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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 BurckhardtWPS Health Solutions
  •  
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 TaylorTibco
  •  
Louis BedorCognosante
  •  
Mary L. BushmanAnthem
  •  
Melanie Combs-DyerCMS
  •  
Michael CabralCMS
  •  
Michael GouldIBC
  •  
Sudhir NairAnthem
  •  
Rian
  •  
Palmetto gba
  •  
Sandeep
  •  
Sreekanth PuramMettle Solutions
  •  
Jeffrey DanfordAllscripts
  •  
James Gallagher Jr.Premera
  •  
Joseph Figueroa
  •  
Tony LittleOptum
  •  
Pallavi TalekarEMDI/ Scope Info Tech
  •  
Thomas KesslerCMS
  •  
Todd Omundson
  •  
Tony ShengZeOmega
  •  
Karen L. ZapataAnthem
  •  
Rachel GoldsteinCAQH
  •  
Ralph Saint-PhardHealow
  •  
Susan LestinaAHA
  •  
Briana BarnesScope Info Tech
  •  
Hans BuitendijkCerner
  •  
Cassandra Bell
  •  
Deepthi ReddyMettle Solutions
  •  
Cognosante
  •  
Patrick MurtaHumana
  •  
Prashanth Golconda
  •  
Rajesh Godavarthi
  •  
Rim Cothren
  •  
Scott LawrenceCMS
  •  
Chris JonesHumana
  •  
Christina BorgLumeris
  •  
Julie MaasEMR Direct
  •  
Kathleen Connor
  •  
Matt ReidAMA
  •  
Mike BerkmanCoverMyMeds
  •  
Monse SerenilHumad
  •  
Rian RaineyCoverMyMeds
  •  
Sandra StuartKP
  •  
Sheryl TurneyAnthem
  •  
Wanda Govan-JenkinsHHS
  •  
Chris HutchinsonCoverMyMeds

Agenda Topics

Agenda Outline

Agenda Item

Meeting Minutes from Discussion

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



Milestones
  • TSC approved early July ballot
  • TSC will approve timeline on Monday 4/1
  • Anticipated deadlines
    • HL7 Connectathon - May 4-5
    • NIB - May 20
    • Jacksonville, FL Connectathon - May 29-30
    • Sign up for ballot opens - June 1
    • Initial content due - June 3
    • Final Content due - June 24
    • Ballot opens - July 1
    • Ballot closes - July 30
  • Concern re: aggressive timeline given other Da Vinci activity occurring in parallel


"Classes" of Services
  • WEDI Prior Authorization Categories reviewed - different from the categories discussed on the call last week
    • Home health is not included
      • Physical Therapy, Occupational Therapy, and Speech/ Language Pathology are differentiated
    • Surgery, Oncology, Imaging - top volume
  • Are there situations where a 278 is all that's needed to satisfy a prior authorization, and there's no additional information required?  Yes
    • Maternity, newborns don't typically require 78additional documentation
    • Some DME don't generally require more info other than it's needed
    • Once hemophilia is established, no additional info is typically needed
    • Established pattern of needing or continuation of 'special services' (not the initial)
  • Need to suport both scenarios
    • 278 only
    • 278 and documentation (275 or other attachment)
  • Need to be able to determine if initial PA or subsequent PA (which may determine need for additional documentation or not)
  • Should our efforts focus on Surgery, Oncology, Imaging and DME?  Do these represent the top PA volume for participants?  What are top priorities?
    • Send out a survey to participants to gauge interest/ identify areas of focus
    • Preferred method would be to send via email, and then compile de-identified responses
    • Would also like to add a question to the survey re: who is using standard clinical guidelines (e.g., Milliman)


Content for the 278

Goal: FHIR-enabled process, reach into EHR to gather data

  • What FHIR resource will EHRs be asked to use to populate the 278?
    • Alternative 1: Claim resource
    • Alternative 2: Patient, Practitioner, Practitioner Role, Organization, Location...
      • This option is more likely to be supported by EHRs
    • Need to have further discussion with EHR participants
    • Also need to discuss with 278 SMEs to make sure these resources cover what needs to be populated in the 278


Scope
  • Are we considering scenarios where it's not the clinician submitting the PA?
    • Sometimes it's a practice management system that has the ability to link to various portals and can somewhat automate process
    • Sometimes it's a non-clinical person sifting through EHR data to pull what's needed to support and submit via portal or some other out-of-band process
    • How often does this occur within clinical workflow (EHR) vs. how often is it done in practice management system?
  • Content for supporting documentation
    • HRex, CDex, DTR
  • Limit scope to what's ordered by MD or NPP and performed by MD or NPP
  • What workflow(s) do we want to cover?
    • Payer side only
    • Exchange via 278 (/275)
      • We'll focus on this workflow
      • Assumes a real-time/ synchronous 278 response
    • Provider side only

Management Next agenda
  • Review draft of PA priority/ volume survey

 Adjournment
 Adjourned at 4pm ET

Supporting Documents

Outline Reference

Supporting Document

Minute Approval


Tasks

  •