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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
  •  
Raymond Delano

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 ChanCW Global Consult
  •  
Ric LightHumana
  •  
UHC
  •  
Celine
  •  
Anil VezendlaMCG
  •  
Marty StaszakVoluware


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


DTR Dependency
  • Prior Auth Support has a dependency on DTR going back to STU ballot in September - need Mitre to update the DTR IG, but availabilty is unclear


Mapping Update
  • HL7 and X12 have been having discussions re: building this out so that vocabulary value set can be resolvable for those who have licensing - not yet clear when this will happen
    • If provider has an X12 license, there should be a way they can grab those code sets back electronically as an 'instance' and use them as they're processing (rather than go to X12, log in, access information, etc.) - this won't happen this year, but it's in progress
    • This will be available for the IG, but it won't be there day 1 and will be manual at first


Prior Auth Requirements
  • Do we need to support requesting multiple services in the same request - things that are approved independently of each other?
    • Not planning on 2 separate authorization processes in the same request
    • Wound care example - 5 different lines on this request - could approve 3 of them and pend 2
    • Assuming we need to support partial approvals and partial pends
    • Jean Duteau will follow up with Lloyd McKenzie on this topic
    • Every time you get back a pend, might need to submit a new subscription and cancel the old one
    • Multiple potential responses to a singl prior auth
    • Peter Muir will write up a brief paragraph to describe that only related services could be included in the request, not multiple unrelated services:
      • Provided via Chat: "Requests MAY include multiple items but SHOULD be related to the same order/diagnosis such that CPAP machine and supplies, incontinence supplies and diabetic supplies would require three separate supply requests with supporting diagnosis but each of those may contain multiple subitems such as CPAP machine, mask and tubing as separate line items within one request."

  •  How do we want to handle updates? Do providers need to make a new request and cancel old one, or can they update the existing request?
    • Some plans don't allow updates to an existing authorization - they want it to be a brand new authorization request
    • Individual has 6 PT visits approved - they want to extend that authorization for a total of 12 visits - the transaction allows the provider to change the previous authorization (instead of making a brand new request) - 2 large payers don't allow that
      • Plan recognizes they already have an auth and they handle it on backend
      • No discussion regarded pended authorizations, and whether or not they could be updated while it's pended
      • Everything is manual - they call in and change it
    • Depending on timing of workflow, payer may cancel the first request on the backend
    • Scenarios
      • Submit one CPT and then change it to a different CPT
      • Request 12 PT visits and now asking for 16 visits
    • These scenarios may need to be dealt with differently - either going to be a cancel and replace, or it's going to be a modify
    • Need to maintain both
    • If changing CPT, is supporting documentation going to be any different? Yes, it can be
      • This is really a cancel and replace scenario - provider is going to cancel and ask for a new one
    • Continuation - extension of the existing request if it's already been approved and I need more of something
    • Renewal - approved for services for a particular set of time, and want to renew it for a new timespan, can renew or revise (request additional or other procedures for the same patient event)
    • Depends on timing of request - is patient already done, or just submitted and now need to change
    • These different scenarios need to be documented in the IG
    • From a technical perspective, Mary Kay McDanielcan outline what we discussed, what the triggers are going to be and will send out for review by end of day Monday 7/15 and participants need to provide feedback by end of day Tuesday 7/16
  • Chat comment: when a member changes coverage from one Payer to another, the first Payer might want to cancel existing Prior Authorizations.

  • Should we reference alerts use case a way for the payer to inform the performing provider that an approval has happened assuming there's an endpoint known for the performing provider


Next agenda

 Adjournment
 Adjourned at 4:02 pm 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

  •