Claim Request - Professional Services

Overview

Many stakeholders have expressed interest in a claim standard specialized for adjudicating professional service claims. Some examples include medication reviews, injection administrations, fees for therapeutic substitution, etc. Currently, these claims are adjudicated as prescriptions with pseudo-dins, and prescription-like data. While these claims are fiscal in nature, they often do not involve a drug product, and many of the prescription related fields such as repeats, authorized quantity, drug cost and upcharge are irrelevant when dealing with a fee for service. Further, additional information such as injection site, clinical outcome, and many other aspects may be required when tracking and paying for a professional service claim. The current CPHA message has only been used because it was what was available at the time the professional service programs were introduced.

This new message supports the Pharmacy submitting a claim to an adjudicator for professional services. The structure is close to the Claim for a Dispense, however there is no Medication Dispense or Prescription (Medication Request) information present in the professional services claim. Though coordination of benefits is unlikely to be used, the message supports it in case it is required in the future. The professional service claim for FHIR introduces a new transaction code to indicate a professional service.

This message has been created with some input from provincial payors; however further input is desired. The requirements need to provide enough information to be able to apply regulated limitations to the services with mandatory coverage (e.g. Quebec).

Requirement for Implementation by Payors/Adjudicators

The migration timeline to support the new Professional Services claim will be determined by each Implementer or ideally will be agreed to across multiple implementers. This new transaction is mappable from the current dispense transaction and ideally both vendors and payors will support this transaction from the initial MVP stage so that benefits are realized from the onset.

The alternative is that payors who do not support this would need to reject the claim with a “transaction code not supported” error. This burdens the pharmacy vendor and potentially the pharmacy user as well as they would need to revert to a dispense message. This also means that all implementers would need to support two mechanisms for processing professional services claims.

For these reasons it is strongly recommended that this new transaction be supported from the onset during the MVP stage using mapping. Refer to the mapping section of this document for details, found here.

Profile Summary

Profile Name	Profile Link
Bundle	Bundle Profile
MessageHeaderRequest	Profile for MessageHeaderRequest
Focus	ProfessionalServicesClaim

Requirements from BC

BC has introduced 2 concepts in addition to the usual intervention codes for professional services. We will need to review as a group and ensure that these are represented in the standard

MMI - Medication Management Intervention
CS - Clinical Service Codes

CS codes have a child relationship to MMI types - Taryn has a spreadsheet