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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
  •  
Marty StaszakVoluware

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
  •  
UHC
  •  
Cloud Cray
  •  
Surescripts


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 updateMary Kay has more time scheduled with vocabulary folks to keep working on this

Prior Auth requirements
  • If Prior Auth is pended, the plan would be to continue polling until it's not pended anymore
    • If it gets resolved in between those polls, is there a push at the point of resolution by the payer?
    • Also supporting status checking?
    • If payers received a 278, pended it, then later resolved it - what do payers do upon resolution? Is there a push? Or do you expect providers to keep checking status?
      • Humana writes the event to a queue in case someone can subscribe to it (nobody is subscribing yet)
      • In practically most are doing 278 inquiry to find out if something has been approved
      • Preferred method is to do both
      • Most payers would have some work to do to support event publication - they'll have to do this anyway, because relying on a 3rd party to constantly poll to determine if status changed is not the best experience - payer should be notifying proactively
      • Event notification vs. full payload?
        • Humana publishes things to queues, currently all internal - would like to turn these into FHIR and publish externally
    • V1 specification to support delivery of asynchronous Prior Auth responses using the Status Request query.  Implementers can either poll or use Subscription to cause notifications to flow to the EHR whenever the Prior Auth response was updated.  The EHR would then execute the Status Request query in response to the subscription notification.  (Push of the actual Prior Auth Response itself is out of scope for V1.  The subscription notification + query approach will meet the need for 'immediate' delivery of prior authorization responses)
      • Subscription would be based on submitted Prior Auth ID - if you get back a response that's pended, you have option of creating a subscription, and will receive a notification if anything changes on that prior auth, and can then go query it
      • Can also query via polling on a regular basis 
      • Gives baseline support for those can only do polling, but also gives 'smarter' option for those able to do subscription
      • Implicitly create a subscription upon submit?
        • No reason to if you're getting a synchronous response back with the results
      • When onboarding providers, would determine if subscription model is their preferred approach - out of scope for FHIR process right now
      • Critical for plan to have capability to send response immediately when it's ready - polling to see if payer system has a decision is perpetuating the current problem
        • Can we mandate support for subscription?
        • We don't have EHR vendors on the phone today to give input re: what they can support
        • If we mandate support for subscription, we create a barrier for people to implement it at all
        • Polling is easiest option, Subscription is next easiest, and then Direct Push would be difficult for EHRs to take on
          • Most EHRs are looking to support Communication in the next year or so - we could choose to use that as the event notification?
          • Communication is not an appropriate mechanism for this scenario - in the end, we're trying to communicate the Prior Auth Response, so wrapping it in Communication doesn't buy us anything
          • Leaning towards not having a Push in this release at all
            • ClaimResponse resource instance would be pushed in this scenario
            • Subscription would be the notification that something exists
      • If there are multiple CPT codes, and they have different dispositions, will this handle that?
        • Yes, it should
        • Prior Auth Request comes in - if they are all adjudicated immediately, then PRior Auth response is complete
        • If only get responses to some and not to all - overall response is still in Pended state
        • Would use subscription mechanism or polling mechanism to communicate when final resolutions on different pieces have been completed


  • When sending an update or a cancel, do you need to provide reason why?
    • Would like to have a reason, but it's not required today
    • Julia Chan Chat Comment: good to have reason capture for improving efficiency and continuous learning automation
    • The other consideration, is there a home for that in the X12 that we're mapping it into?
      • Group doesn't think so
    • Assuming not including a reason


  • When requesting status information, are you expecting to get back a snapshot of what the Prior Authorization response looks like right now with statuses, or expecting info to be embedded (e.g., phoned Dr. Smith on Tuesday but haven't heard back yet)
    • Through electronic inquiry, all you get back is the PA repsonse that is currently available - not the extra information


  • Need to know if X12 transactions are different in terms of data conveyed for updates, status requests or cancellations?
  • X12 implementation guide for 278 inquiry/response but not a HIPAA mandated transaction - how does it differ?
    • Mary Kay McDaniel and Robert Dieterle to follow up on this
    • Would like to have a FHIR-only stack to support the inqury since it's not mandated by HIPAA
    • Would look the same from EHR side

Next agendaNo call July 5th due to holiday weekend
 Adjournment
 Adjourned at 3:59pm 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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