01-Claim Request - Medication - New Fields

The following table provides a detailed view of the key fields and functionality that implementers will see within the FHIR claim request for Dispensed Medication. The table describes what the changes are and whether or not they are in scope for the MVP Phase. It also provides Sender and Receiver responsibilities. The details of "how" these changes are realized in the FHIR messages (eg the field name, datatype and placement within the message) can be found within the FHIR profiles.

Note: This list covers the vast majority of new fields; however some new mandatory fields in FHIR that contain fixed values or those that are structural in nature, or fields that are used for mapping to/from CPHA3 may not be included here as there is no business impact. These are clearly outlined in the FHIR profiles (links in the table below).

Feature	MVP Scope	Details & Link to Profiles	POS - Sender Responsibility	Adjudicator - Receiver Responsibility
GENERAL
MESSAGE STRUCTURE Combine Pay Cardholder + Pay Provider Claim Request	MANDATORY	Transactions that are separate in CPHA today will be combined into a single transactions that will specify the requested payee. This may be handled through mapping. The claim response will specify who the adjudicator will be paying. BENEFIT: Technical- streamlined messaging	MANDATORY	MANDATORY
NEW FUNCTIONALITY Claims over 10K in a single request	RECOMMENDED	PCS FHIR allows claims to be submitted over 9999.99. As this is not mandatory, vendors must continue support for sending split claims in FHIR until all adjudicators are capable of receiving claims over 10K. Note: Implementers must continue to support split claims over 10K in PCS FHIR until this feature is implemented. BENEFITS: Reduced audit and clawbacks; more accurate/streamlined adjudication	RECOMMENDED to be determined amongst implementation partners. Adjudicator determines timing, coordinates with vendors	RECOMMENDED to be determined amongst implementation partners. Adjudicator determines timing, coordinates with vendors
DEPRECATION OF CODES The codes DA and DB are not required in FHIR. DA = secondary claim - orig to prov plan and DB = secondary claim - orig to other carriers	MANDATORY	These codes will not be used in PCS FHIR; a more advanced mechanism is in place to convey this information. BENEFIT: The decision to deprecate these codes was made as it is not always possible for the pharmacy to accurately set the value of DA/DB as they do not always have the required information to do so. In PCS FHIR, the prior payor adjudication result contains the plan type used in adjudication, which will be accurate. As such, these codes are not required in FHIR secondary request. For implementers mapping from FHIR-CPHA3, the code DA/DB can be derived from the FHIR secondary claim request using the plan type (eg public, private, etc). The "plan type" is set by the primary adjudicator and is therefore reliable.	MANDATORY POS vendors/pharmacies will no longer need to send these codes	MANDATORY to send Coverage Type in the claim response instead. (identified below). Note: If adjudicators wish to continue use of the DA/DB in their back end systems, they can calculate the code based on the adjudicated coverage type indicated. Refer to the mapping section of this specification
PATIENT	Patient Profile
NEW FIELD PMS Patient Identifier	OPTIONAL	Used when there is no JHN as the patient identifier BENEFIT: Clearly identifies the type of identifier being sent as a PMS generated identifier.	OPTIONAL Should be sent when there is no JHN.	OPTIONAL May be consumed as required
COVERAGE	Prior Coverage Profile
NEW FIELD Coverage Type	MANDATORY for sending applications Value may be "unknown"	Provides accurate plan type that the adjudicated claim was paid under. BENEFIT: Clear communication to pharmacy and to the downstream payors as this is included in downstream claim requests. Note: used in place of DA/DB codes to indicate type of coverage, eg public or private	MANDATORY for downstream claims	OPTIONAL downstream payors should consume when possible; Insurers should send if data is available
DISPENSE INFORMATION	Medication Dispense Details Profile
NEW FIELD Units of measure for products	OPTIONAL	The quantity unit field will allow for a coded unit, eg unit, package, mL, L,g, kg BENEFIT: Provides more accuracy when sending the dispensed quantity as the quantity unit is The quantity unit field will allow for a coded unit, eg unit, package, mL, L,g, kg BENEFIT: Provides more accuracy when sending the dispensed quantity as the quantity unit is explicitly stated.	OPTIONAL POS must include where value is known	OPTIONAL Adjudicators may ignore initially; should support when possible
NEW FIELD Rendered Dosage Instruction - SIG	OPTIONAL	New field for pharmacies to submit the SIG as part of the claim request. Language may also be specified BENEFIT: Enhanced adjudication /audit capability.	OPTIONAL Sending system must include where known	OPTIONAL Receiving system may ignore.
