<status value="draft" /> <description value="Reversal Parameters OUT profile" /> <purpose value="Reversal Parameters profile OUT" /> <fhirVersion value="4.0.1" /> <kind value="resource" /> <abstract value="false" /> <type value="Parameters" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/Parameters" /> <derivation value="constraint" /> <differential> <element id="Parameters.parameter"> <path value="Parameters.parameter" /> <slicing> <discriminator> <type value="value" /> <path value="name" /> </discriminator> <rules value="open" /> </slicing> <mustSupport value="true" /> </element> <element id="Parameters.parameter:AdjudicationDate"> <path value="Parameters.parameter" /> <sliceName value="AdjudicationDate" /> <comment value="Usage: The date, as determined by the processor, on which the claim, transaction or request being responded to has been adjudicated. This date is found in the ClaimResponse.created data element. This must be present when reversal a claim that has been adjudicated. CPHA Map: D.77.03 Adjudication Date" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:AdjudicationDate.name"> <path value="Parameters.parameter.name" /> <fixedString value="AdjudicationDate" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:AdjudicationDate.value[x]"> <path value="Parameters.parameter.value[x]" /> <min value="1" /> <type> <code value="dateTime" /> </type> <mustSupport value="true" /> </element> <element id="Parameters.parameter:TraceNumber"> <path value="Parameters.parameter" /> <sliceName value="TraceNumber" /> <comment value="Usage Note: Trace number from the claim which is echoed back in the response CPHA map: E.02.03 Trace Number." /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:TraceNumber.name"> <path value="Parameters.parameter.name" /> <fixedString value="TraceNumber" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:TraceNumber.value[x]"> <path value="Parameters.parameter.value[x]" /> <type> <code value="Identifier" /> </type> <mustSupport value="true" /> </element> <element id="Parameters.parameter:TraceNumber.value[x].system"> <path value="Parameters.parameter.value[x].system" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:TraceNumber.value[x].value"> <path value="Parameters.parameter.value[x].value" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ReferenceNumber"> <path value="Parameters.parameter" /> <sliceName value="ReferenceNumber" /> <comment value="Usage Note: This is an internal reference number assigned to each claim by the processor. This is optional as Pharmacies may reverse a claim when no adjudication response has been received. CPHA map: E.04. 03 Reference Number" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ReferenceNumber.name"> <path value="Parameters.parameter.name" /> <fixedString value="ReferenceNumber" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ReferenceNumber.value[x]"> <path value="Parameters.parameter.value[x]" /> <comment value="Usage Note: The system should be included when known." /> <type> <code value="Identifier" /> </type> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ReferenceNumber.value[x].system"> <path value="Parameters.parameter.value[x].system" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ReferenceNumber.value[x].value"> <path value="Parameters.parameter.value[x].value" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ClaimOrCurrentRXNumber"> <path value="Parameters.parameter" /> <sliceName value="ClaimOrCurrentRXNumber" /> <comment value="Usage Note: Prescription Number appearing on the label of the dispensed prescription or on the record of the service provided. In FHIR this is found in the MedicationDispense.identifier for dispenses or in the claim.identifier for professional services claims CPHA Map: D.55.03" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ClaimOrCurrentRXNumber.name"> <path value="Parameters.parameter.name" /> <fixedString value="ClaimOrCurrentRXNumber" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ClaimOrCurrentRXNumber.value[x]"> <path value="Parameters.parameter.value[x]" /> <comment value="Usage Note: In FHIR, the system is known and must be present when known. It is optional for backward compatibility to CPHA3." /> <min value="1" /> <type> <code value="Identifier" /> </type> </element> <element id="Parameters.parameter:ClaimOrCurrentRXNumber.value[x].system"> <path value="Parameters.parameter.value[x].system" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ClaimOrCurrentRXNumber.value[x].value"> <path value="Parameters.parameter.value[x].value" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ResponseStatus"> <path value="Parameters.parameter" /> <sliceName value="ResponseStatus" /> <comment value="Usage Note: Set Value = R = rejected OR V - reversal accepted CPHA Map: E.05.03 Response Status" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ResponseStatus.name"> <path value="Parameters.parameter.name" /> <fixedString value="ResponseStatus" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ResponseStatus.value[x]"> <path value="Parameters.parameter.value[x]" /> <min value="1" /> <type> <code value="code" /> </type> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ResponseCodes"> <path value="Parameters.parameter" /> <sliceName value="ResponseCodes" /> <comment value="Usage Note: Only used when Response Status = R Examples are: A7-submit manual reversal A8 - no reversal made-orig. claim missing A9-reversal processed previously" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ResponseCodes.name"> <path value="Parameters.parameter.name" /> <fixedString value="ResponseCodes" /> </element> <element id="Parameters.parameter:ResponseCodes.value[x]"> <path value="Parameters.parameter.value[x]" /> <type> <code value="code" /> </type> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ReversalAmount"> <path value="Parameters.parameter" /> <sliceName value="ReversalAmount" /> <comment value="Usage Note: Must be present when the reversal is successful. CPHA Mapping:" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ReversalAmount.name"> <path value="Parameters.parameter.name" /> <fixedString value="ReversalAmount" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ReversalAmount.value[x]"> <path value="Parameters.parameter.value[x]" /> <comment value="Usage Note: Canadian Dollars is assumed and therefore currency is not required" /> <type> <code value="Money" /> </type> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ReversalAmount.value[x].value"> <path value="Parameters.parameter.value[x].value" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:PayeeType"> <path value="Parameters.parameter" /> <sliceName value="PayeeType" /> <comment value="Usage Note: This is the payee type from the reversed claim. Set value = "Patient" or "Provider". This is found in the payee field of the claim response and request. This value must be present. CPHA Map: This is not on the claim reversal today and is therefore optional. Value must be present" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:PayeeType.name"> <path value="Parameters.parameter.name" /> <fixedString value="PayeeType" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:PayeeType.value[x]"> <path value="Parameters.parameter.value[x]" /> <min value="1" /> <type> <code value="string" /> </type> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ReversalRefusalReason"> <path value="Parameters.parameter" /> <sliceName value="ReversalRefusalReason" /> <comment value="Usage Note: Used when adjudicators need to provide a textual description of reasons that a claim reversal was not accepted. CPHA Map: E.20.03 Message Data Line" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ReversalRefusalReason.name"> <path value="Parameters.parameter.name" /> <fixedString value="ReversalRefusalReason" /> <mustSupport value="true" /> </element> <element id="Parameters.parameter:ReversalRefusalReason.value[x]"> <path value="Parameters.parameter.value[x]" /> <min value="1" /> <type> <code value="string" /> </type> <mustSupport value="true" /> </element> </differential> </StructureDefinition>