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Chair:  Robert DieterleViet NguyenAnupam Goel

Scribe: Dana Marcelonis
 

Attendees

Present

Name

Affiliation

  •  
Enablecare
  •  
Stratametrics
  •  
Point of Care Partners
  •  
BCBSAL
  •  

Emily Calvert

CMS
  •  

Erica Ross

CMS
  •  
HeatherAMA
  •  
Optum
  •  

Kelly Anderson

BCBSAL
  •  
InterSystems
  •  

Mark Mundt

InterSystems
  •  
Megan SoccorsoCigna
  •  

Mike Funk

Humana
  •  
Nancy SpectorAMA
  •  
Terry CunninghamAMA
  •  
Tori WillowsWellcare
  •  
BCBSFL
  •  
Aim/ Anthem
  •  

Marci Maisano

Cigna
  •  
Edifecs
  •  
Edifecs
  •  
United Healthcare
  •  
Anthem
  •  
Christy Dodson
  •  
BCBSAL
  •  
Laura Hoffman
  •  
WPS Health Solutions
  •  
Optum
  •  
Edifecs
  •  
CMS
  •  

  •  

  •  
Raj
  •  
Ray WilkersonScope Info Tech
  •  
BCBST
  •  
Taha AnjarwallaCAQH
  •  
Tom
  •  
Sonja Ziegler
  •  
Intersystems
  •  
Nandini GangulyEMDI/ Scope Info Tech
  •  
BCBSM
  •  
Kasi
  •  
EMDI Team
  •  
Anthem
  •  
Bart CarlsonAzuba
  •  
Cambia
  •  
Duane WalkerBCBSM
  •  
InterSystems
  •  
Tibco
  •  
Louis BedorCognosante
  •  
Anthem
  •  
CMS
  •  
CMS
  •  
IBC
  •  
Anthem
  •  
Rian
  •  
Palmetto gba
  •  
Sandeep
  •  
Sreekanth PuramMettle Solutions
  •  
Allscripts
  •  
James Gallagher Jr.Premera
  •  
Joseph Figueroa
  •  
Tony LittleOptum
  •  
Pallavi TalekarEMDI/ Scope Info Tech
  •  
Thomas KesslerCMS
  •  
Todd Omundson
  •  
ZeOmega
  •  
Emily TenEyckCAQH
  •  
Mark Taylor

Present

Name

Affiliation

  •  
Anthem
  •  
Rachel GoldsteinCAQH
  •  
Ralph Saint-PhardHealow
  •  
Susan LestinaAHA
  •  
Briana BarnesScope Info Tech
  •  
Cerner
  •  
Cassandra Bell
  •  
Deepthi ReddyMettle Solutions
  •  
Cognosante
  •  
Humana
  •  
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
  •  
SureScripts
  •  
Gevity
  •  
Melanie JonesCMS
  •  
eClinicalWorks
  •  
Tammy SchreinerWPS Health Solutions
  •  
Amy PetersonHumana
  •  
Dave Trotter, MD
  •  
BCBSIL
  •  
Renee Fuller
  •  
Helina Gebremariam
  •  
Cambia
  •  
Intepro
  •  
Carradora
  •  

  •  

  •  
MaxMD
  •  
Cindy Monarch BCBSM
  •  
Dawn PerreaultBCBSM
  •  
Cognizant
  •  
Mitre
  •  

  •  
Missy BoserSurescripts
  •  
CAQH
  •  
Phranil MehtaeClinicalWorks
  •  
Dylan TuggleBCBST
  •  
JPSys
  •  
Mario JarrinChange Healthcare
  •  
Jim AdamsonArkansas Blue Cross
  •  
Brian PoteetBCBST
  •  
Tony LaurieNoridian
  •  
Optum
  •  
Bonnie SirottZeOmega
  •  
MCG
  •  
ESAC
  •  
Geeta KrishnanEdifecs
  •  
Katherine LuskChildrens
  •  
Michael NovalesBCBSIL
  •  
Tracey McCutcheonKPMG


