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

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
  •  
Robert Bowman CAQH
  •  
Phranil MehtaeClinicalWorks

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 17
  • Ballot opens - July 1
  • Ballot closes - July 30


Connectathon Links

CDS/ DTR Based Prior Authorization
  • Using CDS Hooks to establish conversation between provider and payer
  • Goal is to pass contextual information to the payer, along with token that lets them access record (or subset) to get context - based on that, determine if PA is needed or not
  • If PA is required, CDS Hooks card will be returned with context for reaching into payer system to get templates/rules/questionnaires, and enabling a SMART on FHIR app that can access payer environment and patient record in context of that encounter/ provider
  • Goal is to create a standard that every payer and EHR vendor can adopt - only one process used by providers
  • Are we trying to recreate the criteria with the documentation templates?
    • No, we're creating standard by which that conversation occurs
    • Not the standard for the knowledge, it will be the standard for how the knowledge is structured for exchange
    • Payers use many different rule sets
    • Universal API method for providers asking the payer, what do you need to know from me and payer can respond


Information required for processing PA (populating 278)
  • For General Identification, will be using:
    • Prior Authorization Profile on FHIR Claim Resource
    • Prior Authorization Profile on FHIR ClaimResponse Resource
    • FHIR Coverage Resource (currently in HRex as custom Da Vinci profile, but will try to get in US Core since it's critical for payer workflows)
  • For Clinical Information:
    • FHIR R4 US Core profiles
    • Via questionnaire
  • For Attestation:
    • Via questionnaire
  • Need to package all of the above to populate 278


  • To communicate clinical resources and questionnaireReponse, proposing to use FHIR Bundle, base64 encode it, and place in 275 BIN segment - this is compliant with X12 at this point, since there's no Attachments rule
    • Is it an option to use XML? Not currently
    • Further conversation during Structured Docs Workgroup meeting this week
  • A number of payers are putting content into message segment of 278 as text - do we also need to support this?
  • CAQH just released core 278 rules and is working on a pilot for the industry and is talking to X12
    • Speaking to HHS re: operating rule that would account for using FHIR and X12
    • Need to a deeper dive here, continue conversation with CAQH - Robert Bowmanand Rachel E. Foersterwill be in Montreal and can meet up with Robert Dieterle


Homework

Final request for payer input - please complete Prior Authorization Survey.docx

  • If you prefer not to enter information into the survey, you can email Robert Dieterleor set up time to walk through it with him 

 Adjournment
 Adjourned at 3:38pm ET

Supporting Documents

Outline Reference

Supporting Document

Minute Approval


Tasks

  •