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 |
| Profile Name | Profile Link |
|---|---|
| Bundle | Bundle Profile |
| MessageHeaderRequest | Profile for MessageHeaderRequest |
| Parameters OUT | Reveral Parameters:OUT |
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 |