Claim Request - Over 10K - Proposal

The following is for consideration by the Implementation Committee to determine whether there is any advantage or disadvantage to having a separate message to handle claims over 10K. This has been proposed by some stakeholders and provides a starting point for discussion.

A new FHIR message has been created to support any claim over $10,000. Though this could technically be supported using the Claim Request - Dispense Message, the transition from the current state of split claims to the end state of a single claims submission will be easier to manage if there is a separate message for claims over 10K.

As background, the current approach for processing claims over 10K is that a single claim must be split into two or more claims and processed by the adjudicator as a split transaction. Often the adjudicator cannot correctly process two claims for the same medication on the same day as this will appear to be a duplciate. To overcome this challenge, pharmacists need to send the first portion of a claim on day 1 and the second portion of the claim on day 2.

If we look at the transition process between split claims and processing a single claim over 10K, the following must be considered:

  1. The Pharmacy Management System (PMS) must understand what adjudicators support a single claim versus a split claim for claims over 10K.
  2. The PMS must handle single claims over 10K and split claims at the same time.
  3. The PMS must be advised by the adjudicator when they have the capability of handling a single claim over 10K, and may only send a single claim over 10K when this capability is supported by the ajudidicator. This must be configurable within the PMS to ensure that single claims over 10K are not inadvertently send and rejected by adjudicators who do not have this capability.
  4. The adjudicator must handle single claims over 10K and split claims at the same time.
  5. The adjudicator must advise the PMS of the date in which they have the capability to receive and adjudicator a single claim over 10K
  6. The adjudicator must clearly recognize that a single claim over 10K is being submitted, versus a split claim being submitted. A SSC code is used for this purpose today (eg R = partial claim, exceeds $9999.99, S=remainder of claim, cost exceeds $9999.99). This approach will continue to be used until all adjudicators and PMS systems can fully support a single claim over 10K.
  7. The SSC field is being used today as there needed to be a place in CPHA3 to convey information about split claims. The use of this field is inappropriate and it is not advisable to carry this forward to FHIR. This will be carried forward for mapping purposes and will not be required once adjudicators can support the single claim approach. The current CPHA3 definition: Table 3 contains SPECIAL SERVICE CODES to be used by the provider, in Field D.57.03 to claim compensation for special services provided. These codes will usually apply to the provision of Professional Services.

Outstanding Issues for Review with Implementation Commitee:

  1. Do we anticipate professional services claims to be over 10K? Do we need to add a message for this purpose?
  2. There is no technical advantage to having a separate message for claims over 10K, other than managing a capability at the message level versus as a system feature. What is the preference by the implementation committee? Will it requrie more management to have a new message for this?