If the value in the process Note/text is "Not Covered", would a reject reason such as "Prior authorization denied…

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    • Type: Change Request
    • Resolution: Persuasive with Modification
    • Priority: Medium
    • US CARIN Real-time Pharmacy Benefit Check (RTPBC) (FHIR)
    • Pharmacy
    • RTPBC Response Profile (ClaimResponse) [deprecated]
    • Profiles and Extensions
    • Hide

      In the ClaimResponse profile's Must Support section...
      CHANGE:
      The error composite MUST be populated when the responder cannot complete processing due to a business rule or data exception. Otherwise, the item composite MUST be populated

      TO:
      Every response must contain either an item composite or an error composite, but not both. The Item composite MUST be populated when sufficient information is received to be able to answer the request.

      The error composite MUST be populated when the responder cannot complete processing due to insufficient or invalid information in the request. 

      Show
      In the ClaimResponse profile's Must Support section... CHANGE: The error composite MUST be populated when the responder cannot complete processing due to a business rule or data exception. Otherwise, the item composite MUST be populated TO: Every response must contain either an item composite or an error composite, but not both. The Item composite MUST be populated when sufficient information is received to be able to answer the request. The error composite MUST be populated when the responder cannot complete processing due to insufficient or invalid information in the request.  
    • Melva Peters / Pooja Babbrah : 13-0-1
    • Clarification
    • Non-substantive
    • 0.1.0

      If the value in the process Note/text is "Not Covered", would a reject reason such as "Prior authorization denied. Provider not authorized to Rx this drug. Need a Prior Authorization from a different prescriber go into ...error/text?

            Assignee:
            Unassigned
            Reporter:
            Zabrina Gonzaga
            Watchers:
            1 Start watching this issue

              Created:
              Updated:
              Resolved: