Claim Request - Dispensed Product

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.

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 Claim Response	Profile for Prior Adjudication Details
Extension - Medication Profile	Ingredient Percentage Total Cost
Extension - Medication Profile	Ingredient Quantity
Extension - Claim	Rendered Dosage Instruction

**This is a draft, to be fully reviewed by the TWG before it is finalized**.