02-Claim Request - Professional Services-New Message

The overall structure of the message algins with the Claim for a Medication Dispense, where possible. Many resources are identical, including Bundle, Message Header, Patient and Coverage resources. The Professional services claim request does not include dispense data, though it will reference medications when the service relates specifically to a medication or to a pharmacist adaption. Only message changes that are specific to Professional Services claims are outlined below. .

Support for New Fields during MVP

As a general rule, new fields that have been added to support the Professional Services claim will be optional for MVP. The PCS standard allows for provision of the data if the data is present and already captured as discrete data in the Pharmacy application. There is no desire or expectation that the Pharmacy User should need to take extra steps to input data that is not collected today during the initial MVP rollout. If the data is present as a discrete data field in the pharmacy application, it may be sent as part of the MVP work.

From the adjudicator perspective, there is no expectation that new fields will be populated during MVP unless indicated specifically. The longer term benefit of the additional data is to reduce auditing and claw backs. Over time and as use cases evolve and systems evolve, the additional data will be sent in order to fully realize these benefits.

Pharmacy Adaption

The Professional Services Claim structure allows for fields to specify details about the adaption. There is no expectation that this will be supported during MVP as it is unlikely that Pharmacy POS application capture data in discrete data fields. This data may be captured in the future.

New Fields and Functionality - MVP Scope

Feature	MVP Scope	Details	POS - Sender Responsibility - MVP	Adjudicator - Receiver Responsibility - MVP
CLAIM INFORMATION	Professional Claim Request Profile
NEW MESSAGE New Professional services message	MANDATORY	A new transaction to support the Professional service. BENEFIT: Provides a claim rquest that is specifically designed for this purpose. New fields specific to professional services have been added and redundant fields that exist today in CPHA3 have been eliminated. Mandatory support from onset;	MANDATORY	MANDATORY
STREAMLINED CLAIM REQUEST	MANDATORY	The new transaction eliminates unnecessary fields and allows for new data to be sent BENEFIT: Additional information should reduce audits and claw backs	All new fields are optional though must be populated where data is available	Should consume as required
NEW FIELD ORIGINAL MEDICATION/DIN - PRESCRIPTION DATA	RECOMMENDED Mappable	Use Case: Pharmacy Adaptation. Useful for adjudicators to understand the original prescription. BENEFIT: Additional information should reduce audits and claw backs	RECOMMENDED Data should be sent if sent in CPHA3 today for certain professional services. POS should include if data is available, however, no additional inputs should be required by Pharmacy users	RECOMMENDED Data should be consumed as it is today for use cases where data is supplied today using CPHA3 or other message formats.
NEW FIELD ADAPTED PRESCRIPTION: SUBSTITUTED DIN - PRESCRIPTION DATA	OPTIONAL	Use Case: Pharmacy Adaptation. May be useful for adjudicators BENEFIT Enhances adjudication capability with new information; may reduce audit and claw backs	OPTIONAL Not required for MVP. POS may include if data is available, however, no additional inputs should be required by Pharmacy users. BENEFIT: Additional information should reduce audits and claw backs	OPTIONAL No expectations that data will be provided for MVP.
NEW FIELD Clinical Notes	OPTIONAL	Use Case: Pharmacy Adaptation. BENEFIT: Enhances adjudication capability with new information; may reduce audit and claw backs	OPTIONAL Not required for MVP. POS may include if data is available, however, no additional inputs should be required by Pharmacy users BENEFIT: Additional information should reduce audits and claw backs	OPTIONAL No expectations that data will be provided for MVP. . No expectation that data will be present.
NEW FIELD Adjusted/modified Dosage/Formulation - Text Claim:Supporting Information	OPTIONAL	Use Case: Pharmacy Adaptation BENEFIT: Enhances adjudication capability with new information; may reduce audit and claw backs.	OPTIONAL No expectations that data will be provided for MVP. POS may include if data is available, however, no additional inputs should be required by Pharmacy users. BENEFIT: Additional information should reduce audits and claw backs. Only text will be supported.	OPTIONAL No expectation that data will be present.
NEW FIELD Originating Prescriber ID Sent in Prescription/Medication Request	OPTIONAL	Use Case: Pharmacy Adaptation. BENEFIT: Enhances adjudication capability with new information; may reduce audit and claw backs	OPTIONAL Not required for MVP. POS may include if data is available, however, no additional inputs should be required by Pharmacy users. BENEFIT: Additional information should reduce audits and claw backs.	OPTIONAL No expectations that data will be provided for MVP. No expectation that data will be present.
