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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
  •  
Julia SkapikCognitive Medicine
  •  
Michael BrodyCME Online
  •  
Michcelle ZuttermanHumana
  •  
Surescripts
  •  
Laurie DarstMayo
  •  
Marianna SinghCAQH

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
  •  
Anupam ThakurBCBS FL
  •  
Cathy PlattnerKP
  •  
Srinivasarao Eadara
  •  
Availity
  •  
ZeOmega
  •  
Dennis ZanettiNantHealth
  •  
Haris BegCambia
  •  
Kishore MetlaMettle Solutions
  •  
Sunitha Godavarthi
  •  

  •  
C-HIT
  •  
SriniesMD


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
  • September ballot cycle schedule
    • NIB - June 30
    • Sign up for ballot opens - July 8
    • Initial content due - July 14
    • QA period - July 21
    • Final Content due - August 4
    • Ballot opens - August 9
    • Ballot closes - September 9


Schedule Change
  • 2 IGs not ready for early ballot cycle: PDex Directory and Prior Auth Support
  • Both will be included in regularly scheduled September ballot cycle
  • Prior Auth Support
    • Due to X12 mapping work, Operations definition, etc.


Survey Update

Reviewed top volume Prior Auth categories - see slide deck posted to Confluence

Will summarize comments and review in future call



FHIR Supported Prior Auth Review - Flow, Components
  • Time limit on a final response?
    • CAQH Core - no requirement yet for a final response once a response is pended, but are examining this
    • CMS contractors have 10 days and 20 days
    • Regardless of timeframe, IG will require that response is electronic
  • Operations endpoint will differ per payer
  • Once package is received by payer's system - payer can program system to immediately send back a pend, and move along to whatever internal process is
    • Initial pend response would need to satisfy the under 15 seconds response time requirement
  • 278 repsonse communicating back to provider allows to send frequency, number of visits, authorized service, etc.
  • 3 possible workflows:
    • Traditional
      • Focus of this Implementation Guide
      • Create FHIR bundle to interact with payer
    • Payer side
      • CRD only
      • Or optional DTR for missing information
      • Covered by existing IGs
    • Provider side (or provider-focused prior authorization)
      • CRD
      • DTR
      • No prior authorization support, covered by existing IGs


Information required
  • Information needed to populate 278
    • Prior Authorization Profile on FHIR Claim resource
    • Prior Authorization Profile on FHIR ClaimResponse resource
    • Da Vinci HRex profile on FHIR Coverage resource
  • Clinical information
    • Via rules using FHIR R4 US Core profiles
    • Via questionnaire/ questionnaireResponse
  • Attestations
    • Via questoinnaireResponse


Priority Order for PA Services
  • Initial focus is on use cases where we can get real-time responses
    • PA where information needed is attestation
    • PA where information needed is attestation and structured information that is defined in US Core Profiles on R4 resources (but not textual documents)
    • PA where evaluation of textual documentation is required - those would be pended and handled asyncronously
  • Based on discussion with Da Vinci payers, we believe up to 75% of PA requests can be resolved in real-time with attestation only or attestation and structured documentation 
    • Did survey give us an indication of what category/classification of services could fall into that 75% group?
      • Yes, but need to summarize for group next time we meet
      • Diagnostics and Imaging, Medication, Hospital Admissions are likely answered in real-time


Mapping
  • Mapping is underway, will be reviewed by X12 and they'll go through some publication process
    • Assuming artifact will be for purchase via X12
    • Timeline?
      • Information requirements from gap analysis and mapping will be available in the HL7 IG where we'll see the FHIR side
      • X12 details will be published by X12, guessing around September timeframe?
      • Operation definitions will be in the IG for the ballot - we'll have the request, but unsure if we'll have a Push response
        • SHALL support the request, and MAY provide a Push
        • We know we can do a request
  • Scenario where Pend is sent as response
    • Need a way to keep checking for an answer on that specific one, or maybe check to see if there's an answer for all pended requests


Next agenda

 Adjournment
 Adjourned at 4pm ET

Supporting Documents

Outline Reference

Supporting Document

Minute Approval


Tasks

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