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  1. FHIR Specification Feedback
  2. FHIR-33487

Pharmacy EOB: Addition of Refills Authorized to profile

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    Details

    • Type: Change Request
    • Status: Applied (View Workflow)
    • Priority: Medium
    • Resolution: Persuasive with Modification
    • Specification:
      US CARIN Blue Button (FHIR)
    • Raised in Version:
      current
    • Work Group:
      Financial Mgmt
    • Related Artifact(s):
      C4BB ExplanationOfBenefit Pharmacy
    • Grouping:
    • Resolution Description:
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      Add SupportingInfo slice for Refills Authorized, NCPDP #415-DF, defined as ‘Number of refills authorized by the prescriber.’

      Slice name: refillsAuthorized

      Add code "refillsauthorized" "Refills Authorized" "NCPDP value indicating the number of refills authorized by the subscriber (0, 1, 2, etc.)" to http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType with code required for slice category.

      Slice cardinality of 1..1 MS

      value[x] only Quantity with cardinality 1..1 MS

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      Add SupportingInfo slice for Refills Authorized, NCPDP #415-DF, defined as ‘Number of refills authorized by the prescriber.’ Slice name: refillsAuthorized Add code "refillsauthorized" "Refills Authorized" "NCPDP value indicating the number of refills authorized by the subscriber (0, 1, 2, etc.)" to  http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType  with code required for slice category. Slice cardinality of 1..1 MS value [x] only Quantity with cardinality 1..1 MS
    • Resolution Vote:
      Corey Spears / Mark Roberts : 17-0-0
    • Change Category:
      Enhancement
    • Change Impact:
      Non-compatible

      Description

      (Submitted by Prime Therapeutics, PBM)

      One item that has come up as a data element that would be useful for members is to see - along with which refill number a claim was for - but also how many refills have been authorized by the prescriber. The Pharmacy EOB Profile includes the refill number (00 for first fill, 01 for the first refill etc.). But there isn't an element or CPCDS data mapping for the number of refills authorized.

      The use case we have is to alert a patient that a prescription must be renewed of if they had their last fill.

      Is this something that could be added to the Pharmacy EOB profile (possibly a slice of supporting info along with the refill number?
      Or would we have to populate a reference to a MedicationRequest Resource (which has an aligned element 'numberOfRepeatsAllowed') and _include that resource with the results? I worry about one more resource which would likely repeat the same data as what is on the EOB (patient, medication, prescriber, substitution allowed) just to add one more element. But I agree that it is an attribute more of prescription than of claim.

      My understanding is that in NCPDP D.0 refills authorized is not a required input (unless there is a payor rule for this). So it's not always populated and would need to be optional in the mapping.  And if it is reported there is no source validation (against the actual prescription or eRx) happening at the payor. We take in the value as reported by the pharmacy and store it on the claim.  

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            Unassigned Unassigned
            Reporter:
            kxdech Kate Dech
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