MAPPABLE NEW FIELD Therapeutic Substitution Code	MANDATORY For applicable use cases	This is conveyed in CPHA3 as an intervention code. The existing codes will be used but will be conveyed in a field specifically for this use. Examples are: supply disruption, patient safety or allergy. BENEFIT: Enhances adjudication capability with new information; may reduce audit and claw backs	MANDATORY For applicable use cases. Though optional in the message this must be supported where Therapeutic substitution applies as it does currently	OMANDATORY For applicable use cases. Supported only where the professional service code indicates that the professional service is Therapeutic Substitution
NEW FIELD Adjusted Dosage or formulation	OPTIONAL	Must be sent for Prescription Adaptions if available and supported today BENEFIT: Enhances adjudication capability with new information; may reduce audit and claw backs	OPTIONAL - May be provided when available and applicable.	OPTIONAL Must be consumed where possible and applicable
NEW FIELD Clinical Notes	OPTIONAL	Not required for MVP BENEFIT: Additional information should reduce audits and claw backs.	OPTIONAL No expectations that data will be provided for MVP. May optionally include if data is available. No additional inputs should be required by Pharmacy users	OPTIONAL No expectation that data will be present.
MAPPABLE FIELD - SERVICE CODE	MANDATORY	Professional Service Codes. The codes are typically conveyed as PINS today in CPHA3 in the DIN/MEDICAITON field. This field will support multiple professional service codes (for the same service) to allow for movement to a national code set over time. Special service codes will also be supported though they are rarely used BENEFIT: Pharmacy systems will benefit through use of single national code set; this technical enhancement will allow movement to a national coding system over time	MANDATORY Must send the code used by adjudicators today and if available, should send the new national service code (being developed in 2026) for MVP.	MANDATORY Must support the PIN used today. No expectation to support the national code set during MVP
NEW FIELD LOCATION	OPTIONAL	A code to indicate where the service occurred, eg virtual, Patient's home, in pharmacy, etc. BENEFIT: Enhances adjudication capability with new information; may reduce audit and claw backs	OPTIONAL No expectations that data will be provided for MVP. May optionally include if data is available. No additional inputs should be required by Pharmacy users** for MVP**	OPTIONAL for MVP
MAPPABLE FIELD - CARE TEAM	MANDATORY Mappable	Used to specify the Pharmacist responsible for the service. Includes a role. In future, may also be used to specify other members of the care team, such as a Nurse, Nurse Practitioner. BENEFIT: Enhances adjudication capability by allowing additional care team members (eg nurse); may reduce audit and claw backs	MANDATORY for Pharmacist; no expectation that other care team will be specified for MVP. If known and data available the data may be sent	MANDATORY For Pharmacist, for mapping purposes. Any additional data may be ignored
NEW FIELD Care Team - Contact Indicator - Prescriber Contact Indicator - True or False.	OPTIONAL	Indicates that the prescriber has been contacted, which is important for certain use cases. BENEFIT: Enhances adjudication capability with new information; may reduce audit and claw backs	OPTIONAL May become mandatory for some implementers for specific use cases No expectations that data will be provided for MVP otherwise. POS may include if data is available, however, no additional inputs should be required by Pharmacy users. BENEFIT: Additional information should reduce audits and claw backs.

FHIR Message

Following are some key points of note regarding the Claim request message structure:

1. Allows for "Prescription" data to be optionally included. Important for some use cases but not all. This includes the Prescriber and the medication/DIN, as well as a link from the Adapted Prescription. Though the "Medication Request" may convey full prescription details, only a few necessary fields are supported in the Professional services claim.
2. Adapted Prescription Details - are only included if required. This can identify the Pharmacist as a Prescriber where applicable. Notes are also included as an optional data element.
3. Claim - this allows for a few additional fields for professional services as identified above, including the service location, care team members, adjusted/modified dosage/formulation, Therapeutic Substitution code and Clinical Reason code. All fields are optional and will vary by use case. None of these fields are expected during the MVP phase, though may be sent if the POS vendor wishes to do so and where no additional data must be entered by the user.
4. Though COB is rare for professional services, the message structure optionally allows for it, using a mechanism that is identical to the claim for dispensed medications. As such, minimal if any additional work is required to support this.