Daily Totals - Mappings from CPHA
CPHA-FHIR Request Mappings
| FIELD NAME | FIELD # | FHIR | Notes |
|---|---|---|---|
| A.01.01 | IIN | Message Header.Destination and Parameters.parameter:AdjudicatorID | |
| A.02.03 | Version Number | N/A | DEPRECATED |
| A.03.03 | Transaction Code | MessageHeader.event code = 31 | |
| 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 | N/A - maps to start date | 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. Value = true when restriction is in place; adjudicators must restrict the result set and implementation partners can determine if FHIR paging is supported. |
| 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 |
CPHA-FHIR Response Mappings
| FIELD NAME | FIELD # | FHIR | Notes |
|---|---|---|---|
| E.01.03 | AdjudicationDate | This is the date assigned by the processor. | |
| E.02.03 | TraceNumber | Parameters.parameter:TraceNumber | |
| E.03.03 | Transaction Code | MessageHeader.event.code | |
| E.04.03 | Reference Number | Parameters.parameter:ReferenceNumber | This is the internal reference number assigned, by the processor to the request for daily totals |
| E.05.03 | Response Status | Parameters.parameter:ResponseStatus | This indicates the status of the request transmitted AY=accumulated daily totals R=request rejected |
| E.06.03 | Response Codes | Parameters.parameter:ResponseCodes | |
| G.41.03 | Total Claims Approved | Total number of pay provider claims accepted for payment for the requested adjudication date | |
| G.42.03 | Total Payable by Carrier | The total payable to the provider, by the carrier, for the requested adjudication date | |
| G.43.03 | Total Reversals | The total number of reversals processed against pay provider claims approved on the adjudication date to which the response refers | |
| G.44.03 | Total Value of Reversals | The total value of reversals processed against pay provider claims approved on the adjudication date to which this response refers | |
| G.45.03 | TotalPriorReversals | The total number of reversals processed on the adjudication date which refer to pay provider claims processed on a previous adjudication date | |
| G.46.03 | Total Value of Prior Reversals | The total value of reversals processed on the adjudication date which refer to pay provider claims processed on a previous adjudication date | |
| G.47.03 | Total Claims Captured for Batch Processing | No Mapping - Deprecated field | The total number of pay provider claims captured by the adjudicator for batch processing on the requested adjudication date. |
| G.48.03 | Total Reversals Captured for Batch Processing | No mapping - deprecated field | Total number of reversals of pay provider claims captured by the adjudicator for batch processing on the requested adjudication date |
| G.49.03 | Date of Deposit | Date upon which the banking institution is expected to post the deposit to the providers account | |
| G.50.03 | Transaction Fees | Total value of transaction fees | |
| G.51.03 | GST charged on Transaction Fees | The applicable amount of GST for the transaction fee charged | |
| G.52.03 | Amount of Deposit | The amount of the EFT deposit for the adjudication date concerned | |
| G.53.03 | Total Claims Captured for Reimbursement to Card Holder | Total number of claims captured by the adjudicator for reimbursement to cardholders on the requested adjudication date |
**FHIR Profiles
ParametersIn: (https://simplifier.net/pharmacyeclaim/dailytotalsdetailsparametersin)
IN Parameters:Request & CPHA Mappings
| Parameter | Part | Name | Cardinality | Type | Details | 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 not same as start date; 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 | Messa | e Header.Destination. | |
| Parameter | Carrier/Group | 0..* | N/A | See Part - Carrier ID + optional Group ids | |||
| Part | Carrier ID | 0..1 | string | C.30.03 Carrier ID | |||
| Part | Group ID | 0..1 | string | C.31.03 Group ID |
Out Parameters: Successful Response & CPHA Mappings
Response is a FHIR parameters instance with a MessageHeader.event code = 80.
Each record returned - group by date and trxn type (always return two records, one for 01 and one for 11. One record for each date that will return two rows.
Total Claims Captured for Batch Processing G.47.03 and Total Reversals Captured for Batch Processing G.48.03 have been deprecated as they are not being used by any adjudicators today.
| Parameter | Cardinality | Type | Binding | Details | ||
|---|---|---|---|---|---|---|
| Parameter | Adjudicator ID | 1..1 | identifier | also in message header | ||
| Parameter | Results Rule | 1..1 | code | Add value set* | All, Include, Exclude, as per the request | New, not in CPHA |
| Parameter | Reference Number | 1..1 | identifier | internal reference number assigned,by the processor to the request for daily totals | Reference Number E.04.03 | |
| Parameter | Response Status | 1..1 | This indicates the status of the request transmitted Y=accumulated daily totals R=request rejected |
Response Status E.05.03 | ||
| Parameter | Response Codes | 1..5 | Codes to define responses that identify errors and other reasons that may cause the request to be rejected or the response to be incomplete. | Response Codes E.06.03 | ||
| Parameter | Date | 1..1 | dateTime | Repeats for each date within the requested date range; one date record is returned for each date | ||
| Part | Trxn type | Value = 01 (Claim) or 02 (Reversal) or 03 (Prior Day Reversal) | ||||
| Part | Total amount paid to patient | Not directly mappable; Set value = blank when not applicable, eg during MVP phase. Post MVP this must be populated properly | ||||
| Part | Total amount paid to pharmacy | Total Payable by Carrier G.42.03 or Total Value of Prior Reversals G.46.03 or Total Value of Reversals G.44.03 | ||||
| Part | Total number of trxn for this date | Map: Total Reversals G.43.03 OR Total Claims Approved G.41.03 or Total Prior Reversals G.45.03 |