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
  • Jacksonville, FL Connectathon - May 29-30 - May Onsite Connecthon - Guidewell
  • Early ballot cycle schedule
    • NIB - May 19
    • Sign up for ballot opens - May 21
    • Initial content due - May 19
    • Final Content due - June 17
    • Ballot opens - June 21
    • Ballot closes - July 21
  • There's a possibility that we may push this IG to the September ballot instead of the early ballot cycle - we'll know more over the next couple of weeks


Connectathon Links

Survey Summary
  • Responses from 6 payers, representing 60 million commercial members and 62 million government
  • General results - very little detail regarding volumes (across the board)
  • Compiling results and will share during next meeting


Implementation Guide
  • X12 elements marked as required, but not necessarily identified as data payers are paying attention to
    • Assuming we need them anyway, because it's required for it to be a valid X12 transaction
    • Many of these are in optional or situational segments
    • Can we assume that communication between provider and payer, we are going to marry FHIR and X12 278
  • FHIR expects identifiers to be globally unique
  • FHIR Claim resource is being used for prior authorization data
    • From payer perspective, there's paying the claim, but also there's a decision support component around appropriate use and care
    • FHIR data model should support what's required
    • There's nothing in the 278 response that commits the payer to make payment for the service, even though they may authorize the service to be provided
    • In the context of FHIR, Claim resource is for prior authorization, claims, and pre-determinations
    • We are constraining that Claim resource to do what we need it to do for prior authorization
    • Missing components of 278 workflow that are intended to be addressed with LOINC code structure and request for additional information and the response through subsequent 278?
      • We are assuming a different workflow
      • Payer has communicated what the docuentation requirement is to the provider in advance of getting a 278 request
      • Then provider gathers info and sends it back with the iniital 278 request
      • Still need to map unsolicited attachment payload to some kind of LOINC code response coming in
      • Assuming that we're using PWK segment to indicate that you're submitting the data electronically, and sending an unsolicited 275 along with it
      • FHIR allows for more robust information, but not radically changing workflow?
      • Need to review workflow next time to make sure we're all on the same page


Workflow example
  • Current state, expected, and future state
  • Current state
    • Payers are mandating use of their portals, using 278
    • Request for additional information would be using LOINC codes in 277
  • Expected - current with new tools - SMART on FHIR-Optimized
    • This is what we expect we can do at a Connectathon using tools that we have available today, such as SMART on FHIR
      • Diabetic medical workflow example is one flow, and there will be infinite numbers of them
      • Providers and vendors are free to build a flow that works for them
      • For example, specialists might do things a little differently for a new patient
    • Retrieving data electronically - does this happen in background with SMART on FHIR app, or does ordering practitioner need to get involved?
      • #13-18 steps - if you have a rule set with the appropriate logic, you can gather what's needed from the medical record - don't need the provider for that
      • If data not found, provider may need to get involved - step #15
      • Only interact with provider for 2 things:
        • Identify missing info
        • Clarify alternatives
        • Everything else should come out of the record automatically
      • Provider decides to do something - order or a referral requires prior auth from payer - SMART on FHIR app will use rules from payer to gather data from EHR using CQL - finds diagnoses, medications, etc. but doesn't find the last piece of information needed, for example:
        • Proivder would need to indicate that data is missing because result wasn't entered into EHR, it's on a piece of paper, now they'll enter it
        • Provider would need to indicate they didn't perform a particular procedure
    • This workflow may not be any better than what's in the market today?
      • Prior Auth today does require multiple requests and responses
      • There are existing apps using FHIR that can look in medical record, pre-populate with data, and ask questions for missing information
      • These apps aren't doing this with a standard approach
      • This approach allows exchange to happen within the application with the appropriate logic - not necessarily going back and forth between provider and payer
      • Need to show how this fits in with DTR as well
  • Aspirational
    • In the future, artificial intelligence algorithms


Next agenda
  • Share results of payer survey
  • Review revised workflow to incorporate DTR

 Adjournment
 Adjourned at 4:03pm ET

Supporting Documents

Outline Reference

Supporting Document

Minute Approval


Tasks

  •