Health New Zealand Te Whatu Ora Shared Care FHIR API - Local Development build (v0.4.5) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Pharmacy Claiming

Health NZ | Te Whatu Ora provides the agreement and payment services for New Zealand's Integrated Community Pharmacy Services Agreement (ICPSA). The ICPSA is the national contract under which Health NZ purchases community pharmacy services from community pharmacy providers.

Pharmacies are paid according to specific service eligibilty rules and payment formulae described in the ICPSA.

The Pharmacy Management System (PhMS) at each pharmacy will electronically submit requests for payment ("Pharmacy Claims") for dispensed medications, under the terms of the ICPSA, to a FHIR Claim API endpoint published via Health NZ's Digital Services Hub. This replaces an electronic claiming process that transfers a claim CSV file, formatted according to the Pharmacy Transactions Data Specification (PTDS), over a legacy integration system.

It is intended for the PhMS to provide some kind of review and approval capability where pharmacists may review listed dispensing transactions and approve their release for inclusion in a payment claim. This may be as granular as one payment claim per patient per prescription per day and can be submitted continuously throughout each business day – or batched & submitted periodically during the week (e.g. every couple of hours, end of day, or end of week) as desired by each pharmacy.

Although the new submission process allows the payment claims to be submitted as frequently as desired by the pharmacy, the Health NZ claim processing system will still be performing a weekly determination run for each Claim Period & pharmacy – as it does today. Near-realtime pre-determination remains a future-state capability.

The PhMS will be notified when a submitted payment claim has been processed (approved/rejected) and the PhMS will be able to fetch the outcome of the claim ("Pharmacy Claim Response") from a FHIR API endpoint and present the results to the PhMS user. Payments for each Claim Period will be according to the current ICPSA schedule.

Overview

This section summarises the FHIR REST API endpoints used to exchange:

• Pharmacy Claims as operational reporting of payment requests for reimbursement for funded services delivered under the ICPSA.
  • Source profile: NZ Pharmacy Claim (a profiled Claim)
  • Referencing:
    • Pharmacy Medication Dispense
      • Source profile: NZ Pharmacy Medication Dispense (a profiled MedicationDispense)
    • Pharmacy Medication Request
      • Source profile: NZ Pharmacy Medication Request (a profiled MedicationRequest)
• Pharmacy Claim Responses for Health NZ to detail the outcome of a payment request (i.e. claim) including validation errors and/or adjudication outcomes describing why the payment request was approved or denied.
  • Source profile: NZ Pharmacy Claim Response (a profiled ClaimResponse)

Note: When viewing a profile, look at the 'Snapshot Table' tab for the consolidated view of the resource profile.

These Pharmacy Claiming artefacts are exchanged using standard FHIR RESTful interactions on their base resource types: Claim, MedicationDispense, MedicationRequest, and ClaimResponse.

Each "Pharmacy Claim" will consist of a POST of a FHIR Bundle containing a single FHIR Claim along with associated MedicationDispense and MedicationRequest resources.

This Shared Care FHIR server’s ​Capability Statement should be treated as the source of truth for which interactions/search parameters are enabled.

Pharmacy Claiming Use Cases

1. Submit a new request for payment of a Pharmacy Claim (status of "active") in a Bundle with referenced resources
2. Submit an update to a request for payment of a Pharmacy Claim (status of "active") in a Bundle with referenced resources to correct a validation or adjudication failure, for a credit, or for a credit & resubmission)
3. Fetch a Claim Response describing the outcome of a request for payment of a Pharmacy Claim (payment validation & adjudication results)
4. View a request for payment (Pharmacy Claim) that has been submitted (details of the Claim)

Not currently supported

1. Submit a cancellation of a request for payment of a Pharmacy Claim (status of "cancelled")

FHIR API endpoint conventions

Applicable to all use cases.

Base URL

• [base] = Shared Care FHIR Server base endpoint (environment-specific).

Common attributes (as profiled)

The profile of Claim requires a meta.source and a correlation-id slice for tag to be included in the request body.

Request-Context header

All requests must include a standard Health NZ 'Request-Context' custom header (Base64 encoded). The purpose of use should be "HPAYMT".

NZ Pharmacy Claim (Claim)

What it represents

A specific profiled Claim resource for requests for payment for each component of a dispensed medication originating from each pharmacy's PhMS - performed in accordance with the ICPSA.

It is how the PhMS submits a request for payment through Health NZ's "front door" for a pharmacy and period of time.

It represents the ICPSA payment request by the provider via their PhMS for dispensing(s) at the pharmacy for either:

• One specific patient (NHI) during the claim period; or
• All supply orders during the claim period
  • These do not have a patient and instead a data-absent-reason of "not-applicable" must be supplied in the mandatory patient attribute instead of the reference to a Patient.

It can be identified from the type (pharmacy) and subType (ICPSA) attributes of the Claim in addition to its specific profile.

It is recommended to submit a FHIR Bundle including the Claim and referenced resources for each patient (or supply orders) per prescription per day.

