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Chair:  Dr.Nita Thingalayaand Dr. Julia Skapik

Scribe: Dana Marcelonis
 

Attendees

Present

Name

Affiliation

  •  
Robert DieterleEnablecare
  •  
Stratametrics
  •  
Nita ThingalayaIBC
  •  
Cambia Health Solutions
  •  
Duane WalkerBCBSM
  •  
Gregory MagazuCaseNet
  •  
Jeanie SmithBCBSFL
  •  
Corey SpearsInfor
  •  
Greg Linden
  •  
Joseph QuinnOptum
  •  
Ashley SteddingCMS
  •  
Barbara AntunaAIM Specialty Health/ Anthem
  •  
Mary Kay McDanielCognosante
  •  
Michael GouldIBC
  •  
Laurie BurckhardtWPS Health Systems
  •  
Serafina Versaggi
  •  
Sreenivas MallipeddiMCG Health
  •  
Susan BellileAvaility
  •  
Susan LangfordBCBST
  •  
Taha AnjarwallaCAQH
  •  
Tony BensonBCBSAL
  •  
Tracey McCutcheonKPMG
  •  
Brent WoodmanBCBSM
  •  
Sonja ZieglerOptum
  •  
Dawn PerreaultBCBSM
  •  
CMS
  •  
Anupam ThakurBCBS FL
  •  
Anthem
  •  
Jeffrey DanfordAllscripts

Present

Name

Affiliation

  •  
John BialowiczBCBSM
  •  
Nandini GangulyScope Info Tech/ EMDI
  •  
Peter Muir
  •  

  •  
Pallavi TalekarScope Info Tech
  •  
Julia SkapikCognitive Medicine
  •  
Kelly TaylorCMS
  •  
Karen L. ZapataAnthem
  •  
Brandon RaabAnthem
  •  
Cindy MonarchBCBSM
  •  
Michael CabralCMS
  •  
Nick RadovUHC
  •  
Anne MeisheidCMS
  •  
Isaac Vetter Epic
  •  
James Derrickson
  •  
Laurie Woodrome Labcorp
  •  
Ric LightHumana
  •  
Harvey KuangExpress Scripts
  •  
BCBS AL
  •  


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Minutes Approved as Presented 


This is to approve minutes via general consent. "You have received the minutes. Are there any corrections to the minutes? (pause) Hearing none, if there are no objections, the minutes are approved as printed."


Agenda Topics

Agenda Outline

Agenda Item

Meeting Minutes from Discussion

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


ManagementBallot and Connectathon Schedule
  • Jacksonville Connectathon - May 29-30
  • Goal is to ballot for September ballot cycle
    • Jun 30th -- NIB
    • July 8th - Ballot sign up starts
    • Jul  14th – Initial Content IG
    • Jul 21st - Ballot QA Period Starts
    • Aug 4th – Final content
    • Aug 9th – ballot voting starts
  • HL7 Atlanta Connectathon - Sept 14-15


Reminder that Early Ballot Cycle Opens Today, June 21
  • Tuesday, June 25th - session re: how to participate in ballot - will be recorded and posted in Confluence
  • We'll be using gforge for comments for early ballot cycle
  • Unclear if we'll be using gforge for ballot comments in September ballot
  • Plan is to move to JIRA for ballots moving forward

Julia and BobReview Proposed Approach towards IG Creation
  • Review FHIR Care Plan and define use
  • Define larger patient context-- Longitudinal Care Plan?
  • Align to Prior Auth as a component of the Care Plan

Julia and BobReview FHIR Care Plan
  • Participants are familiar with the resource, but not actively using it on the payer side
  • Emma Jones and Jeffrey Danford from Allscripts presented this at DevDays last week - Viet Nguyenwill provide so we can post on Confluence
  • Could payers use this resource to communicate patients that are enrolled in a particular care management program?
    • Haven't had a use case come up re: care management programs yet
    • What about for care that's needed, such as gaps in care?
      • Gaps in Care and Information, is a use case that will be starting up in Q3
      • This will be a whole framework, not just a single resource
      • When we kick off this use case, will announce via Da Vinci listserv
    • This Payer Coverage Decision Exchange use case is bounded to 'portability of treatment'
  • Do folks think there a different primary resource we should use to communicate active problems and treatment between payers?
    • Other option would be to populate a 'custom' bundle, but not necessarily recommending this
    • Chat Comment: C-CDA on FHIR as alternative to Care Plan?

      • Heavy lift - replication of what's in CCDA care plan - includes a lot of information that may not be available to a payer
      • Intended for a different use case, would be difficult to meet all the conformance requirements
  • Only issue with care plan, is that most patients don't actually have a care plan - tends to be for patients with chronic conditions that are being actively managed in some way - mis-aligned with the way clinicians think about care plans?
    • Payers have looked at care plan for managing wellness as well
    • Collecting various conditions on a patient, and what activities are related to the patient
    • Supports team-based care for the patient
    • There's no constraint re: including a care team, so we don't need to include it if we don't have requirements to do so
  • Authorization content we'd be trying to pass between payers - who's the member, what service or category of service is being asked for, authorized to a requestor (e.g., hospital/surgeon), duration
    • There will be data needed to share active treatments for chronic conditions - payer doesn't require a re-authorization every 6 months or year, they're just going to continue to support the treatment (e.g., diabetes, COPD)
    • Initial re-authorization requirements are different from continuation of care requirements (e.g., sleep apnea)
    • Period for care plan, and then status/period for the activity itself
  • How would you express units allowed? And of those units, patient has received half of it already?
  • Some data will need to be handled as text, and not computable? A lot of the documentation will require manual review anyway
    • We could likely accommodate the most common cases with structured information
  • Is it possible to add authorization or re-authorization?
    • Yes, we can create an extension if needed for something that occurs often
    • Can create additional elements and describe them accurately, point to them with a URL, and then create a profile that sits over the top that binds the two together
    • We'll be making decisions on this type of detail over the next 4-6 weeks as we go through the specific use cases we're covering

BobAlign to Prior Auth
  • Prior Authorization Support use case is focused on automating Prior Authorizations in provider's clinical workflow
    • Knowing what requires authorization
    • Identify what is it trying to get authorization for
    • What clinical information is necessary to support prior authorization
      • Attestation only
      • Attestation + structured information
      • Information contained in textual notes
    • HIPAA requirement for prior authorization transaction using X12 278
      • Creating a Prior Authorization profile using the FHIR Claim resource
      • Creating a bundle to provide to an endpoint that can translate the information into a 278 (and potentially X12 275)
    • Real-time transaction
    • Payer would be asking for discrete clinical data (e.g., diagnoses, medications, etc.) not a care plan to make their decision re: authorization
    • Care Plan for Payer Coverage Decision Exchange use case would be the mechanism for communicating the decision and the data that went into that decision, to another payer
  • If need an example to look at, some states have established a mandated submission form for pharmacy auth that does not differ from payer to payer

ManagementNext agenda
  • Review1-2 of the use cases for continuity of treatment and how they would populate the Care Plan resource

 Adjournment
Adjourned at 3pm ET

Supporting Documents


Action items


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