Reversal Response

In FHIR, there is only a single type of Reversal Response that is used when the claim reversal has been processed successfully. This maps to both the 61 and 64 transactions from CPHA. This transaction is used to request a reversal for both dispense and professional services claims.

CPHA Reversals

In CPHA3, one of the three responses would be received for reversals. As FHIR combines the reversal request into a single transaction, there is only a single response for a reversal to cover all scenarios

CPHA Transaction	Description	FHIR - CPHA Mapping
61	response to request for reversal of a pay provider claim which has been adjudicated. 61 will cover both support for 64 also; Pay Cardholder Claims. As both the provider and adjudicator understand this there is no need to separate this aspect of the claims.	If the reversal was for a pay cardholder claim this maps to 61 in CPHA
64	response to request for reversal of a pay cardholder claim	If the claim request for reversal is for for a pay cardholder claim, map to 64 for CPHA
67	response to request for reversal of a pay provider claim which has been captured but not adjudicated	Deprecated; the request for this type of reversal has been deprecated also

FHIR Claim Reversal Response Types

Following are the types of responses for a reversal of a Pay Provider Claim (01).

Request	Outcome	Response	FHIR Profile TBD, Add Links
Claim reversal	Successfully Processed	HTTP 200 + MH + Parameters OUT	Reversal-Success Note: Reversal may be Accepted or Denied. If Denied response codes may be present to provide explanation
Error Handling
Claim reversal	Communication Failure	HTTP 4xx or 5xx	N-A
Claim reversal	Application Error	HTTP 200, with Bundle, MH and Operations Outcome	Operation Outcome Example: Missing mandatory data

Reversal Claim Structure

The response will be a bundle with a message header and the focus will be the Paramamters OUT resource, the details of which are shown below

Reversal Parameters OUT - Mapping to CPHA

CPHA	FIELD NAME	FHIR Parameter	Details
E.01.03	Adjudication Date	ClaimResponse.created	Reversal Date
E.02.03	Trace Number	ClaimResponse.tracenumber	Trace number from the claim request
E.04. 03	Reference Number	ClaimResponse.identifier	Reversal Ref number
E.05.03	Response Status	ClaimResponse.decision	R = rejected V - reversal accepted
E.06.03	Response Codes	Reversal Response Codes	Only used when Response Status = R A7-submit manual reversal A9-reversal processed previously
E.20.03	Message Data Line	Reversal Refusal Reason	Only used when the response status = R
New	N/A	Reversal Amount	Only used when response status = V
New	N/A	Payee Type	Patient (CPHA 64) or Provider (CPHA 61)