues Detected | Profile for Detected Issue |
| Prior Payment Details | Profile for Prior Claim Response Details |