Daily Totals and Adjudication Details Request
The request, Parmaters:IN is identical for the Daily Totals and the Adjudication Details request and is distinguished by a unique transaction identifier (MessageHeader.event id) that will be the URL of the profile being used. The Daily Totals Request in FHIR will replace the CPHA Transactions 30, 31 and 32. This will use the MH.event type to map to CPHA 3transaction type as CPHA 30.
This new Request for Totals is for a specific adjudication date, with a paramater that allows for specific Carriers and/or Groups to be either included or excluded in the result set. Though structurally different than CPHA3, this fulfils the same business requirement in a modernized fashion. While mapping may be achievable to existing CPHA3 functionality, it is significantly more beneficial to the Pharmacy users to natively support the new FHIR queries in order to take advantage of new functionaliy and the flexibility that it offers. It may also be more efficient for adjudicators to support new FHIR queries while continuing support for CPHA 3 queries for a period of time, rather than to map between the two message standards.
This FHIR query covers all of the existing functionality with the following improvements:
- The 14 day restriction has been removed in PCS. While the time period is open ended, the maximum recommended period is 31 days which all adjudicators are expected to support in FHIR. Each implementer will communicate their supported time period.
- The FHIR structure specifies an "include" or "exclude" rule that allows vendors to specifically request that one or more carriers and/or groups be included or excluded in the result set.
- Paging is not supported once FHIR is natively supported by the sending and receiving applications; all results will be returned in a single response message for FHIR.
- Backward compatibility to CPHA is maintained; however the parameters for beginning and end records will be phased out over time as implementers move to FHIR.
- The result set will include both claims and reversals which supports mappings to CPHA results; data that is irrelevant may be ignored.
Parameters:IN Structure
The structure of the Parameters IN is identical for the Daily Totals and the Adjudication Details. The only difference will be the MessageHeader.eventType which will distinguish the type of message that is being processed.
The FHIR Profile is found here
| FHIR Parameter | Part | Name | Cardinality | Type | Details | CPHA 3 Mapping Rules |
|---|---|---|---|---|---|---|
| Parameter | Trace Number | 1..1 | string limited to 6N today; FHIR will support unlimit | B.23.03 | ||
| Parameter | Start Date | 1..1 | dateTime | F.90.03 Adjudication Date | ||
| Parameter | End Date | 1..1 | dateTime | New; reject if the time period specified cannot be supported; configurable by adjudicator | ||
| Parameter | Results Rule | 1..1 | Code | Code= Include/Exclude/All All=Return everything (Carrier/Group list MUST be blank) Include=Return only carrier/groups that are specifed in the list Exclude=Return everything EXCEPT carrier/groups that are specified in the list |
New; map all to return everything; else reject | |
| Parameter | Adjudicator ID | 1..1 | identifier | also in message header | Message Header.Destination. | |
| Parameter | Carrier/Group | 0..* | N/A | See Part - Carrier ID + optional Group ids that are specified when REsults Rule = Include or Exclude | ||
| Part | Carrier ID | 0..1 | string | C.30.03 Carrier ID | ||
| Part | Group ID | 0..1 | string | C.31.03 Group ID |
Parameters:OUT Structure
The structure of the Parameters OUT is identical for the Daily Totals and the Adjudication Details. The only difference will be the MessageHeader.eventType which will distinguish the type of message that is being processed.
The DRAFT FHIR Profile is found here
Note: Updates to this message are expected once message samples are produced and mappings can be validated.
| Parameter | Part | Name | Cardinality | Type | Details |
|---|---|---|---|---|---|
| Parameter | TraceNumber | 1..1 | identifier | also in message header | |
| Parameter | Date | 1..1 | date | May repeat? | F.90.03 Adjudication Date |
| Parameter | Claim Total for Period (trxn type=01) | 1..1 | money | Total for time period specified | |
| Parameter | Claim Reversal Total for Period (trxn type=11) | 1..1 | money | Total for time period specified | |
| Parameter | Claim Record Details | 1..* | see below | repeats for each record | |
| Part | AmountPaidToPatient | 1..1 | money | ||
| Part | AmountPaidToPharmacy | 1..1 | money | ||
| Part | RX Number | 1..1 | identifier | ||
| Part | Date | 1..1 | dateTime | ||
| Part | TrxnID | 1..1 | code | Value = 01 for claims or 11 for reversals |
Backward Compatibility
There are two new FHIR queries that will be introduced to replace the existing queries for Totals and Adjudications results. These queries have been streamlined to support only the required data and have been structured in a way that assists vendors in getting the data that they need in a more logical manner than what is in place with CPHA3 today.
The two queries that map from CPHA3 are as follows:
- Daily Totals Request - Event Code 30
- Daily Totals Response - Event Code 80
- Adjudication Details Request - Event Code 31
- Adjudication Details Response - Event Code 81
As the queries must be backward compatible, it may be necessary to restrict the result set to 14 records, as is done with CPHA. In this case, paging is introduced. If mapping queries from CPHA to FHIR, there must be continued support for the 14 day restriction and it will be up to implementers to determine how this is handled between partners.
It is strongly encouraged that all implementers natively support the FHIR queries in the MVP stage; however this will be determined by the PCS Implementation group. Mapping is possible but it is not ideal.