CARIN RTPBC FHIR IG Proposal

CARIN Real-time Pharmacy Benefit Check

Owning Workgroup

HL7 Pharmacy WG

Committee Approval Date:

November 2019

Publishing Lead

Frank McKinney (fm@frankmckinney.com)

Contributing or Reviewing Work Groups

HL7 Financial Management WG

FHIR Development Project Insight ID

TO BE ADDED

Scope of coverage

This is a guide for implementing the consumer-focused real-time pharmacy benefit check (consumer RTPBC) using FHIR R4.

The process is limited to medications that are covered under the pharmacy benefit portion of the patient’s health insurance, which typically excludes medications administered during hospital care or as part of medical procedures. Is is further limited to commercially available medication products that are not compounded at the pharmacy.

The guide is for use in the United States only.

Content location

TO BE ADDED

Proposed IG realm and code

us/pharmacy

Maintenance Plan

The CARIN Alliance is committed to the maintenance of the content.

The Pharmacy and Financial Management Workgroups are engaged and will continue to provide guidance and review through completion of the guide.

Short Description

CARIN RTPBC FHIR Implementation Guide

Long Description

With consumer RTPBC, a patient can learn how their medications will be covered at the pharmacy, including out of pocket costs, prior authorization requirements and any limits that might apply.

The communication flow consists of...

• a request submitted by a consumer application that contains information about the patient, the prescription and their insurance coverage
• a response from the patient's insurer that contains cost and coverage information for the requested product, alternative products, and different pharmacy options.

This IG defines FHIR profiles for resources representing...

• the set of information provided in the RTPBC request that enables the insurer to locate the patient's membership details and determine coverage for the requested product. This includes profiles of Claim, Patient, Practitioner, Organization and MedicationRequest resources
• the pricing and coverage information returned in the RTPBC response, using a profile of the ClaimResponse.

In addition, the guide identifies terminology to identify the referenced entities and aspects of insurance coverage.

Involved parties

The RTPBC IG is being authored by the CARIN Alliance in collaboration with the National Council for Prescription Drug Programs (NCPDP), HL7 Pharmacy and Financial Management workgroups.

The aim of the CARIN Alliance is to advance the ability for consumers and their authorized caregivers to easily get, use, and share their digital health information when, where, and how they want to achieve their goals.

Expected implementations

CARIN Alliance members including health plans, pharmacy benefit managers and consumer application vendors.

Content sources

The CARIN consumer RTPBC process is an adaptation of the NCPDP provider-focused Real-time Pharmacy Benefit Check transactions. The CARIN Alliance is consulting NCPDP in addition the HL7 Pharmacy and Financial Management workgroups in process of developing this guide.

Example Scenarios

Retrieve patient-specific cost and coverage information for a medication product

IG Relationships

The IG is based on FHIR R4.

Timelines

TO BE REVIEWED / ADJUSTED: 
Informative Jan 2020 Ballot
STU May 2020 Ballot