51-52- Claim Response - Medication & Proff services - New Fields

This Claim response message is used two purposes:

1. Message event type = 51 - Response to a Claim for Dispensed Medication.
   
2. Message event type = 52 - Responses to a Claim for Professional Service.
   

Some adjudication details will only be used in Claims for medication dispenses (eg Drug Cost paid) and will not apply to Professional services.

Refer to Claim Response Message Mappings

COB Prior Claim Response Profile

The COB-Prior Claim Response profile conveys the adjudication details that are intended for use by downstream payors. As such, the structure of the claim response and the COB Prior Claim Response profiles are almost identical. The data in the COB Prior Response will be populated by the adjudicator in accordance with what they wish to share with downstream adjudicators. This could be the same data in the primary claim response or may be a subset of this data, though typically, only data deemed to be private or not required for adjudicating secondary claims should be eliminated.

In summary: The structure of the Claim Response and the Prior Claim Response are identical with a few exceptions:

1. Claim response identifiers are not specified in the Prior Claim Response
2. Coverage data is not typically specified in the Prior Claim Response

The following table contains details on new fields and functionalities in the Claim Response. Field that can be managed with mappings between CPHA3 and FHIR are not included.

Implementers should consult the mapping section of the specification or the FHIR profiles (links below) for further details.

