Adjudication Category
Usage: ClaimResponse.item
Code System http://pharmacyeclaims.ca/FHIR/CodeSystem/adjudication-category-codes
Value Set http://pharmacyeclaims.ca/FHIR/ValueSet/adjudication-category-codes
CPHA Mapping
In CPHA, these are distinct fields; in FHIR they represent the type of adjudication. Each is associated with an amount
| Code | Description | CPHA Field Length | |
|---|---|---|---|
| DrugCost | The value accepted for drug / product before any adjustment provided for | D6 | *** |
| Upcharge | The amount accepted as an upcharge on the drug cost/product value before any adjustment provided for in Fields E.15.03 to E.17.03 inclusive. This reflects the amount claimed in Field D.67.03. | ||
| GenericIncentive | This indicates the amount which will be paid by the payor as an incentive for the use of a generic product The value will be calculated separately for each claim. | D5 | |
| ProfFee | The amount accepted as a professional charge before any adjustments provided for in Fields E.15.03 through E.17.03. This reflects the amount claimed in Field D.68.03. | D5 | |
| CompoundingCharge | The amount accepted as a compounding charge before any adjustments provided for in Fields E.15.03 through E.17.03. This reflects the amount claimed in Field D.70.03. | D5 | |
| SSF | The amount accepted as a special services fee before any adjustments provided for in Fields E.15.03 through E.17.03. This reflects the amount claimed in Field D.72.03. | D5 | |
| Copay | The co pay amount which the provider collects from the beneficiary for a specific claim. This refers to "co pay" as defined in the carrier's benefit brochure. | D6 | |
| Deductible | The deductible amount which the provider collects from the beneficiary for a specific claim. This refers to "deductible" as defined in the carrier's benefit brochure. | D6 | |
| Co-Insurance | The co-insurance amount which the provider collects from the beneficiary for a specific claim. This refers to co-insurance" as defined in the carrier's benefit brochure | D6 | |
| TotalQuantityDispense | This is the Total Quantity Dispense Accumulated. The total number of pills "adjudicated" for a special auth number. An Adjudicator authorizes the number of pills against a special auth number; the dispense may occur across several pharmacies. This accumulated total is returned as part of the adjudication result as informational data. This field does not exist in CPHA | N/A |