PRIOR ADJUDICATOR PAYMENT DETAILS	Prior Claim Response Details Profile
NEW FIELDS COB -Prior Payment Details included in Downstream Claim request	RECOMMENDED	New resource/fields to support inclusion of adjudication details from previous payors in the claim request, including fiscal details as well as the claim type (eg public, private, etc). The prior adjudication results are included in downstream claim requests along with information about the prior payor (eg, Amounts paid, Intervention codes,Response Codes, fiscal amounts, claim type). BENEFIT: More accurate adjudication; may reduce audit and claw backs	RECOMMENDED POS should include data when received in the primary response to downstream claim requests	RECOMMENDED Adjudicators receiving this information in downstream request should consume when possible to realize the benefits.
NEW FIELDS Digital Signature on Prior Adjudication Results	OUT OF SCOPE	The use of a digital signature guarantees that the contents of the adjudication results that are sent in downstream claims have not been inadvertently tampered with. As technical discussions are yet to be had regarding this feature, it is out of scope for the MVP. Note: The specification does include support for this as optional BENEFIT: Ensures downstream payors can accurately adjudicate as the secondary claims include accurate prior payment results.	OUT OF SCOPE	OUT OF SCOPE
MEDICATION	Medication Details Profile
NEW FEATURE & FIELDS Compound ingredient Breakdown	RECOMMENDED	New fields to allow a list of compound ingredients to be specified. New fields include: Product code (eg DIN) specified as code or text, quantity, Ingredient Percentage Total Cost, Flag to indicate Ingredient is Active BENEFIT: Will enhance adjudication /audit capability.	RECOMMENDED POS should include data when known	RECOMMENDED Adjudicators should minimally store data and use for audit purposes. Should fully support when capable.
NEW FIELD Medication code system	RECOMMENDED	Add “system” identifier on medication (eg DINS) to identify origin of pseudodins (NPN, Opinions,etc). BENEFIT: This assists adjudicators in selecting/interpreting the correct product code to be used for adjudication, as there can be overlap between codes. The addition of system guarantees uniqueness.	RECOMMENDED POS systems should send if known	RECOMMENDED Receivers may use the data as required
NEW FIELD Medication Code.Text	OPTIONAL	A new, optional text field to specify the name of the compound BENEFIT: Useful for audit purposes	OPTIONAL should be specified when capable	OPTIONAL May be consumed when desired
CLAIM INFORMATION	Claim Medication Dispense Profile
NEW FIELD Pharmacy ID Assigning Authority (static value)	MANDATORY For sending applications	OID aligns with other standards; this is fully mappable BENEFIT:Technical alignment	MANDATORY POS systems must map and send	OPTIONAL Receivers may use the data if deemed necessary
UPDATE FIELDS Increase price fields to support submission of a Single Claim over 10K	RECOMMENDED	Increase all dollar amounts on request and response message (eg >9999.99 for cost, and >999.99 for fee, special service fee) BENEFIT: Allow for claims over 10K	RECOMMENDED Each POS vendor will determine timing of support for Claims over 10K in accordance with the adjudicators schedules and partner agreements. Capability tracking and coordination between implementers is required. These fields must be supported for single claims over 10K and are not likely to be implemented beforehand.	RECOMMENDED Each implementer will determine timing and whether in scope for initial rollout/MVP. Capability tracking and coordination with POS vendors is required
