Claim Reversal
The Claim Reversal Request will be structured as a Bundle, with a Message Header and the focus will be a Parameters resource.
This transaciton can be directly mapped to the existing CPHA Reversal transaction although it has been streamlined to include only the required data elements.
Parameters IN Request
The following resource will be used for all adjudicated requests, both successful and those with errors. The request will be structured with a standard Bundle and Message Header Request. The transaction code will indicate that this is a claim reversal request.
This is not completely mappable from the CPHA Reversal request as there is data in the request that is completely unnecessary. Adjudicators will have enough data in the FHIR request to query their own systems to get any other data that they may require (eg coverage information).
The reversal may be for a claim accepted and adjudicated on the current or a previous adjudication date. The processor accepts or rejects the request for reversal and advises the provider via a response status . An accepted request will result in the reversal of the claim and on adjustment of the adjudication date totals. A rejected request advice will be followed by a response code or a detailed response to indicate the reason for rejection of the request.
There is no provision in the Standard for an adjustment on a previously submitted and accepted claim. It will be necessary to request a reversal and to resubmit the adjusted claim.
CPHA-FHIR Mappings
*REMOVE THIS AFTER RECONCILIATION
Refer to the Field Level Mappings section found here
| CPHA | FIELD NAME | FHIR Parameter | Notes |
|---|---|---|---|
| E.01.03 | Adjudication Date | ClaimResponse.created | The date, as determined by the processor, on which the claim, transaction or request being responded to has been adjudicated |
| E.02.03 | Trace Number | ClaimResponse.ClaimResponse.request.identifier | Trace number from the claim response, assigned by the provider |
| E.04. 03 | Reference Number | ClaimResponse.identifier | This is an internal reference number assigned to each claim by the processor |
| D.55.03 | Current Prescription Number | MedicationDispense.identifier and Claim.identifier | |
| B.22.03 | Provider Transaction Date | Claim.created |