Page tree
Skip to end of metadata
Go to start of metadata

Chair:  Robert DieterleViet NguyenAnupam Goel

Scribe: Dana Marcelonis
 


Attendees

Present

Name

Affiliation

  •  
Enablecare
  •  
Stratametrics
  •  
Dana MarcelonisPoint of Care Partners
  •  
Tony BensonBCBSAL
  •  

Emily Calvert

CMS
  •  

Erica Ross

CMS
  •  
HeatherAMA
  •  
Joseph QuinnOptum
  •  

Kelly Anderson

BCBSAL
  •  
Lynda RoweInterSystems
  •  

Mark Mundt

InterSystems
  •  
Megan SoccorsoCigna
  •  

Mike Funk

Humana
  •  
Nancy SpectorAMA
  •  
Terry CunninghamAMA
  •  
Tori WillowsWellcare
  •  
BCBSFL
  •  
Anthem
  •  

Marci Maisano

Cigna
  •  
Edifecs
  •  
Lindee ChinEdifecs
  •  
Anupam GoelUnited Healthcare
  •  
Anthem
  •  
Christy Dodson
  •  
Kevin LambertBCBSAL
  •  
Laura Hoffman
  •  
Laurie Burckhardt
  •  
Optum
  •  
Lindee ChinEdifecs
  •  
Lorraine DooCMS
  •  
Peter MuirESAC
  •  

  •  
Raj
  •  
Ray WilkersonScope Info Tech
  •  
Susan LangfordBCBST
  •  
Taha AnjarwallaCAQH
  •  
Tom
  •  
Sonja Ziegler
  •  
Clayton LewisIntersystems
  •  
NandiniEMDI/ Scope Info Tech
  •  
John BialowiczBCBSM
  •  
Kasi
  •  
EMDI Team

Agenda Topics

Agenda Outline

Agenda Item

Meeting Minutes from Discussion

Decision Link(if not child)
ManagementReview ANSI Anti-Trust Policy



Introduce co-chair for Prior Authorization Support Use Case

Anupam Goel will be co-chair with Robert Dieterle for this use case



Overview of Approach
  • Reviewed the approach discussed in last week's call
  • Use FHIR to communicate with providers' EHRs
  • Will need to be conformant with X12 278 (and 275 if there is an attachment rule)
  • Building upon work already done with other Da Vinci Use Cases: Coverage Requirements Discovery (CRD), Health Record Exchange (Payer Data Exchange - PDex), Documentation Templates & Rules (DTR)
  • CQL (Clinical Quality Language) - will use this for clinical decision support capability
  • Clinical Scenario: provider orders CT scan using Coverage Requirements Discovery, communicates with payer, and patient does need prior authorization for the CT
    • DTR - gather prior auth information from medical record; determines gaps in record and prompts provider to enter information; triggers a prior auth submission and waits for a return message
  • Are we specifying the SMART on FHIR app?
    • DTR is specifying most of the functionality of what the SMART on FHIR app is supposed to be able to do
    • Once the information is collected for prior authorization, (out of record and provider-input), is it automtaically sent to payer, or does provider want control (click to approve)?
    • Need to reduce burden by getting information into the right place in the chart/ EHR so that it can be pulled by CQL - need as much as possible to be structured data - getting the data in the right spot consumes a lot of PCP time - agree with the way we're proposing to pull the data out
    • Is there another workgroup/ effort to address getting data into the EHR in a structured way? Data is coming into EHR in a lot of different forms - DICOM, LOINC, etc.


Happy Path
  • Provider enters an order, prior auth is required, data is found in record or provider enters some additional data, information returned to payer who can return a response in real-time


What do we do when happy path does not work
  • Scenario 1: Provider does not have necessary information to answer the prior authorization request
    • Suspend session (SMART on FHIR app) until information is available
    • Put a task in someone else's queue
    • Move session to another individual
    • Level of specificity of information that provider can provide to the payer in order to get a prior authorization (e.g., Head CT vs. Head CT with or without contrast - HCPCS/ CPT codes)
    • Test is ordered by PCP, but the person who needs the authorizatoin is the servicing provider - the servicing provider needs to be able to do an inquiry on the status of that prior auth, and then needs ability to edit the request for the original procedure (Head CT) vs. the more specific procedure (CT with contrast)
    • Need an artifact that can be forwarded to the servicing provider
    • Does this model need to be altered if the payer is using a 3rd party to manage utilization management?
      • End point for the provider/ EHR is the payer, and the onus is on payer to route the transaction to the appropriate end point
    • Need to look at patterns for other use cases for specialty, for example (we started with PCP point of view) (e.g., radiology)
    • Formulary is out of scope for this use case (unless part of medical benefit)
    • We have an initial technical approach, and may be slightly different for inpatient/ outpatient
    • There are different types of prior auth (DME, specialty meds, imaging, etc.) - address commonalities first and provide many exemplars
    • Not focusing on medications in this use case - covered by NCPDP; we're primarily working with medical benefits
  • Scenario 2: Payer cannot make a real-time determination - 'pending' response
    • Notification to provider that it's pending
    • Define how response comes back asynchronously
      • Provider queue
      • Out of band process (e.g., call, fax, etc.)
      • Need ability to push result back to provider without provider needing to initiate a query
        • Needs to go into their clinical workflow (drop it into a queue that the provider would normally review so that they know it has occurred)
        • Need some predictability in the timing of a response
        • Response needs to be flagged for priority, and so that it's easy to redirect in the practice to someone else
    • 278 limitation - no defined method to respond after a request was pended - how do you communicate the final decision
    • CAQH Core has a rule going out to ballot later this month that addresses what a payer should do when they pend a request
      • If they pend for additional info/ documentation, they have to state what they're asking for in the pending response


Discuss use of claim resource and next steps

Did not get to this agenda item


Management Next agenda

 Adjournment
 Adjourned at 4pm ET

Supporting Documents

Outline Reference

Supporting Document

Minute Approval


Tasks

  •