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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
  •  
Anna MeisheidCMS
  •  
Cyrus PeyrovianFastAuth
  •  
Janice BakosAetna
  •  
Joseph AthmanSureScripts
  •  
Lloyd McKenzieGevity
  •  
Melanie JonesCMS
  •  
Rohit ShindeeClinicalWorks
  •  
Tammy SchreinerWPS Health Solutions
  •  
Amy PetersonHumana

Agenda Topics

Agenda Outline

Agenda Item

Meeting Minutes from Discussion

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



Milestones
  • Mitre will be developing Reference Implementation
  • Gevity/ Lloyd McKenzie will be lead to author Implementation Guide


  • 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


Request for Information from Participants
  • Questionnaire will be sent out next week
  • Bob and Viet will de-identify and aggregate responses
  • Top PA by volume by category
  • Top PA services by priority
  • PA issues participants would like to resolve
  • Standards vs. proprietary/ custom being used
  • PA determinations in-house vs. contracted service
  • Determinations in real-time? Via 278/275?
  • Other specific considerations
  • WEDI put together similar information and participants might already have collected this info
  • Should include referrals that require specific authorizations
  • Indicate if specific information is required (and if differences between initial request vs. subsequent)
  • Would be helpful to include PA by complexity (i.e., easier or harder to implement) - which PAs have 'easy' rules vs. 'complex' rules
  • Should add post-acute care service category
  • IVIG (Part B drug benefit for Medicare FFS), AAT (probably also Part B benefit for Medicare FFS) examples of medical benefit drugs that require authorization
    • Pharmacy benefit PA is out of scope, but medical benefit coverage of drugs is in scope
    • IVIG is diagnosis-specific
  • Intent is to submit 278 and 275 transactions together (decision re: 275 pending attachment rule)
  • CRD use case - asks the question, is PA something we need to consider
  • PA use case - doing the authorization
  • What computer language(s) will Mitre use to implement PA Reference Implementation?
    • Will be built upon CRD, so assuming will be the same language (Java)
    • DTR is browser side code, so it's in Javascript
    • Mitre will be on call next week


Information required for processing PA (X12 278)
  • Need to make sure that X12 278 covers everything we need
  • Plan to use the Claim resource to tie together all the pieces needed to populate the 278
  • Is our scope a single PA request at a time or multiple at the same time?
    • Specification allows you to submit multiple requests
    • Medicare FFS allows provider to submit one request for more than one period of time - a single authorization
    • Scope will be to submit one PA at a time
  • What will link the clinical data to the Claim resource?
    • Claim resource represents the prior authorization, and will be inside of a bundle
    • Also inside of the bundle will be other resources referenced by the Claim resource (QuestionnaireResponses, lab results, etc.)
    • How does Claim link to an Observation?
      • Link inside Claim points to supporting information - can be a reference to any resource
      • It can point to another bundle
      • Should one bundle be all the 278 info, and another bundle be for the supporting documentation?
        • Makes it messier, and doesn't seem to be a reason to do it that way
        • May have to split up 278 vs. 275 data
        • There may be another way to manage this


Connectathon
  • HL7 Montreal Connectathon - May 4-5 - PA track will be merged with CRD/ DTR
  • Da Vinci Connectathon in Jacksonville, FL - May 29-30
  • Following the Da Vinci Connectathon, Da Vinci members will meet to discuss future use cases (May 30-31)
  • Indicate interest in HL7 Montreal Connectathon in Confluence (and links to register): HL7 May Connectathon (Montreal)
  • Indicate interest in Da Vinci Connectathon in Confluence: May Onsite Connecthon - Guidewell

Management Next agenda

 Adjournment
 Adjourned at 4:02pm ET

Supporting Documents

Outline Reference

Supporting Document

Minute Approval


Tasks

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