New Fields and Functionality

Feature or Field	MVP Scope	Details	Sender Responsibility-Adjudicator	Receiver Responsibility - POS
CLAIM RESPONSE	Claim Response Prior Claim Response
NEW FUNCTIONALITY Specify Payee as Provider or Patient	MANDATORY	As there is a single claim request used for both Pay Provider and Pay Patient claims, the Payee field in FHIR will indicate whether the Provider or Patient will be paid. BENEFIT: Technical - streamlined response	MANDATORY	MANDATORY Data must be consumed so it is clear who is to be paid
NEW FIELDS & FUNCTIONALITY Separate clinical data from fiscal data	OPTIONAL	DUR messages will be separated from fiscal information. BENEFIT: Once implemented, DUR data will be more easily identified by POS and can be better managed.	OPTIONAL Must support when possible; Ideally, DUR messaging to be split and should not appear in Process Notes	OPTIONAL It is recommended that vendors look for DUR information in Process Notes and in DUR fields until all adjudicators can support new DUR fields. POS may wish coordinate with Adjudicators
NEW FIELD Special Auth Approved Days Supply	OPTIONAL	New field in the response to convey the authorized says supply. The Special Authorized days supply for this prescription is independent of where it is dispensed. Today may be used for LU codes in Ontario BENEFIT: Supports Pharmacist decision making	OPTIONAL Will be supported only by Adjudicators who require this	OPTIONAL POS should accept this value when possible
NEW FIELD Special Auth Remaining Quantity	OPTIONAL	Total quantity remaining on a prescription special authorization after this dispense. Recognizing that the quantity is relating to the unit and the strength of the product, this may also be specified. eg 10 tabs of 5mg strength is equivalent to 20 tabs and 2.5 mg. Limits may vary and may depend on the indication; sometimes the patient requires 2 strengths of tablets. Some SAs can cover multiple DINs; there will be support for text as well in the specification. BENEFIT: Supports Pharmacist decision making	OPTIONAL Adjudicators Conformance Rule: When codified, the quantity remaining must be based upon the DIN strength in the claim request. For more complex limits (eg multiple DINs), text should be used. Adjudicators should send when applicable	OPTIONAL Pharmacy vendors should consume when possible. .
NEW FIELD Special Auth Total Quantity Dispense Accumulated	OPTIONAL	The total number of pills "adjudicated" for a special auth number. An Adjudicator authorizes the number of pills against a special auth number; the dispenses may occur across several pharmacies. This accumulated total is returned as part of the adjudication result as informational data. Used in NFLD today and may be used by other provinces. BENEFIT: Supports Pharmacist decision making	OPTIONAL Send when possible and applicable	OPTIONAL Consume when possible
NEW FIELD Special Auth Period	OPTIONAL	New field in the Claim Response to convey start and expiry dates of a special auth BENEFIT: Supports Pharmacist decision making	OPTIONAL Send when applicable	OPTIONAL Receivers may use the data when possible
NEW FIELD Pertinent Adjudication Details	OPTIONAL	New field in the Claim Response and Prior Claim Results to convey details that are informational but relevant to adjudication. More specifically, one use case has come forth whereby BC codes are conveyed in CPHA3 in the message fields. The data is passed in a response code, which is then transposed into a downstream claim request in the special auth field. BENEFIT: POS vendors no longer need to transpose data when both primary and secondary are using PCS FHIR.	OPTIONAL Adjudicators who require this should coordinate with vendors	OPTIONAL Vendors should coordinate with adjudicators to understand when to expect this data. Vendors may need to support both mechanisms for a period of time
NEW FIELD Alert Codes	OPTIONAL	In CPHA3, Alert codes are sent along with Response codes in the same field. BENEFIT: Technical - Streamlined message by introducing a new field specifically for this purpose	OPTIONAL Adjudicators should send if possible	OPTIONAL vendors should expect Alert codes to be either in the Response code field or the Alert code field for the MVP stage
EXTEND FIELD Increase Response/Error Codes to 10	OPTIONAL	Increase the number of error codes on claim response to. BENEFIT: Additional information supports Pharmacist decision making and reduces adjudicator constraints on data sharing	OPTIONAL Adjudicators may send additional codes when ready and should understand if POS can handle the increase	OPTIONAL POS should support from the onset if possible
EXTEND FIELD Response Code System	RECOMMENDED	New field to specify the response code system, eg CPHA, BC, RAMQ, etc. These are fixed values. BENEFIT: Allows downstream adjudicators and POS applications may clearly understand what system the response code belongs to, which ensures there is no duplication across systems	RECOMMENDED should support when possible	RECOMMENDED In order to properly interpret codes
NEW FIELD Target Audience Indicator (Patient or Pharmacist) on Message	OPTIONAL	New field on response message to indicate if it targeted at the patient or pharmacist. BENEFIT: Supports Pharmacist decision making in conveying information to the patient and downstream payor ability to understand the codes	OPTIONAL Support as soon as feasible.	OPTIONAL POS systems should consume data as soon as feasible
NEW FIELD Print or Display Message	OPTIONAL	Indicates whether the message should be printed on the receipt for the patient BENEFIT: Adjudicators may clearly indicate when the data should be presented to the patient	OPTIONAL	OPTIONAL
EXTEND FIELD Message Line Length and Number	OPTIONAL	Allows more data to be returned. Note: The Field length will be handled by default by using JSON in the FHIR message. This becomes a list of 0..20 (10 english, 10 french). Each line increases from 40 characters per message to 1000 BENEFIT: Further details about adjudicated result can be conveyed	OPTIONAL Adjudicators may start populating longer messages whenever they are ready. In CPHA, there are 3 lines of 40 characters that will be extended.	OPTIONAL POS vendors will accept the new maximum length
NEW FIELD Support Language on Message Lines Returned-	MANDATORY for sender	Language code (English/French/not specified) to response messages. BENEFIT: Allows vendor to display based on the user language. This is not static as a single prescription/dispense may be viewed & managed by users of both languages over the lifetime of a prescription Adjudicators may specify if unknown (eg CPHA3 mappings scenario), and for FHIR, both English and French are expected if possible. FHIR responses will contain English + French combined	MANDATORY	OPTIONAL
NEW FIELD Payee Deferred	MANDATORY	This new field - Clearly delineates the dollar value paid to patient and enhances COB. BENEFIT: The response message will indicate deferred payments (insurer pays patient). This will enable additional COB (downstream claims) which are blocked today under certain circumstances. More specifically, there is logic in the PMS today (CPHA3)that blocks COB if a code QJ is returned because pharmacy systems do not know the amount to be paid to the patient and cannot properly calculate and submit the previously paid amount on claims to downstream payors. PCS FHIR will specify the pay to patient amount, which allows downstream claims to be sent. This ensures that prior payments to patients are communicated which will prevent subsequent payors from overpaying the claim. Note: The QJ code will be deprecated and replaced with a specific field in PCS FHIR to indicate the dollar value paid to the patient. .	MANDATORY Payors that support pay patient claims (transaction type 04), will return the amount paid to the patient in the new field, and return 0 in the amount paid to the pharmacy field. CPHA transaction 04 will be deprecated	MANDATORY Vendors will be able to remove the COB restriction because the paid amount will be known in PCS FHIR
UPDATE FIELDS Increase price fields to support Claims 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: Technical - allows for larger dollar amounts in support of 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. Coordination between implementers is required.	RECOMMENDED Each implementer will determine timing and whether in scope for initial rollout/MVP. Coordination with POS vendors is required
Prior Payment Results	Prior Claim Response
NEW FIELDS COB-Prior Claim Response	MANDATORY	This new "resource" includes data that is intended to be passed on adjudication details to downstream payors in downstream claims. Fields will indicate cost/markup/fee cutbacks. A coverage type used for adjudication (eg private/public) is also included. This data is passed on in downstream/secondary claims and may contain a digital signature. BENEFIT: Improves adjudication, reduce audits and cutbacks. The policy type allows more claims to be submitted as it is definitive information from the source	MANDATORY Adjudicator must include this data in the response when the claim is not paid in full.	MANDATORY POS must store this resource as they will need to include this resource in the downstream FHIR claims
Digital Signature	Provenance Profile
NEW FUNCTIONALITY Digital Signature on Prior Claim Results	OUT OF SCOPE	A provenance resource is optionally included in the Claim Response message with a Digital signature. The digital signature applies only to the Prior Claim response BENEFIT: Provides assurance to downstream payors that the prior claim results have not been inadvertently modified/tampered with	OUT OF SCOPE Mapping only, eg if provenance supplied in Claim Response it must be included in downstream claim requests. Further information is available in the Technical section of this specification.	OUT OF SCOPE Further information is available in the Technical section of this specification.
COVERAGE	Prior Coverage
NEW FIELD Coverage Type	MANDATORY for sender	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	MANDATORY	OPTIONAL should consume when possible

Claim Structure

The same claim structure is used for both dispensed Medication claims and Professional services, as shown below.