Claim Request Medication Message Structure
A single FHIR message structure will support both the Pay Provider Claim (01)and the Pay Cardholder Claim (04). The Message Header.event.code will identify whether this is a Pay Provider Claim, "01" or a Pay Cardholder Claim, "04". This will also be identified in the Claim.payee data elements. The "01" and "04" are only retained for backward compatibility and efficiency for systems who are mapping between FHIR and CPHA.
The diagram below depicts the structure of a FHIR Claim Request, followed links to all FHIR profiles. Each profile has details with respect to mandatory and optional fields and conformance rules as well as links to the field values (aka terminology).
FHIR Message Structure
The follow diagram depicts the high level structure, showing all resources that are included in the message and how they are linked together.
Profile Summary
| Profile Name | Profile Link |
|---|---|
| Bundle | Bundle Profile |
| MessageHeaderRequest | Profile for MessageHeaderRequest |
| eRX ClaimRequest | Profile Claim Dispensed Medication |
| Dispense | Profile-Dispense |
| Prescription | Profile for Prescription |
| Medication | Profile for Medication |
| Patient | Profile for Patient |
| Pharmacy Organization | Profile for Pharmacy |
| Coverage | Profile for Coverage |
| Prior Coverage | Profile for Prior Coverage |
| Prior Claim Response | Profile for Prior Adjudication Details |
Coordination of Benefits
In support of COB, much more detailed information about prior adjudication results will be available in downstream claims. Today, only a prior paid amount is available. The additional information will be beneficial as it will support more precise adjudication and fewer audits and clawbacks.
Following are some guidelines for Adjudicators and POS vendors
Coverage Type
The coverage type will be returned on the claim response and will also be included in the prior claim adjudication details that will be passed on to downstream payors in downstream claim requests. This definitively identifies the coverage type that was used for adjudication, and removes any guess work from the Pharmacist. This is a key field in determining COB Order.
Coverage Order
Guidelines will be published to vendors in the future to assist in determine COB order based on the coverage type. TBD
Pharmacist Choice when receiving a REJECTED Disposition
When receiving a REJECTED status, the Pharmacist MUST decide to:
- retry claim with different data. In this case secondary payor will see ONLY the second submission. No history of the rejected claim will be passed on to the secondary
- cancel the prescription, eg try different drug, or cancel if patient doesn’t want the rx. In this case, the secondary payor will not receive the claim
- skip the plan entirely and move to secondary payor. In this case the secondary will receive the claim with prior results, disposition = REJECTED, with the results, eg error code + zero payment. Adjudicators must look at the error codes when rejected status is received.
Adjudicator Guidance on Error Codes
Downstream adjudicators will now recieve full adjudication details from upstream claim responses. This incldues Error Codes. Some prior plan error codes (eg Provincial Health Number error) may result in a clawback. If the new prior plan error code is NOT accounted for during adjudication, it may be identified post-audit resulting in a clawback.
As such, Adjudicators should focus on key “reject” codes that will impact adjudication and account for this in their adjudication logic where possible. The more logic that is implemeneted, the fewer post-audit clawbacks.
COB - High Cost Drugs - Outstanding work
This topic will be explored in 2026 and must be understood well before the first implementation of an adjudicator supporting a single claim over 10K.