Clarification Required: BCDA V3 Pharmacy Claims – Beneficiary Payment Amount Mapping

[Ashvani goyal]

Hi BCDA Team,

We would like to request clarification regarding the beneficiary payment amount mapping for Pharmacy claims in BCDA V3.

As per the BCDA V3 Data Dictionary, the beneficiary payment amount at the Item-level Adjudication is identified using the following FHIR path:

ExplanationOfBenefit.item.adjudication.where(category.coding.where(system='http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication' and code='paidbypatient').exists() and category.coding.where(system='https://bluebutton.cms.gov/fhir/CodeSystem/Adjudication' and code='CLM_LINE_BENE_PMT_AMT').exists()).amount.value

Based on this definition, we expected CLM_LINE_BENE_PMT_AMT to be available within the Item-level Adjudication for Pharmacy claims.

However, in the Pharmacy claim data we are receiving, CLM_LINE_BENE_PMT_AMT is not present at the Item level. Instead, we are seeing the corresponding beneficiary payment amount at the Total level under the following code:

CLM_BENE_PMT_AMT

Could you please confirm the expected behavior for Pharmacy claims and advise on the appropriate mapping approach?

Specifically:

• Should CLM_LINE_BENE_PMT_AMT be available at the Item-level Adjudication for Pharmacy claims as indicated in the Data Dictionary?
• If not, should CLM_BENE_PMT_AMT from the Total section be considered the appropriate source for the beneficiary payment amount?
• Is the current behavior specific to Pharmacy claims, or does it indicate a potential discrepancy between the Data Dictionary and the BCDA V3 source data?

Your clarification will help us ensure that our Pharmacy claim mapping is aligned with the expected BCDA V3 implementation.

[Beneficiary Claims Data API (BCDA) Community]

Hi Ashvani,

Thanks for the question about beneficiary payment amounts on pharmacy claims. 

Our team has identified some duplicate fields for pharmacy claims in the v3 data dictionary. We will release an updated version of the v3 data dictionary and provide some additional guidance to address your question.

Thanks,

The BCDA Team