UPDATE FIELD Quantity - Increase Decimal Places and support Unit Type	OPTIONAL	Change quantity to include up to 3 decimal places. Quantity unit may be a drug form (e.g. TAB) an administrable drug (e.g. PUFF) form or a unit of measure (e.g. mg). eg g, mg, ml. BENEFIT: More precise specification of quantity. This will enhance adjudication capability	OPTIONAL should be specified when capable	OPTIONAL should consume when capable
NEW FIELD Related Claim Reference	OPTIONAL	New field to co-relate a claim to a professional service BENEFIT: Adjudicators can establish a clear link between claims using this definitive field.	OPTIONAL POS systems must send as Professional services claims are supported from the onset	OPTIONAL Adjudicators should consume this data when possible
UPDATE FIELD Extend Diagnosis, up to 5 optional. Code system should be specified when possible	RECOMMENDED	Allow up to 5 diagnosis codes. BENEIFT: Enhances adjudication capabilities; may reduce audits and claw backs	RECOMMENDED Sending system must include where known	RECOMMENDED Receiving system should consume when possible
UPDATE FIELD Days supply - Increase	OPTIONAL	Extended to allow specification of a larger duration. It is currently limited to 999 days, but some products (eg IUD's) may last for up to 5 years. BENEFIT:Allows an accurate days supply to be specified as some dispenses are over the current limit of 99	OPTIONAL Sender must increase where possible;	OPTIONAL Receiving systems may map anything over 999 to 999
UPDATE FIELD Increase Intervention Codes	OPTIONAL	Increase the number of intervention codes on claim request to 10. BENEFIT: Allows for more precise adjudication	OPTIONAL	OPTIONAL Receiver may reject if necessary (eg mapping failure) or ignore additional codes Coordination between implementers may be required
NEW FIELDS New Quebec Pricing Fields	MANDATORY	Quebec Professional Fee, Quebec Wholesale Price,Quebec Guaranteed Selling Price BENEFIT: New fields provide the ability to support jurisdictional requirements in Quebec	MANDATORY Must send values in accordance with legislation when applicable	OPTIONAL Consume when required
NEW FIELD EligibleAmtProvincialPlan	RECOMMENDED For sending applications	New optional field to capture the Eligible Amount (total cost and fee) for a given medication for a provincial plan. May be used for coordinated claims in Ontario, where this amount represents the amount the pharmacy is looking to be paid. This is not the difference between total submitted and the previous paid amount. This may be used by adjudicators to drive specific adjudication rules. BENEFIT: This provides a discrete field specifically for the intended purpose	RECOMMENDED POS vendors who support this use case today should support	OPTIONAL Consume when required; mappable to SSF
UPDATED FIELD Refills Remaining Increase to 3 decimals	OPTIONAL	This field will allow up to 999 to be specified. BENEFIT: The extension meets today's requirements as some prescriptions allow over 99 refills. Allows for more precise adjudication and may reduce auditing	OPTIONAL Must send when possible	OPTIONAL Consume when possible
NEW FUNCTIONALITY Multiple Coverages may be specified	OPTIONAL	All claims will include all known instances of insurance BENEFIT: Upon receipt of a claim, the adjudicator may examine other coverages to determine correct order.	OPTIONAL	OPTIONAL
PRESCRIPTION INFORMATION	Prescription Profile
NEW FIELD Jurisdictional Prescription ID	OPTIONAL	Generated by EMR or PMS BENEFIT: Allows provinces with a DIS to track a prescription through its life cycle	OPTIONAL at the request of the Adjudicator	OPTIONAL support as required
NEW FIELD PrescribeIT Prescription Number	OPTIONAL	PrescribeIt RX Number BENEFIT: Allows jurisdictions to establish a link between a PrescribeIT prescription and a claim	OPTIONAL Send value if known when requested from Jurisdiction	OPTIONAL Consume if required

Message Structure