Claim Response - Dispense
The processor adjudicates the claim as it is received, and returns the results of adjudication immediately. The results will include an explanation using response codes and text should the claim be rejected. An accepted claim includes payment details which will align with the payment to the provider.
The MessageHeader.eventCode will indicate whether this is a CPHA 51, 54. Additionally, for a pay cardholder claim, the ClaimResponse.payeeType will indicate who will be paid.
The same response is used for both the claims that are paid to the provider (51) as well as claims that are paid to cardholders (54). In CPHA, there was a response to pay providers for batch (57) which has now been deprecated.
Business Rules
Claim Response - Disposition and Outcome
The Claim Response and the Prior Claim Response both contain the Disposition and Outcome fields. These are crucial for the POS vendor and Pharmacy User to understand what has occurred so they may take appropriate action. The following is provided as guidance to Adjudicators in setting these values that will be passed on to downstream payors.
When setting the outcome:
- The outcome will be set to "complete" when the claim can be fully adjudicated, even when the claim is rejected due to plan restrictions.
- The outcome will be set to "error" when there are corrections to be made, eg when the plan or plan member cannot be found.
When setting the disposition:
- Adjudicators should return “accepted” in the disposition, IF the claim has been fully adjudicated. Note: Plan may pay zero dollars
- Adjudicators should return “rejected” when they are unable to fully adjudicate the claim. In this case, the outcome will be "error"
- For REJECTED status, Pharmacist MUST decide to a) retry claim with different data b) cancel the prescription, eg try different drug, or patient doesn’t want the rx c) skip the plan entirely and move to secondary payor
Profile Summary
| Profile Name | Profile Link |
|---|---|
| Bundle | Bundle Profile |
| MessageHeaderResponse | Profile for MessageHeaderResponse |
| eRX ClaimResponse | Profile Claim Response |
| Prior Payor Response | Prior Claim Response Details |
| Patient | Profile for Patient |
| Pharmacy | Profile for Insurer Organization |
| Clinical Issues Detected | Profile for Detected Issue |
| Error Response | Profile for Error Response |