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Objective

The objective of this proposal is to provide fields to fulfill the use case of plan's providing alternative medication fill suggestions.

We'd like to use the Claim and ClaimResponse resources to transact PreDetermination Requests on behalf of the provider or patient. While it works suitably well for this use case at present, a major use case for Payers is to be able to provide alternative pricings (for therapeutic alternatives and alternative dispensing locations) to help reduce treatment abandonment and lower cost to the patient and cost to the payer.

It should be noted that these new fields fulfill a need that is likely specific to the US Healthcare system. The US Healthcare system lacks price transparency at the point of prescribing. The provider usually does not know what the medication will cost their patient. If they prescribe a medication that the patient cannot afford, the patient will abandon therapy a significant percentage of the time. If the provider can understand the costs associated with their prescribed medications and be provided alternative pharmacies and/or medication prices, then they can intelligently prescribe something that will more reliably get the patient on therapy.

Definition



Code

"suggested-alternative"
ContextThis extension is used in the ClaimResponse resource
Short DefinitionPricing for an alternative item/location combination suggested by the entity receiving the pre-determination.
DefinitionIdentifies an alternative pricing for items/location combinations that fulfill the therapeutic objective of the MedicationRequest associated with the Pre-Determination as suggested by the entity receiving the Pre-Determination.
Comment
Cardinality0..* (entity receiving the claim can suggest no alternatives or as many as they'd like)
Type
InvariantsNo invariants
Is ModifierMaybe? This would not be used for a ClaimResponse in most contexts, only when the ClaimResponse is used for pre-authorization or quoting the potential claim. The pricings in the ClaimResponse would not necessarily be legally binding in any way.
Binding(no binding - not a coded value)


^^ see description in the code block


Basic Structure

Additional Fields

TypeCardinalityDescription

prescription (same as Claim.prescription)

Reference(DeviceRequest | MedicationRequest | VisionPrescription)

1..1Product/Drug associated with the alternate price

facility (same as Claim.facility)

Reference(Location)

1..1Facility/Dispensing Location associated with the alternate price

pricing

Money

Coding

1..1Pricing. Each pricing has a money field and a coding which identifies what the dollar amount represents (CoPay, Patient Pay, Amount counting towards deductible, etc.).

Structure Definition

Structure Definition JSON
{
  "resourceType": "StructureDefinition",
  "id": "suggested-alternatives",
  "extension": "",
  "url": "http://hl7.org/fhir/StructureDefinition/suggested-alternative",
  "version": "4.1.0",
  "name": "suggested-alternative",
  "status": "draft",
  "date": "",
  "publisher": "",
  "description": "Identifies alternative pricings for items/location combinations that fulfill the therapeutic objective of the MedicationRequest associated with the Pre-Determination as suggested by the entity receiving the Pre-Determination.",
  "fhirVersion": "4.1.0",
  "mapping": "",
  "kind": "complex-type",
  "abstract": false,
  "context": "",
  "type": "Extension",
  "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Extension",
  "derivation": "constraint",
  "SuggestedAlternative": [
    {
      "id": "alternative-1",
      "ClaimResponse.item": [
        "adjudication": [
          {
            "category": {
              "coding": [
                {
                  "code": "eligible"
                }
              ]
            },
            "amount": {
              "value": 135.57,
              "currency": "USD"
            }
          }
      ],
      "facility": {
        "reference": "Organization/1"
      }
    },
    {
      "id": "alternative-2",
      "ClaimResponse.item": [
        "adjudication": [
          {
            "category": {
              "coding": [
                {
                  "code": "eligible"
                }
              ]
            },
            "amount": {
              "value": 135.57,
              "currency": "USD"
            }
          }
      ],
      "facility": {
        "reference": "Organization/2"
      }
    }
  ]
}

Use Case Examples


Use Case DefinitionProductDispensing LocationPrice
1Benefit check for product for which the insurer knows of cheaper generic alternative medication. Plan returns pricing for the submitted medication at the submitted pharmacy. Plan returns one "suggested-alternative" with the alternative item and the requested facility.


2Benefit check for product and pharmacy for which the insurer knows of cheaper dispensing location. Plan returns pricing for the submitted medication at the submitted pharmacy. Plan returns one "suggested-alternative" with the requested item and the alternate facility.


3Benefit check for product for which the insurer knows of a cheaper generic alternative medication and a cheaper dispensing location. Plan returns pricing for the submitted medication at the submitted pharmacy. Plan returns three "suggested-alternative". One for the requested pharmacy and an alternative medication, one for the alternative pharmacy and requested medication, and one for the alternative pharmacy and alternative medication.



