Claim Reversal
The Claim Reversal Request will be structured as a Bundle, with a Message Header and the focus will be a Parameters IN resource. There is a single Bundle and Message Header profile that is used for all messaging in this PCS specification.
This transaction can be directly mapped to the existing CPHA Reversal transaction although it has been streamlined to include only the required data elements. The claim status will be updated to cancelled on a FHIR server when the reversal is successful.
Profile Summary
The request will be structured with a standard Bundle and Message Header Request with a focus being the Parameters IN resource. The MessageHeader.EventCode will identify that this is a claim reversal request.
| Profile Name | Profile Link |
|---|---|
| Bundle | Bundle Profile |
| MessageHeaderRequest | Profile for MessageHeaderRequest |
| Parameters IN | tbd |
Parameters IN Request
This message is not completely mappable from the CPHA Reversal request as there is data in the request that is completely unnecessary and unused today. Adjudicators will have enough data in the FHIR request to query their own systems to get any other data that they may require to complete the CPHA3 request (eg coverage information).
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 - PARAMETERS IN
Status: TO BE REMOVED AFTER RECONCILIATION/REVIEW, REPLACED WITH PROFILE
Refer to the Field Level Mappings section for Bundle and Message Header mappings, 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 to the claim request, 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 RX Number | MedicationDispense.identifier and Claim.identifier | |
| B.22.03 | Provider Transaction Date | Claim.created |