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Chair:  

Scribe: Dana Marcelonis
 

Attendees

Present

Name

Affiliation

  •  
Robert DieterleEnablecare
  •  
Stratametrics
  •  
Nita ThingalayaIBC
  •  
Cambia Health Solutions
  •  
Gregory MagazuCaseNet
  •  
Jeanie SmithBCBSFL
  •  
Corey SpearsInfor
  •  
Optum
  •  
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
  •  
BCBSAL
  •  
Tracey McCutcheonKPMG
  •  
Dawn PerreaultBCBSM
  •  
CMS
  •  
Anupam ThakurBCBS FL
  •  
Anthem
  •  
Allscripts
  •  
BCBSM
  •  
Chris JohnsonBCBSAL
  •  
MITRE
  •  
ZeOmega
  •  

  •  

  •  
Cigna
  •  
eClinicalWorks
  •  
Tibco
  •  
Eddy NievesEpic
  •  
Christopher Gracon


  •  
Centene
  •  
Andrea KentCoverMyMeds
  •  
BC Idaho
  •  
Keya ShahCasenet
  •  
Neena Dakua
  •  
Cara BerryAvaility
  •  
NCPDP

Present

Name

Affiliation

  •  
John BialowiczBCBSM
  •  
Nandini GangulyScope Info Tech/ EMDI
  •  
Peter Muir
  •  
CAQH
  •  
Pallavi TalekarScope Info Tech
  •  
Kelly TaylorCMS
  •  
Karen L. ZapataAnthem
  •  
Brandon RaabAnthem
  •  
Cindy MonarchBCBSM
  •  
Michael CabralCMS
  •  
Nick RadovUHC
  •  
Epic
  •  
James Derrickson
  •  
Laurie WoodromeLabcorp
  •  
Ric LightHumana
  •  
Harvey KuangExpress Scripts
  •  
BCBS AL
  •  
Gevity
  •  
Julia ChanCW Global Consult
  •  
Ken Lord
  •  
Edifecs
  •  

  •  
Roland Gamache
  •  
Alberto S. LlanesAnthem
  •  
Mark ScrimshireNew Wave
  •  
EMR Direct
  •  
Patrick MurtaHumana
  •  
Ranjith KandurAnthem
  •  
MITRE
  •  
Joe MinieriMITRE
  •  
Dave Foster
  •  
Providence
  •  
Betty SullivanAllscripts
  •  

  •  
June Bronnert
  •  
Cynthia GinsburgCMS
  •  
Eshaa DhalleClinicalWorks
  •  
Ronald MacDurmon
  •  
Cigna
  •  
Edifecs
  •  
Cigna
  •  
Mona ChandrapaleClinicalWorks
  •  
Sonja ZieglerOptum
  •  
Celine LefebvreAMA 
  •  
 Ben Largley
  •  
Dawn PerraeultBMBSMI 
  •  
Emily TenEyck CAQH
  •  
Joe QuinnOptum 
  •  
Lindee Chin Edifects 
  •  
Lorraine Doo CMS 
  •  
Padame Metal Solutions 
  •  
Rajesh g
  •  
Josh Lamb
  •  
Edifecs
  •  
Sreekanth


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




  • Question re: discrepancy between example given and the documentation in the Implementation Guide
    • Example in the Communication Response is misaligned with what was documented inside the PCDE IG
    • Submit a JIRA issue
    • What should we refer to in the response Communication?
    • Communication should point to a CommunicationRequest, not to a bundle


HIMSS20 Clinical Scenario 

HIMSS20 Clinical Scenario


  • PCDE Sub-Scenario#5 - Medicare Advantage: patient turns 65, and decides she wants to change plans, and wants a Medicare Advantage plan
  • Expectation is one care plan per treatment
    • Treatment - a condition, a guideline, or a prior auth, etc.
    • Instead of duplicating conditions, they would be done by reference instead of repeating them
    • Intent was to use care plan to bundle together the documentation relative to something
    • e.g., Treatment = Home Health, with a number of things that have to be delivered (OT, PT, DME, etc.)
    • Definition of 'treatment' needs to be documented somewhere
    • Minimum set to do prior auth - e.g., you request prior auth for home health
    • Robert Dieterle will submit a JIRA request for this clarification to be added to the PCDE IG
  • How many buckets of treatments should we have? What would the groupings be?
    • Anticipate that old payer would know there's a reason reference code for every treatment, and know to put the series of ICD-10 codes by condition - the old payer would do this grouping
    • One option to do this grouping would be by 'policy groups' - 3 buckets in this scenario (per Medicare groups, www.cms.gov/mcd): 
      • Oxygen & Oxygen Equipment
      • Nebulizers
      • Drugs
    • Would you group all drugs under one care plan?
    • Not just current treatment, but anticipated treatments?  For example, if I have a chronic condition that needs monitoring once per month for recurrance, but am not doing anything active at the moment
      • Monitoring is an active treatment - biling for services, patient coming into the office
      • Medicare FFS example - 90 day/100 day/1 year global period where payment is made immediately to the surgeon, but all the monitoring during that timeframe is considered already paid for
        • How does this work if patient transitions to a new health plan with same or different providers?
      • Passing this information on to new payer seems important, but maybe it's added to the list to address in v2 of IG - need to create an open issues list for future
    • Is medication a treatment or part of documentation?
      • A treatment
      • Need a care plan for every set of related drugs (e.g., nebulizer drug and saline)
  • Participants can review offline and provide feedback - May Terrywill post in Confluence: Sub-Scenario#5 - Medicare Advantage

ManagementNext agenda



 Adjournment

Adjourned at 2:59pm ET


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