2020-03-31 PIE WG Meeting Agenda

• Overarching IG Challenges ( need Pat Taylor on call to discuss)
  • There have been 4 major issues coming from the CARIN BB effort that we're looking to bring to resolution

1. Beneficiary/Dependents. Subscriber vs. Beneficiary. All Member Identifiers (this topic will be addressed by PIE)
   • ID - Local to the resource creator
   • IDENTIFIER - an identifier everyone recognizes. Independent of where the information is created or by whom
   • Developers are generally familiar with data from providers, not data from payers.
   • There are challenges in conveying the definitions of the notion of Subscriber vs. Beneficiary vs. a "Proxy" (e.g., child looking after an elderly parent)
2. Secondary Insurance implications (this topic will be addressed by PIE)
3. Search criteria across IGs. US CORE vs. DV needs (this topic will be addressed by FM and not PIE)
   • Searches for data from a provider will be different for searches for data from a Payer
     • Searching for data from a payer generally need to be based on a Subscriber ID, not a patient identifier
4. Overlaps of claim vs. clinical - Code set mismatches. Different use cases, different code sets. I.e., Pharmacy information NDC vs. RxNorm vs. HCPCS or ICD vs. SNOMED (this topic will be addressed by FM and not PIE)
   • Payer financial data is generally governed by CMS/X12 and uses different value sets from clinical environments
   • We performed an analysis against the US Core codesets and found variances to what payers need
   • Additionally there are licensing obstacles for some code systems
   • New CMS Interoperability Rule requiring claims data be accessible to patient adds to the challenges resulting from these code set mismatches

Goal is for co-chairs and other key stakeholders to come together on 4/2 to discuss how we'll be chasing these issues to resolution.

To address these outstanding issues, the PIE workgroup will begin meeting every week to have time to push through these issues.

We keep getting hung up on nomenclature specifically related to the FHIR Coverage resource

• Linda has volunteered to lead an effort to come up with an inventory of terms and corresponding definitions
• Meetings will occur at 3 CT/4 ET on Monday afternoons
• We need representatives from the VA/DoD Tricare space
• Interested individuals should email Linda (linda.michaelsen@optum.com)

1) Block vote to approve outstanding comments (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 32, 33, 35, 38, 39, 44, 45, 46, 47, 48, 49, 50, 51, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64).

Ballotcomments_HL7_XPARADIGM_PAYER_SB_R1_I1_2018MAY64-LJ-LRN-20200316.xls

Moved: Russ Ott

Second: Lenel James

Vote Carries: 16/0/0

2) Vote indicating the workgroup approves the comment spreadsheet as fully reconciled

Ballotcomments_HL7_XPARADIGM_PAYER_SB_R1_I1_2018MAY_FULLYRECONCILED_20200331.xls

Moved: Russ Ott

Second: Lenel James

Vote Carries: 16/0/0

Planned votes for 4/14:

1) Vote to approve publication request - draft publication request posted: Pub Request - HL7 Cross Paradigm Storyboard – Payer Perspective, Value Based Care

ACTION: Russ to check with Lynn on the approval steps needed for publication (Steering Committees, Management Groups, etc.)