Totals and Details Responses Message Structure

The FHIR Response for Totals and Details have been updated to remove some of the restrictions that exist today. Though structurally different than CPHA3, these transactions fulfil the existing business requirements in a modernized fashion. While mapping may be achievable to the existing CPHA3 functionality, it is significantly more beneficial to the Pharmacy to natively support the new FHIR queries in order to take advantage of the streamlined functionaliy and the flexibility that it offers. Adjudicators will need to support new FHIR queries while continuing support for CPHA queries for a period of time, and it may be more desirable to support FHIR natively, rather than to support mapping between the two message standards.

Totals Response

The Totals Response, "daily-totals-OUT" will return the Totals, based on the criteria that has been specified in the request.

The FHIR MH.event type will be CPHA transaction type 31 for for the Totals response. CPHA transaction types 32 and 33 will be deprecated.

New Functionality in FHIR

• FHIR transactions are streamlined to a single response for totals (transaction 31). The response will include transaction counts/totals for each day requested within the requested time period. Daily totals will be broken down by pay patient and pay providers and will also include reversal counts.
• Details will comply with the time period specified in the request, which may be beyond a single day.
• The response will comply with the "results rule" to indicate whether the carriers specified in the request will be "included" or "excluded". If there are no carrier/groups specified, the default is to include details for all.
• The totals per carrier may be returned when more than one is specified in the request and if agreed to between implementers. This is in addition to the daily totals for all carriers or only those specified or excluded.
• 14 Day Restriction will only be applied if indicated in the request. This will be used for backward compatibility only.
• The 14 record restriction (packets of 13) on the result set does not apply unless a restriction of 14 records is requested. While the time period is not restricted in FHIR, the maximum recommended period is 31 days which all adjudicators should support. Each implementer will communicate their supported time period.
• FHIR paging mechanism. Refer to Discussion re Daily Totals and Details Request

Message Structure

Profile Name	Profile Link
Bundle	Bundle Profile
MessageHeaderResponse	Profile for MessageHeaderResponse
Daily Totals Response	Daily Totals OUT Parameters

Adjudication Details Response

The Details Response, will return the Adjudication Details as per the criteria specified in the request message.

The FHIR MH.event type will be CPHA transaction type 81 for for the Details response. CPHA transaciton types 82 and 83 will be depreacted as the Details will natively include this data.

New Functionality in FHIR

• FHIR transactions are streamlined to support a single response for details (transaction 81). The response will include transaction counts/totals for each day requested within the requested time period. Adjudication details will be provide a list of details sorted by date.
• Details will comply with the time period specified in the request, which may be beyond a single day.
• The response details will comply with the "results rule" to indicate whether the carriers specified in the request will be "included" or "excluded". If there are no carrier/groups specified, the default is to include details for all.
• 14 Record Restriction will be applied as per the request
• The 14 record restriciton (packets of 13) on the result set does not apply unless indicated. While the time period is open ended in FHIR, the maximum recommended period is 31 days which all adjudicators should support. Each implementer will communicate their supported time period.
• FHIR paging mechanism. Refer to Discussion re Daily Totals and Details request.

Message Structure

Profile Name	Profile Link
Bundle	Bundle Profile
MessageHeaderResponse	Profile for MessageHeaderResponse
Adjduication Details Response	AdjudicationDetails OUT Parameters