Claim Request - Professional Services
Overview
Many stakeholders have expressed interest in a claim standard specialized for adjudicating professional service claims. Some examples include medication reviews, injection administrations, fees for therapeutic substitution, etc. Currently, these claims are adjudicated as prescriptions with pseudo-dins, and prescription-like data. While these claims are fiscal in nature, they often do not involve a drug product, and many of the prescription related fields such as repeats, authorized quantity, drug cost and upcharge are irrelevant when dealing with a fee for service. Further, additional information such as injection site, clinical outcome, and many other aspects may be required when tracking and paying for a professional service claim. The current CPHA message has only been used because it was what was available at the time the professional service programs were introduced.
This new message supports Pharmacies submitting a claim to an adjudicator for professional services and therefore has a new transaction id. The structure is close to the Claim for a Dispense, however there is no Medication Dispense data in the professional services claim. This message has been created with some input from provincial payors; however further input will be gathered as implementers gain some experience with these claims over time.
Mandatory for All Implementers who support Professional Services
Professional Services claims will be supported from the onset. This new transaction is mappable from the current dispense transaction as all new information is optional in the message.
Refer to the mapping section of this document for details, found here.
Profile Summary
| Profile Name | Profile Link |
|---|---|
| Bundle | Bundle Profile |
| MessageHeaderRequest | Profile for MessageHeaderRequest |
| Focus | ProfessionalServicesClaim |
FHIR Message
Following are some key notes regarding the Claim request message structure:
- Allows for "Prescription" data to be optionally included. Important for some use cases but not all. This includes the Prescriber and the medication/DIN, as well as a link from the Adapted Prescription. Though the "Medication Request" may convey full prescription details, only a few ncessary fields are supported in the Professional services claim.
- Adapted Prescription Details - are only included if required. This can identified the Pharmacist as a Prescriber where applicable. Notes are also included as an optional data element.
- Claim - this allows for a few additional fields for professional services as identified above, including the service location, care team members, adjusted/modified dosage/formulation, Therapeutic Substitition code and Clinical Reason code. All fields are optional and will vary by use case. None of these fields are expected during the MVP phase, though may be sent if the POS vendor wishes to do so and where no additional data must be entered by the user.
- Though COB is rare for professional services, the message structure optionally allows for it, using a mechanism that is identical to the claim for dispensed medications. As such, minimal if any addtional work is required to support this.
