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

  •  

  •  
MaxMD
  •  
Cindy Monarch BCBSM
  •  
Dawn PerreaultBCBSM
  •  
Douglas DeShazoCognizant
  •  
David HillMitre
  •  
Jean Duteau
  •  
Missy BoserSurescripts
  •  
Robert BowmanCAQH
  •  
Phranil MehtaeClinicalWorks
  •  
Dylan TuggleBCBST
  •  
Galen MulrooneyJPSys
  •  
Mario JarrinChange Healthcare
  •  
Jim AdamsonArkansas Blue Cross
  •  
Brian PoteetBCBST
  •  
Tony LaurieNoridian
  •  
Ann GallagherOptum
  •  
Bonnie SirottZeOmega
  •  
Sreenivas MallipeddiMCG
  •  
Abdullah RafiqiESAC

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
  • NIB - May 19
  • 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

Review PA requirements
  • Establishing a method of communicating information required to support PA using FHIR
    • Info needed to populate X12 278 and 275 (in anticipation of rule for attachments)
    • Information going into FHIR bundle:
      • FHIR Claim Resource
      • FHIR ClaimResponse
      • HRex Coverage
    • CRD to initiate conversation (CDS Hooks)
    • DTR - SMART on FHIR app to grab rules/ questionnaires to gather info from patient's record; ask questions that aren't in the record; attestation
    • Clinical info packaged up as QuesitonnaireResponse
  • PA Operation Endpoint
    • Receive PA bundle
      • Response in real-time
        • Medicare FFS currently gives contractors 20 days
          • CMS team will review USCDI data elements to see if it would work for their PA needs (and therefore they could be automated)
        • Depending on the payer, potentially half of PA requests could be done in real-time based on attestation in a questionnaire
      • Pending the PA may occur - human review may be needed
    • Respond when PA is complete
      • Push response (subscription?)
        • Argonaut working on subscription - defining an event-driven process (instead of repeated query/ subscription)
          • Indicate interest on a topic, and when that event happens, something would be sent back to your registered endpoint
          • Could be that you register subscription to a PA endpoint, and any PA you send in would use that subscription to send back any pended results - waiting to see what comes out of Argonaut
      • Pull response (see query)
    • Provide support for (submitter or performer)
      • Update to existing PA request 
        • May need to adjust dates, number of days, etc.
        • PA may not have been coded correctly (e.g., ordered imaging, but may need to specify type based upon radiologist input)
      • Status 
      • Cancel


PA Workflow Options
  • Payer
    • Pre-requisites, depending upon payer
      • Is patient in a plan
      • Is provider in network and can order/ perform service
      • Have I already paid for this service
    • Assuming PA is required, JWT (Java token) to access a patient record and gather necessary information to determine if PA requirements are met
    • PA number in response or denial
  • Traditional
    • Gather provider information and submit to payer for evaluation
    • 278/ 275
    • If a more complex set of clinical data is required, then would probably would require this transaction workflow
  • Provider
    • Rules for collection and evaluation
    • SMART on FHIR app using payer rules/ questionnaire could confirm that PA requirements are met and communicate PA number back to payer
  • Combination
    • Payer side evaluation may be done and is missing data or attestation
    • Send a questionnaire to provider to gather only the missing pieces of information


  • If using one of the alternate methods above (provider-side or payer-side rules), do you need a prior auth number?  Assuming yes, to submit on the claim
    • Medicare FFS would require some kind of transaction number
    • If not a 278, there may still be a reference number
      • Possible to generate a number from a backend/ authorization rules framework - could still generate a number based on FHIR
      • E.g., UM delegation - since not necessarily covered under HIPAA, could come under a service request in FHIR; underlying Auth system doesn't require a 278, but FHIR system will generate a number
  • If the payer writes the rules and the EHR information for the patient meets the rules for that patient, is there any need to send the information back to the payer?
    • SMART on FHIR app would likely be the payer's app (or one evaluated and selected by the payer)
    • Executing in a trusted payer container using the data from the EHR
    • Some kind of audit trail needed that payer could check?


Homework

Please complete the Prior Authorization Survey.docx

  • If you prefer to schedule a session with Robert Dieterle, you can do that instead of documenting responses in the survey

 Adjournment
 Adjourned at 4:01pm ET

Supporting Documents

Outline Reference

Supporting Document

Minute Approval


Tasks

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