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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
  •  
Labcorp
  •  

  •  
Mariana SinghCAQH
  •  
Madhuri

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 FullerIBX
  •  
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
  •  
Anthem
  •  
Kumar SourabhGRSI
  •  
Julia Chan
  •  
Ric LightHumana
  •  
Nick RadovUHC


Agenda Topics

Agenda Outline

Agenda Item

Meeting Minutes from Discussion

Decision Link(if not child)
ManagementReview ANSI Anti-Trust Policy



Milestones
  • Mitre is developing Reference Implementation
  • Gevity/ Lloyd McKenzie is 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


Mapping Update
  • Put together a spreadsheet of all the code sets and vocabulary and value sets we need to work with to map appropriately in and out of the X12 278
  • Signifiant number of code sets
  • Vocabulary is limited
  • Have constrained the UMO to be the payer - whoever it is that's creating the 278 (in the 'black box'), the EHR is going to tell them who the payer is and it may not be through a FHIR resource
    • Finding minimum amount of information we need to communicate to allow an intermediary to create a 278
  • What is the trigger to the 'black box'?
    • Each EHR vendor needs to come up with their logic or CDS Hook to start the process
    • Or there will be a generic app that someone pulls up to see if a prior auth is needed (via CRD)


Prior Authorization Operation Endpoint Requirements
  • Receive PA Bundle
    • Repsond in real-time
  • Respond when PA complete (e.g., if not real-time answer, PEND)
    • Push response (subscription?)
    • Pull response (query) (278i) - pull any/all auths that are complete?
      • Feedback is that system would know what's outstanding, and pull what's needed, not all of them (not batch)
      • This should be pull response for a single prior auth or a list of outstanding prior auths
    • Should IG support one or both of the above?
      • Supporting both makes sense in the IG
        • Organizations would choose which one they want to implement
      • Orgs might subscribe to different topics, (e.g., prior authorization updates)
      • Need to support variability on provider side or 'black box' side
      • Recommendation that payers should send a response to the provider when the prior auth is complete (timely patient care issue)
        • Provider ability to query/ check the status of a submitted prior authorization request that has been pended
      • Ideally wouldn't need to keep querying to find out if the auth is complete or not
      • EHRs may not have a vehicle to subscribe or receive a repsonse to a subscription
      • Could set up a subscription, but could also implement a query 
      • A lot of 278 management activity isn't done in the EHR
        • 80% will be adjudicated in real-time, and provider will get a response to whatever system generated the request
        • Batch transactions - intermediary wil provide the repsonse back to the submitter on the cadence they've worked out
        • Pend situation
          • Intermediary or system is going to wait for a subscription back from the payer, OR
          • Request updates every 1-2 days (or some cadence)
        • API from EHR or App inside EHR (not a separate 3rd party portal) - app is subscribing to an update from the payer (or can request the information)
          • Concept of batch integration becomes a legacy model because you're interracting with the app in real-time
          • Update will come back asynchronously
  • Provide support for (may be submitter or performer)
    • Update
    • Status (equivalent of 278i)
    • Cancel


Next agenda

 Adjournment
 Adjourned at 4:06pm ET

Supporting Documents

Outline Reference

Supporting Document

Minute Approval
Prior Authorization Support Draft Implementation Guidehttp://build.fhir.org/ig/HL7/davinci-pas/index.html


Tasks

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