Claim Reversal Response
In FHIR, there is only a single type of Reversal Response that is used when the claim reversal has been processed successfully, and the distinction of type of reversal is indicated as a response parameter. This FHIR message 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.
FHIR Reversal Response Type - Details
The reversal may be for a claim that has been adjudicated on the
current or a previous adjudication date. The adjudication response will be one of the following:
| Request | Outcome | Response | FHIR Profile TBD, Add Links |
|---|---|---|---|
| Claim reversal | Successfully Processed | HTTP 200 + MH + Parameters OUT | V - (Success). An accepted request will result in the reversal of the claim. The FHIR claim.status = reversed on a FHIR server and an adjustment of the adjudication date totals. R (Rejected) If Rejected, response codes may be present to provide explanation. The FHIR claim.status will remain as active on a FHIR server. |
| Errors | |||
| 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 | Claim.Status | Active (if reversal successful) or Cancelled (if rejected/denied). Optional. This reflects the status of the claim on the FHIR server |
| New | N/A | Reversal Amount | Only used when response status = V |
| New | N/A | Payee Type | Patient (CPHA 64) or Provider (CPHA 61). This is the payee type on the original claim request |
CPHA Reversal - Deprecated
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. The following will be deprecated
| 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 |