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Chair:  Robert DieterleViet NguyenAnupam Goel

Scribe: Linda Michaelsen
 


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
  •  
Dave Trotter, MD
  •  
BCBSIL
  •  
Renee Fuller
  •  
Helina Gebremariam
  •  
Cambia
  •  
Intepro
  •  
Carradora
  •  

  •  

  •  
MaxMD
  •  
Cindy Monarch BCBSM
  •  
Dawn Perreault
  •  
Douglas DeShazoCognizant
  •  
David HillMitre
  •  
Jean Duteau
  •  
Missy BoserSurescripts






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 - May 19
  • Final Content due - June 18
  • Ballot opens - July 1
  • Ballot closes - July 30


Connectathon Links

Prior Authorization Workflow

Please respond to the Prior Authorization Survey by end of day, May 1st, so that updated content can be reviewed in the next meeting

  • Reviewed Prior Authorization Workflow_Diabetic supplies.pdf (example is for glucose monitoring)
  • Suggestion to add 278 to Visio diagram
  • Questions re: finding out what payer covers (like type of Glucose Meter) before requesting authorization; reminder that CRD/CDS Hooks card does this and could be run first
  • Don’t ask providers to do steps over.  When eligibility information is returned, already do a CRD based on diagnoses patient has, visit type for things the provider might potentially order based on what provider allows (Formulary, etc). 
    • This might not be easy to do in all scenarios
  • Debate over what scenario should be worked first - diabetic supplies or large case like Total Knee, MRI, etc
    • For the large barriers they refer to the specialist who will get things like MRI authorized, adds a visit for patient
  • The more the provider knows about the payer's requirements before they place the order, the better it makes it for provider and reduces burden


X12 update
  • Da Vinci has approval to do mapping to X12 data (X12 gave written permission and table).  This will allow for

  <FHIR><X12 278/275<>FHIR>

  • ANSI X12 will publish this work to be used as Prior Authorization Support
  • The barrier to using the 278 Request and Response is that the update and inquire implementations were not allowed. Need to allow for update and inquire (ANSI X12 X215 and X216) in FHIR Paradigm. 
    • This might be future work. Restated the need for the inquiry, for example for labs.


HomeworkPlease respond to the Prior Authorization Survey by end of day Wednesday, May 1st so that updated content can be reviewed in the next meeting
Management Next agenda

 Adjournment
 Adjourned at 

Supporting Documents

Outline Reference

Supporting Document

Minute Approval


Tasks

  •