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Resource populationDraft for review
RTPBC Request
Request informationClaimCoverageMedicationRequestMedicationKnowledgePatientPractitionerOrganizations (1 representing the Payer 1 representing the Pharmacy)
Patient info.patient.reference to attached Patient resourceAttached to Claim
Name-.name.family, .name.given, .name.given[2]
DOB-.birthDate
Gender-.gender
Address For patient identification-address, address.type, address.line, address.line, address.city, address.state, address.postalcode, address.country
Coverage info.insurance.coverage.reference to attached Coverage resourceReferenced by ClaimPayer Organization referenced by Claim. Overkill for just the Payer ID?
Payer ID.identifier.system = [national system] .identifier.value = [the Payer ID] What ID system to use? -AND/OR- .insurer.reference to attached Organization resource.payor.identifier (and/or reference to the payer Organization resource).identifier.system = ??? .identifier.value = "PAYER ID'" What would be the appropriate system for the payer's ID?
BIN (IIN).insurance.identifier (.system="http://terminology.hl7.org/CodeSystem/coverage-class", .code="rxbin").class.type (.system="http://terminology.hl7.org/CodeSystem/coverage-class", .code="rxbin")
PCN.insurance.identifier (.system="hl7...coverage-class", .code="rxpcn").class.type (.system="hl7...coverage-class", .code="rxpcn")
Group ID.insurance.identifier (.system="hl7...coverage-class", .code="group").class.type (.system="hl7...coverage-class", .code="group")
Patient's PBM Member ID.insurance.identifier (.system="hl7...coverage-class", .code="rxid").class.type (.system=".. coverage-class", .code="rxid")
Cardholder ID[in attached Coverage resource. Not available in Claim].subscriberId (confirm)
Person Code[in attached Coverage resource. Not available in Claim].relationship (confirm)
Service date[Financial Mgmt guidance: .item.productOrService.servicedDate is left empty in Predetermination requests. Assumed to be answered as of the request date]
other mandatory Claim .insurance elements:
.sequence.insurance.sequence.@value = 1
.focal.insurance.focal.@value = "true"
Prescription infoReferenced by ClaimContained in Claim
Medication NDC.item.productOrService.coding (.system=~NDC, .code=[the NDC], .display=[drug name / strength / doseform].medicationCodeableConcept .code.coding (.system=~NDC, .code=[the NDC], .display=[drug name / strength / doseform].code.coding (.system=~NDC, .code=[the NDC], .display=[drug name / strength / doseform]
Medication RxNorm codeas above, but .system=~RxNormas above, but .system=~RxNormas above, but .system=~RxNorm
Prescribed quantity.item.quantity.@value.dispenseRequest.quantity.@valuenot available
Prescribed quantity units.item.quantity... .system.@value = [~NCPDP 600-28] .code@value = [the code] AND .item.quantity.unit = [the code].dispenseRequest.quantity… .system.@value = [~NCPDP 600-28] .code@value = [the code] AND .dispenseRequest.quantity.unit = [the code]not available
Days supplyDiscuss with FM WG: - long-term game plan (include in R5?) - handling until then (Claim.supportingInfo OR common extension) .dispenseRequest.expectedSupplyDurationnot available
Substitution allowedas above.substitution.allowedCodeableBoolean not available
Diagnosis / indication [confirm: if multiple RTPBC diagnoses are submitted, they represent different codings of the same diagnosis].diagnosis.sequence.@id = "1" .diagnosis.diagnosisCodeableConcept .coding.system = http://hl7.org/fhir/ValueSet/icd-10) OR .system=[appropriate ~SNOMED url].reasonCode.coding .system = http://hl7.org/fhir/ValueSet/icd-10) OR .system=[appropriate ~SNOMED url]not available
Other MedicationRequest elements: .sequence.intent="proposal"
status="draft"
.subject = reference to the attached Patient
.requester = reference to the attached Practitioner
Prescriber info.careTeam.provider.reference to attached Practitioner(Optional element) .requester = reference to the attached PractitionerPrescriber infomration referenced by Claim
NPI.careTeam.provider.identifier (.system =~NPI).identifier (.system=~NPI)
Last name.careTeam.provider.display (confirm).name.family
Other Claim-mandatory element: .sequence.sequence: 1
Preferred pharmacy info.provider.reference to attached pharmacy Organization resource(Optional element) .performer = reference to the attached pharmacy OrganizationPharmacy organization referenced by Claim
NPI.provider.identifier (.system=~NPI, .value = [the NPI]).identifier (.system=~NPI)
NCPDP ID.provider.identifier (.system=~NCPDP ID, .value=[the NCPDP ID]).identifier (.system=~NCPDP ID)
Pharmacy Name.provider.display.name
Pharmacy Phone[In pharmacy's Organization resource. Not available in Claim].telecom (.system="phone", .value=[number]
Other processing inputs
Residence Type NCPDP codes. E.g., home, Skilled nursing facility.item.locationCodeableConcept.coding .system = [~NCPDP value set] .value = [the value]
Place of Service CMS codes. E.g., pharmacy, Skilled nursing facility.item.locationCodeableConcept.coding .system = [~CMS value set] .value = [the value]
Other Claim element population
Request ID.id.@value = [set by the requesting app]
Request status.status.@value = "active"
Requested service type.type.coding.system = "http://terminology.hl7.org/CodeSystem/claim-type" .type.coding.code = "pharmacy"
Processing mode.use.@value = "predetermination"
Processing priority.priority.coding.@value = "normal"
Item
.sequence.item.sequence = 1
.diagnosisSequencereference the value set in .diagnosis.sequence.@id
Claim elements not populated…
.subtype
.billingPeriod
.enterer
.fundsReserve
.relatedClaim
.originalPrescription
.referral
.facility
.supportingInfo
.procedures
.item.careTeam
.item.revenue
.item.category
.item.modifier
.item.programCode
.item.servicedDate
.item.unitPrice
.item.factor
.item.net
.item.udi
.item.bodySite
.item.subSite
.item.encounter
.item.detail
.total