August 2024

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). The intent 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.

In 2022, the Canadian Pharmacists Association, Neighbourhood Pharmacy Association of Canada and the Canadian Life and Health Insurance Association began a modernization and update process to ensure that it continues to meet the needs of all users. The initiative is governed by a Steering Committee comprised of representatives from each partner organizations.

FHIR PCS

Beginning in 2024, the PCS will transition to the Canadian FHIR Pharmacy Claims Standard (FHIR PCS). 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.

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?
2. What areas of the Pharmacy Claims Standard are being reviewed and changed, and how will these functional changes benefit me?
3. What is the process to transition from the CPhA PCS to the FHIR PCS?
4. Who is involved in the development of the FHIR PCS?
5. What are the timelines for implementation?
6. How will the FHIR PCS be maintained?
7. Where will the FHIR-PCS reside?
8. What version of FHIR is the specification based on?
9. Does this specification align with other Canadian FHIR specifications?

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 may take several years.

   Version 3 will continue to be maintained and updated by CPhA throughout the transition period.
    

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

   Key areas that will be addressed 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 also addresses pharmacy services.

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

   1. 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.
   2. Quantity Decimal Place Limits: Increases precision to track and record dosing on some medications.
   3. 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)
   4. 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.
   5. 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.
   6. 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.
   7. Intervention Codes: Increases the number of intervention codes on a claim request and error codes on a response message to 10.
   8. Professional Services claim: This new claim type specifically addresses the data requirements for professional services. This reduces audits and claw backs and improve the user experience.
   9. Quebec claim requirements: New fields added to convey pricing requirements for Quebec.
       
3. What is the process to transition from the CPhA PCS to the FHIR PCS?

   The transition will likely occur in phases and must be coordinated between pharmacy software vendors, networks and adjudicators/payors. It is expected that the initial phase will include transformation between the current CPhA PCS v3 and the new FHIR message standard. To assist with this, the FHIR specification includes mapping tables from the FHIR message to CPHA. Adjudicators and PMS software will introduce additional functionality in priority sequence over time.
    

4. Who is involved in the development of the FHIR PCS?

   The development of the new FHIR PCS 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 was established to guide the development of the FHIR PCS with representatives from each key stakeholder group, namely pharmacy, private and public payers, insurers, pharmacy benefit managers and pharmacy practice management systems.
    

5. What are the timelines for implementation?

   Once the FHIR standard is published, a process to provide implementation support will be identified. While no specific timelines for full implementation have been identified, we recognize that this process may take several years.
    

6. How will the FHIR PCS be maintained?

   After the initial publication of the FHIR PCS, stakeholders and users will be able to submit requests for changes.

   Simple changes such as the addition of a new override code will be validated for change on receipt and can generally be accommodated in a timely manner. More complex changes will be collected and assessed for implementation by the Steering Committee.
    

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 in Canada. The PCS implementation guide is available for viewing and allows stakeholders to download the implementation guide and FHIR artifacts.
    

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

   This implementation Guide will be based on FHIR R4.
    

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 declared. This specification is also aligned where possible to PrescribeIT.