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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
  •  
Aim/ 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
  •  
Nandini GangulyEMDI/ Scope Info Tech
  •  
John BialowiczBCBSM
  •  
Kasi
  •  
EMDI Team
  •  
Alberto S. LlanesAnthem
  •  
Bart CarlsonAzuba
  •  
David DeGandiCambia
  •  
Duane WalkerBCBSM
  •  
Russell LeftwichInterSystems
  •  
Jim Taylor
  •  
Louis BedorCognosante
  •  
Mary L. BushmanAnthem
  •  
Melanie Combs-DyerCMS
  •  
Michael CabralCMS
  •  
Michael GouldIBC
  •  
Sudhir NairAnthem
  •  
Rian
  •  

  •  
Sandeep
  •  
Sreekanth
  •  
Jeffrey DanfordAllscripts
  •  
James Gallagher Jr.Premera
  •  
Joseph Figueroa
  •  
Tony LittleOptum
  •  
Pallavi TalekarScope Info Tech
  •  
Thomas KesslerCMS
  •  
Todd Omundson
  •  
Tony ShengZeOmega
  •  
Karen L. ZapataAnthem
  •  
Rachel GoldsteinCAQH
  •  
Ralph Saint-PhardHealow
  •  
Susan LestinaAHA
  •  
Briana BarnesScope Info Tech



Agenda Topics

Agenda Outline

Agenda Item

Meeting Minutes from Discussion

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



Discussion of workflow
  • Referral to a Specialist Scenario
    • Patient sees PCP for complaint of chest pain. Evaluated, and decision is made to refer patient to Cardiologist for further evaluation. PCP enters referral in EHR. EHR uses patient payer data to query payer for need to do a PA (CRD IG process)  PA is required, and data/ documentation requirements are defined via DTR process.  Information is sent to payer to request for adjudication.
    • Preconditions
      • Patient's payer is known by PCP
      • Cardiologist has been identified to provide an initial consultation, and is on the patient's plan (NPRM requirement would make this electronic)
        • No expectation that additional procedures will be performed
      • Prior Auth is required based on information provided by the payer via the CRD IG process
    • In Medicare FFS world, prior auth could be required/ optional for an item or a service
    • Referral is different from a Prior Authorization
      • Referral - provider requests another provider (specialist) see the patient - either to take over care or provide consultation (and provide information back to the requesting provider)
      • Chat comment: "From X12 278 guide: Referral A type of authorization initiated by the patient’s primary care provider (PCP) that enables the patient to receive consultation and/or services of a specialist or specialty entity. Under some UMO arrangements, the PCP is authorized to refer the patient without seeking the permission of the UMO/review entity."

        • Request for review/ approval for referral
        • Approval to deliver services and procedures
      • "Clinical" Referral is provider to provider communication
      • "Administrative" Referral may be required by the health plan and approved based on network status
        • Doesn't typically include a procedure code, where authorization would
      • Chat comment: "An authorization is a review of services related to an episode of care, and a referral is used to refer a member to a specialty provider"

    • Clinical data to be included in this scenario
      • Condition/ diagnosis - confirmed or suspected.  In this case, condition = chest pain
      • Reason for referral
      • Any completed diagnostic studies
      • Member information to identify the member
      • Practitioner/ Organization - Requesting/ servicing provider information
      • Effective and end dates (
      • Procedure codes for service to be performed
  • Need 2 separate use cases
    • Consultation
    • Specific service/ procedure


Request for working session participants
  • Request for participants to get involved in working sessions to progress this use case - email vietnguyen@stratametrics.com 

Management Next agenda

 Adjournment
 Adjourned at 4pm ET

Supporting Documents

Outline Reference

Supporting Document

Minute Approval


Tasks

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