Endpoints (FHIR REST)

• Create (submit claim): POST [base]/Claim
• Update: PUT [base]/Claim/{id}
• Read: GET [base]/Claim/{id}
• Search: GET [base]/Claim?{search-params}

Key information

Claim-level

It is intended to represent a payment request from a pharmacy for a patient (or supply orders) per prescription per day.

Claim item-level

This represents a dispensing transaction and its dispensed medication.

Each Claim item (unless it is a "C"redit transaction) will refer to a FHIR MedicationDispense (describing the dispensing). Each MedicationDispense will refer to a FHIR MedicationRequest (describing the prescription item).

Each Claim item must have one or more detail records – one for each component of the dispensed medication to be approved for payment. The quantity claimed is per component at the item detail-level.

Medication Dispense

This describes the dispensed medication in the dispensing transaction.

Medication Request

This describes the prescribed medication (drug) in the prescription item of the dispensing transaction.

Claim item detail-level

Each detail record represents a claimed component of the dispensed medication. Most dispensing medications have a single component. Extemporaneously compounded products (ECPs) have multiple components - each with separate quantity & pricing.

Legacy attributes not for inclusion

The following (legacy) PTDS fields will not be represented within a FHIR Claim:

• Sequence No (2)
• Sender ID (6)
• Role (7)
• Payee Number (8)
• System (9)
• System Version (10)
• Schedule Date (11)
• Record type (20)
• Total Component Number (25)
• CSC Number (41)
• CSC Expiry (42)
• HUHC Number (44)
• HUHC Expiry (45)
• PSC Number (47)
• Prescription Code (51)
• Prescription Code Standard (52)
• Prescription Quantity (53)
• Formulation Unit (59)
• SIG (73)
• Funder (81)
• Service Agreement Number (83)
• Health Insurance Claim (84)
• Form Number (85)
• Total Claim Value (93)

Example: Submit a Pharmacy Claim (skeleton)

POST [base]/Claim
Content-Type: application/fhir+json
Accept: application/fhir+json

{
  "resourceType" : "Claim",
  "meta" : {
    "source" : "https://standards.digital.health.nz/ns/hpi-facility-id/F12345-A",
    "profile" : [
      🔗 "https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/NzPharmacyClaim"
    ],
    "tag" : [
      {
        "system" : "https://hub.services.digital.health.nz/ns/correlation-id",
        "code": "xxxxxxxx-xxxx-xxxx-xxxx-xxxxxxxxxxxx"
      }
    ]
  },
  // ... remainder per profile requirements: provider, patient, billablePeriod, insurance, item(s),  etc.
}

Example: Retrieve submitted Claim by id

GET [base]/Claim/{id}
Accept: application/fhir+json

NZ Pharmacy Claim Response (ClaimResponse)

What it represents

A profiled ClaimResponse resource describing validation and/or adjudication (determination) results for submitted Pharmacy Claims.

Endpoints (FHIR REST)

• Read: GET [base]/ClaimResponse/{id}
• Search: GET [base]/ClaimResponse?{search-params}

Key information

Each resource references the original claim via ClaimResponse.request.

Claim-level or claim item-level attributes that have failed validation, including where a fee cannot be identified, will be reported as records in the ClaimResponse.error collection. The overall ClaimResponse.outcome will be recorded as "error". Any errors related to a claim item will have the corresponding itemSequence set to the value of the Claim.item.sequence. Claim-level errors will not have a value set for their itemSequence.

Once the claim and its items are validated then each Claim.item (and each of its Claim.item.detail records) will be adjudicated. Information and failure messages relating to the adjudication (approval or denial) for the item will be reported as records within the ClaimResponse.item.detail.reviewOutcome record. If all the items in the claim are approved then the ClaimResponse.outcome will be set to "complete". Otherwise, if any item had a denial then the ClaimResponse.outcome will be set to "partial". Payment may be made for any successfully adjudicated items.

Response-level attributes

The following (legacy) LBL attributes will not be represented within a FHIR ClaimResponse:

• PrescriptionItem
  • UniqueTransactionNumber - already in the Claim.item
  • TransactionCategory - already in the Claim.item
  • TotalNumberOfComponents - already in the Claim.item
  • PrescriptionNumber - already in the Claim.item
  • PrescriptionSuffix - already in the Claim.item
  • ClaimCodeType - already in the Claim.item
  • ClaimCode - already in the Claim.item
  • QuantityDispensed - already in the Claim.item
• Component
  • ClaimCodeType - already in the Claim.item.detail
  • ClaimCode - already in the Claim.item.detail
  • QuantityDispensed - already in the Claim.item.detail
  • SequenceNumber - n/a

Response item-level attributes

The validated/adjudicated dispensed medication (a summary of any components validated/adjudicated detail-level).

Response item detail-level attributes

The validated/adjudicated component(s) of the dispensed medication.

Example: Find Claim Response(s) for a given Claim

GET [base]/ClaimResponse?request=Claim/{claimId}
Accept: application/fhir+json

Example: Read a ClaimResponse by id

GET [base]/ClaimResponse/{id}
Accept: application/fhir+json