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Business Overview

April 19, 2023

FHIR PCS Overview The current CPhA Pharmacy Claim Standard (CPhA PCS) Standard was developed to provide orderly and efficient online processing of prescription drug claims. As drug benefits and pharmacy services have evolved, so must the Pharmacy Claims Standard (PCS).

In 2022, the PCS started a modernization and update process to ensure that it continues to meet the needs of all users. In reaching this goal, the intent of the Standard is to support the needs of as wide a base of potential users as possible, while being flexible enough to change as needs and technology change and to provide simple and easy implementation. Starting in 2023, the Canadian FHIR Pharmacy Claims Standard (FHIR PCS) will begin to replace the existing standard. FHIR - Fast Healthcare Interoperability Resources' standard - is a set of rules and specifications for exchanging electronic health care data. It is designed to be flexible and adaptable, so that it can be used in a wide range of settings and with different health care information systems.

The FHIR PCS a joint partnership by the Canadian Pharmacists Association, Neighbourhood Pharmacies Association of Canada and Canadian Life and Health Insurance Association and is governed by a Steering Committee comprised of representatives from each partner organizations.

Objectives of the FHIR PCS:

  1. To provide a simplified and common claim format for all carriers to use. The goal is to provide real-time claims processing (data collection and payment) through a single device in the pharmacy which will link to all potential networks and carriers with which the community pharmacist may communicate, while avoiding double keying of information.
  2. Facilitate data/information transmission required by federal, provincial or territorial regulations related to drug and pharmacy service utilization.
  3. Address gaps in clinical data in the current standard for the benefit of providers and payers.
  4. Minimize the need for additional standards, reporting solutions etc.

Frequently asked questions

  1. What happens to the current pharmacy claims standard? What is the transition plan?

    The current version (v3) will continue to operate throughout a transition period to allow all stakeholders sufficient time to transition to the new standard. While no deadlines have been established, we recognize that this process will take several years.

  2. What areas of the Pharmacy Claims Standard are being reviewed and changed, and how will these functional changes benefit me?

    Some of the key areas that will be addressed as part of a first phase include: drug price limits, quantity decimal place limits, deferred payments, compounds, coordination of benefits, coding DINs, intervention/error codes, messages, DUR response messaging, special authorization information, and days supply. The FHIR PCS has also identified pharmacy professional services as a key area to be implemented as part of a second phase.

    Some of the changes that we will see with the new FHIR-PCS are:

    • Removing drug price limits This will allow payers to accept electronic claims for more than the existing $9999.99 drug cost and $999.99 fee.
    • Quantity Decimal Place Limits Increases precision to track and record dosing on some medications.
    • Coordination of Benefits Improves visibility of payors adjudicating claims as a non-primary payor. New fields support inclusion of adjudication details from previous payors to be submitted in the claim request (BIN, amount paid, intervention codes)
    • Deferred Payments Adds support to response messages for deferred payments (insurer pays patient) which will enable pharmacy to submit the claim as a coordination of benefits. Also adds responses for delayed adjudication.
    • Compounds Removes the limit of submitting a single DIN. Allows pharmacy to submit a claim that indicates all ingredients in a compound. Improves visibility into active ingredient, ingredient list and quantities of each ingredient, allowing payors to correctly adjudicate the claim.
    • Claim Response Details Adds fields to claim response to indicate how much of cost/markup/fee cutbacks can be passed on to secondary third parties and to patient.
    • Intervention Codes Increases the number of intervention codes on a claim request and error codes on a response message to 10.

  3. What are the timelines for implementation?

    A timeline for implementation is currently under development.

  4. Who is involved in the development of the new standard?

    The development of the new FHIR PCS Standard is a partnership between the Canadian Pharmacists Association, Neighbourhood Pharmacies Association of Canada and Canadian Life and Health Insurance Association and is governed by a Steering Committee comprised of representatives from each partner organizations. A technical working group has been established to guide work with representatives from each key stakeholder group, namely pharmacy, private and public payers, insurers, pharmacy benefit managers and pharmacy practice management systems.

  5. How will the FHIR PCS be maintained?

    The three partners are developing a process for maintenance. There will be a process created so that stakeholders will be able to submit a change request. These updates will be scheduled to meet stakeholder needs. Simple changes such as the addition of a new override code, will be validated for change on receipt. More complicated changes will be collected and assessed for implementation.

  6. Which stakeholders will have an opportunity to review and comment on the updated PCS (FHIR version).

    All impacted stakeholders will have an opportunity to review and comment on the new standards prior to publication. These will include pharmacies, pharmacy associations private and public payers, insurers, PBM, PPMs and regulators. An initial consultation period is expected in May 23.

  7. Where will the FHIR-PCS reside?

    The specification will reside on the FHIR Simplifier platform.SIMPLIFIER.NET is a web based FHIR registry built by Firely (a healthcare IT company based in Amsterdam) that serves as the hosting platform for the Canadian FHIR Registry sponsored by Canada Health Infoway and other FHIR projects. The PCS implementation guide is available for viewing and allows stakeholders to download FHIR artifacts.

  8. What version of FHIR is the specification based on?

    This implementation Guide will be based on FHIR R5,which is the latest publication of FHIR.

  9. Does this specification align with other Canadian FHIR specifications?

    Yes, there will be alignment where possible to the R4 Canadian FHIR baseline profiles (Core-CA) though there is no formal dependency decalared. When creating this specification, we have also aligned where possible to PrescribeIT and considered the Ontario DHDR specification as Pharmacy vendors will likely use both specifications.

  10. Will the specification provide mappings to the existing CPhA Specification?

    Yes. The current specification provides mapping tables to the CPhA Specification which will help to speed up the implementation process.

  11. Is there an environment to host certification testing?


  12. Is there a governing body that will approve/reject certification to the new standard?