Adjudication Details - Message Structure & Mappings
CPHA-FHIR Request Mappings
The following are the same mappings as for the Daily Totals Query as the profile is identical.
| FIELD NAME | FIELD # | FHIR | Notes |
|---|---|---|---|
| A.01.01 | IIN | Message Header.Destination | |
| A.02.03 | Version Number | N/A | DEPRECATED |
| A.03.03 | Transaction Code | MessageHeader.event code = 31 for details | |
| A.04.03 | Provider Software ID | MessageHeader.source.software | |
| A.05.03 | Provider Software Version | MessageHeader.source.version | |
| A.07.03 | Active Device ID | MessageHeader.sender.display | |
| B.21.03 | Pharmacy ID Code | Claim->Organization.identifier.value | |
| B.22.03 | Provider Transaction Date | Bundle.timestamp | YYMMDD, established for the time zone in which the provider is located at the time that the request for totals or details is transmitted |
| B.23.03 | Trace Number | Parameters.parameter:TraceNumber | |
| C.30.03 | Carrier ID | Parameter.Part | |
| C.31.03 | Group Number or Code | Parameter.Part | |
| F.90.03 | Adjudication Date | Parameters.parameter:AdjudicationDate | YYMMDD assigned by the processor in Field E.01.03 at the time the claims were adjudicated or the reversals were processed. Request may be for current day's totals or detail or for closed adjudication date during the last 6 days. |
| F.91.03 | Beginning of Record | Parameters.parameter:BeginningOfRecord | |
| F.92.03 | End of Record | Parameters.parameter:EndOfRecord | |
| N/A | Not in CPHA | Parameters.parameter:14RecordRestriction | Mapping & Backward compatibility. Indicates to adjudicator that sender is resticted to 14 records in the result set, eg when mapped from CPHA |
| N/A | Not in CPHA | Parameters.parameter:StartDate | |
| N/A | Not in CPHA | Parameters.parameter:EndDate | |
| N/A | Not in CPHA | Parameters.parameter:ResultsRule | Mapping: Specifies the type of response desired. Code= All Return everything (Carrier/Group list MUST be blank) Or vendors may set code=Include , Return only carrier/groups that are specifed in the list |
Detailed Record Response Mapping CPHA-FHIR
| FIELD NAME | FIELD # | FHIR | Notes |
|---|---|---|---|
| E.01.03 | Adjudication Date | Assigned by the processor. YYMMDD | |
| E.02.03 | TraceNumber | Parameters.parameter:TraceNumber | Assigned by the provider, to the request to which this response applies |
| E.03.03 | Transaction Code | MessageHeader.event.code | 81=record of accepted claims and reversals for the specified time period |
| E.04.03 | ReferenceNumber | This is the internal reference number assigned to the request for a details | |
| E.05.03 | Response Status | Indicates the status of the request. A 1Z=detailed record as requested R=request rejected | |
| E.06.03 | Response Codes | Codes for errors and other reasons that may cause the request to be rejected. Field length of 10 will accommodate 5 response codes. Examples are: 01=IIN error. 03=transaction code error, etc | |
| H.65.03 | Number of Detail Records | Total number of detail records included. Detailed records will be presented in a time of day sequence. | |
| H.66.03 | Current Rx Number Prescription Numbers | From Field D.55.03 of the first claim or reversal and all subsequent claims or reversals contained in this response | |
| H.67.03 | Amount Payable Reversed | Value of individual claims or reversals as identified by prescription numbers. The current RX and the Amount Payable will continue to repeat until the detail of the accepted claims and reversals record for the IIN or carrier and group # concerned as requested by the Beginning of Record and End of Record has been transmitted or 14 records have been provided, whichever occurs first. |