Use Case 1 - Alternate Medication
{
	"resourceType": "ClaimResponse",
    "id": "CR1556978144R50630",
    "identifier": [
        {
            "value": "CR1556978144R50630"
        }
    ],
    "status": "active",
    "type": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/claim-type",
          "code": "pharmacy"
        }
      ]
    },
    "use": "predetermination",
    "created": "2019-05-04T00:00:00+00:00",
    "patient": {
      "reference": "Patient/1"
    },
    "insurer": {
        "reference": "Organization/1"
    },
    "requestor": {
        "reference": "Organization/1"
    },
    "request": {
        "reference": "Claim/ed6bfee7-2ef9-4dd8-b2ac-8443ef886b7a"
    },
    "outcome": "complete",
    "item": [
        {
            "itemSequence": 1,
            "adjudication": [
                {
                    "category": {
                        "coding": [
                            {
                                "code": "eligible"
                            }
                        ]
                    },
                    "amount": {
                        "value": 65,
                        "currency": "USD"
                    }
                }
            ]
        }
    ],
	"extension": [
    {
      "url": "alternate-suggestions",
      "extension": [
        {
          "url": "alternate-suggestion",
          "extension": {
            "url": "prescription",
            "valueReference": "MedicationRequest/2"
          },
          "extension": {
            "url": "facility",
            "valueReference": "Location/1" 
          },
          "extension": {
            "url": "pricing",
            "valueMoney": {
              "value": 45,
              "currency": "USD"
            },
            "valueCoding": {
              "code": "patientPay",
            }
          },
          "extension": {
            "url": "pricing",
            "valueMoney": {
              "value": 45,
              "currency": "USD"
            },
            "valueCoding": {
              "code": "coPay",
            }
          }
        }
      ]
    }
  ]
}
Use Case 2 - Alternative Pharmacy
{
	"resourceType": "ClaimResponse",
    "id": "CR1556978144R50630",
    "identifier": [
        {
            "value": "CR1556978144R50630"
        }
    ],
    "status": "active",
    "type": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/claim-type",
          "code": "pharmacy"
        }
      ]
    },
    "use": "predetermination",
    "created": "2019-05-04T00:00:00+00:00",
    "patient": {
      "reference": "Patient/1"
    },
    "insurer": {
        "reference": "Organization/1"
    },
    "requestor": {
        "reference": "Organization/1"
    },
    "request": {
        "reference": "Claim/ed6bfee7-2ef9-4dd8-b2ac-8443ef886b7a"
    },
    "outcome": "complete",
    "item": [
        {
            "itemSequence": 1,
            "adjudication": [
                {
                    "category": {
                        "coding": [
                            {
                                "code": "eligible"
                            }
                        ]
                    },
                    "amount": {
                        "value": 65,
                        "currency": "USD"
                    }
                }
            ]
        }
    ],
	"extension": [
    {
      "url": "alternate-suggestions",
      "extension": [
        {
          "url": "alternate-suggestion",
          "extension": {
            "url": "prescription",
            "valueReference": "MedicationRequest/1"
          },
          "extension": {
            "url": "facility",
            "valueReference": "Location/2" 
          },
          "extension": {
            "url": "pricing",
            "valueMoney": {
              "value": 35,
              "currency": "USD"
            },
            "valueCoding": {
              "code": "patientPay",
            }
          },
          "extension": {
            "url": "pricing",
            "valueMoney": {
              "value": 35,
              "currency": "USD"
            },
            "valueCoding": {
              "code": "coPay",
            }
          }
        }
      ]
    }
  ]
}
Use Case 3 - Alternate Medication and Pharmacy
{
	"resourceType": "ClaimResponse",
    "id": "CR1556978144R50630",
    "identifier": [
        {
            "value": "CR1556978144R50630"
        }
    ],
    "status": "active",
    "type": {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/claim-type",
          "code": "pharmacy"
        }
      ]
    },
    "use": "predetermination",
    "created": "2019-05-04T00:00:00+00:00",
    "patient": {
      "reference": "Patient/1"
    },
    "insurer": {
        "reference": "Organization/1"
    },
    "requestor": {
        "reference": "Organization/1"
    },
    "request": {
        "reference": "Claim/ed6bfee7-2ef9-4dd8-b2ac-8443ef886b7a"
    },
    "outcome": "complete",
    "item": [
        {
            "itemSequence": 1,
            "adjudication": [
                {
                    "category": {
                        "coding": [
                            {
                                "code": "eligible"
                            }
                        ]
                    },
                    "amount": {
                        "value": 65,
                        "currency": "USD"
                    }
                }
            ]
        }
    ],
	"extension": [
    {
      "url": "alternate-suggestions",
      "extension": [
        {
          "url": "alternate-suggestion",
          "extension": {
            "url": "prescription",
            "valueReference": "MedicationRequest/1"
          },
          "extension": {
            "url": "facility",
            "valueReference": "Location/2" 
          },
          "extension": {
            "url": "pricing",
            "valueMoney": {
              "value": 35,
              "currency": "USD"
            },
            "valueCoding": {
              "code": "patientPay",
            }
          },
          "extension": {
            "url": "pricing",
            "valueMoney": {
              "value": 35,
              "currency": "USD"
            },
            "valueCoding": {
              "code": "coPay",
            }
          }
        },
        {
          "url": "alternate-suggestion",
          "extension": {
            "url": "prescription",
            "valueReference": "MedicationRequest/2"
          },
          "extension": {
            "url": "facility",
            "valueReference": "Location/1" 
          },
          "extension": {
            "url": "pricing",
            "valueMoney": {
              "value": 45,
              "currency": "USD"
            },
            "valueCoding": {
              "code": "patientPay",
            }
          },
          "extension": {
            "url": "pricing",
            "valueMoney": {
              "value": 45,
              "currency": "USD"
            },
            "valueCoding": {
              "code": "coPay",
            }
          }
        },
        {
          "url": "alternate-suggestion",
          "extension": {
            "url": "prescription",
            "valueReference": "MedicationRequest/2"
          },
          "extension": {
            "url": "facility",
            "valueReference": "Location/2" 
          },
          "extension": {
            "url": "pricing",
            "valueMoney": {
              "value": 25,
              "currency": "USD"
            },
            "valueCoding": {
              "code": "patientPay",
            }
          },
          "extension": {
            "url": "pricing",
            "valueMoney": {
              "value": 25,
              "currency": "USD"
            },
            "valueCoding": {
              "code": "coPay",
            }
          }
        }
      ]
    }
  ]
}
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2 Comments

  1. Mike Berkman We'd be interested in talking with you further about this project. We are working on something similar. CARIN Consumer-facing Real-time Pharmacy Benefit Check PSS

    1. Ryan Howells 💯.  you should be able to get my email address from the Confluence directory