cdj u## Alert Codes DUR? - Response Codes CPHA Table 1 FEEDBACK
TABLE 1, CPHA E.06.03 Response Codes
Usage
Response.detectedIssue.code
This will be an extensible code set
http://pharmacyeclaims.ca/FHIR/CodeSystem/alert-codes http://pharmacyeclaims.ca/FHIR/ValueSet/alert-codes
Discussion: The existing list in the CPHA standard seems to be a mix of clinical and non-clinical alerts, eg DM or CD versus MR Do we want to split out clinical alerts??? April 9, 2024 - Do we need a Clinical Excellence Team to determine where each code belongs and whether it is an "Alert" code? Maintenance process on this?
Lamar's advice is to only do MA through NB - the first ones can go into response codesMar 24
Table 1 - Alert Codes
Table 1 contains ALERT CODES which the claims processor will use to return messages relating to possible concerns about the claim received. The Codes and Code Values are included in Field E.06.03, RESPONSE CODES of the Pharmacy Claim Standard.
If additional message components are required they will be assigned by the **Canadian Pharmacists Association (CPhA)** upon receipt of a legitimate request. Not included in this table, but contained in **Field E.06.03** of the Standard, codes "01" to "99" refer to information which is missing in the provider claim. ALERT CODES, as the name implies, are intended to be used to draw the attention of the provider to possible complications that may result from the medication concerned. In serious situations the claim may be rejected. Processors are encouraged to use discretion, on the use of this table, to avoid sending unnecessary "ALERT CODES" as they can be extremely interruptive to the routines of the provider and cause undesirable processing and service delays.
2015 Requirement -split these clinical alerts and return in another field... are these a reason for cutback, or maybe we can add a category
Some payors return DUR alerts such as drug-drug interactions and duplicate therapies in the claim response. The data is currently returned in one of the 3 message fields in the claim response; however there is no common structure to the response messaging across payors. As a result, there is no way for vendors to use that information and add additional business functionality (such as requiring a pharmacist to approve the interaction) to their adjudication response handling logic. Further, the current limits on the message fields often prevent multiple DUR alert messages from being returned to the pharmacy.
The follow are a subset of the Response and Error codes but they are listed separately in the messaging standard.
| CODE | VALUE CODE | Notes |
|---|---|---|
| CD | Patient Not Entitled to Drug Claimed | |
| D1 | DIN/PIN/GP#/SSC Not a Benefit | |
| D9 | Call Adjudicator | |
| DM | Days Supply Exceeds Plan Limit | |
| DQ | Quantity is Less Than Minimum Per Claim | |
| ML | Drug Incompatibility Indicated | |
| MM | Prior ADR on Record | |
| MN | Drug Allergy Recorded | |
| MP | Duration of Therapy May be Insufficient | |
| MQ | Duration of Therapy May be Excessive | |
| MA | Avoidance of Alcohol Indicated | |
| MR | Potential Drug/Disease Interaction | |
| MB | Avoidance of Tobacco Indicated | |
| MS | Potential Drug/Pregnancy Contraindication | |
| MC | Drug/Lab Interaction Potential | |
| MT | Drug/Gender Conflict Indicated | |
| MD | Drug/Food Interaction Potential | |
| MU | Age Precaution Indicated | |
| ME | Drug/Drug Interaction Potential | |
| MV | Additive Effect Possible | |
| MF | May be Exceeding Rx Dosage | |
| MW | Duplicate Drug | |
| MG | May be Using Less Than Rx Dosage | |
| MX | Duplicate Therapy | |
| MH | May be Double Doctoring | |
| MY | Duplicate Drug Other Pharmacy | |
| MI | Poly-Pharmacy Use Indicated | |
| MZ | Duplicate Therapy Other Pharmacy | |
| MJ | Dose Appears High | |
| NA | Duplicate Ingredient Same Pharmacy | |
| MK | Dose Appears Low | |
| NB | Duplicate Ingredient Other Pharmacy |