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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
  •  
Heather McComasAMA
  •  
Optum
  •  

Kelly Anderson

BCBSAL
  •  
InterSystems
  •  

Mark Mundt

InterSystems
  •  
Megan SoccorsoCigna
  •  

Mike Funk

Humana
  •  
Nancy SpectorAMA
  •  
Terrence 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
  •  

  •  
CAQH
  •  
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
  •  
Michelle ZuttermanHumana
  •  
Surescripts
  •  
Laurie DarstMayo
  •  
Marianna SinghCAQH
  •  
Labcorp
  •  

  •  
Mariana SinghCAQH
  •  
Madhuri
  •  

  •  
Bob THompson
  •  
Ben LangleyMITRE
  •  
Michelle PriestAllscripts
  •  
Michael Hurley
  •  
Cedars-Sinai
  •  
Roland Gamache
  •  
Dave HCRT INC
  •  
Barbara WoodPNC
  •  

  •  
Padma KondaveetiMettles
  •  
Unknown User (meryl_bloomrosen)Premier
  •  
Cambia
  •  
Judy Williamson
  •  
Matthew Maurer
  •  
Smitha HarishMettles
  •  
BC Idaho
  •  
Michael LunzerAltegra Health
  •  
Rush
  •  
Shilesh NairGdit
  •  
Steve Favilla
  •  
Optum
  •  
Texas Health
  •  
Keya ShahCasnet
  •  
Epic
  •  
Josh Lamb
  •  

  •  
Edifecs
  •  
Max MD
  •  
Allen SaundersChange Healthcare
  •  
Molly Malavey
  •  
Rich BlochLumedic
  •  

  •  
Thomas GrannanAzuba
  •  
Beth ConnorCMS
  •  
MA Health Data
  •  
Kellie Ruff

Present

Name

Affiliation

  •  
Rachel GoldsteinCAQH
  •  
Ralph Saint-PhardHealow
  •  
Susan LestinaAHA
  •  
Briana BarnesScope Info Tech
  •  
Cerner
  •  
Cassandra Bell
  •  
Deepthi ReddyMettle Solutions
  •  
Cognosante
  •  
Humana
  •  
Prashanth Golconda
  •  
Rajesh GodavarthiMCG
  •  
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 EadaraesMD
  •  
Availity
  •  
ZeOmega
  •  
Dennis ZanettiNantHealth
  •  
Haris BegCambia
  •  
Kishore MetlaMettle Solutions
  •  
Sunitha Godavarthi
  •  

  •  
C-HIT
  •  
SriniesMD
  •  
Anthem
  •  
Kumar SourabhGRSI
  •  
Julia ChanCW Global Consult
  •  
Ric LightHumana
  •  
UHC
  •  
Anil VezendlaMCG
  •  
Ken LordBook Zurman
  •  

  •  
Christopher GraconIndependent Health
  •  
Gary GryanMitre
  •  
Mitre
  •  
Marty StaszakVoluware
  •  
Stephen ReckfordGRSI
  •  
Joe HamiltonUnity Point
  •  

  •  
Dave Foster
  •  
Betty SullivanAllscripts
  •  
Cigna
  •  
Juzer KhorakiwallaUHC
  •  
Unknown User (patricekuppe)Surescripts
  •  
Express-Scripts
  •  
Celine LefebvreAMA
  •  
Eshaa DhalleClinicalWorks
  •  

  •  
Aakash DeliwalaeClinicalWorks
  •  
Chris JohnsonBCBSAL
  •  
Megan RileyMITRE
  •  

  •  
Crystal HyattTransunion
  •  
Epic
  •  
AEGIS
  •  
BCBSM
  •  
Pawan RegmiRush
  •  
Rajesh GarlapatiRush
  •  
Rush
  •  
Scott HoltItiliti Health
  •  
Cigna
  •  
Cigna
  •  
UHC
  •  
Steve KirbyCoverMyMeds
  •  
Neena DakuaWPS Health
  •  
Evicore


Agenda Topics

Agenda Outline

Agenda Item

Meeting Minutes from Discussion

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



HL7 Virtual Connectathon - update

HL7 Virtual Connectathon - May 13-15

  • Combined Coverage Requirements Discovery (CRD), Documentation Templates & Rules (DTR), and Prior Authorization Support (PAS) Track: 2020-05 Da Vinci CRD/DTR/PAS
  • Track orientation recording posted in Confluence: HL7 Virtual Connectathon - May 2020
  • Step by step instructions for setting up CRD/DTR/PAS are available on the track page - PDF and video available
  • New X12/FHIR mapping spreadsheet will be added to the track page for participants
    • Readme file will be posted under the Track Preparation section of the track page, which include instructions re: how to obtain spreadsheet for this particular Connectathon
    • Readme file will point to a place on X12 website where you can download the spreadsheet
    • Spreadsheet will remain available up until MiHIN Connectathon end of May
    • **Need feedback on the mapping spreadsheet**
  • Are we expecting OAuth for CRD or PAS server for the Connectathon?
    • Requires that you reference some OAuth server for CRD/DTR
    • Sreekanth will follow up with Larry Decelles
  • Focus on Home Oxygen Therapy - are we allowed to use any other procedure codes?
    • If there's another case participants want to explore, we can support
    • Oncology and one other - Sreekanth will send Larry Decelles and Gary P. Gryan an email
  • Any kind of testing to verify X12 or some kind of testing mechanism for the 278s that get generated - is it valid
    • MITRE does not have a mechanism since they don't have an X12 implementation
    • Is Tibco/Jim Taylor going to be there?  They have a validation server system... Mary Kay McDanielwill follow up to see if he can join us as well as John Kelly
    • CMS Asset - function to upload a file to test it
      • Not sure if you need to have an EDMI in order to use it
      • You need to create an account
      • Asset does not take into account CMS companion guide, it's just for testing the transaction
  • Are any of the MACS (e.g., Noridian or Palmetto) participating in this work?
    • Palmetto has participated in past Connectathons
  • AMA and Peter Muir planning to attend track


Prior Authorization Support - next steps
  • Shifting from Implementation Guide development and ballot reconciliation to focus on implementation support - questions re: IG, implementer experience, possibly create FAQ
  • Group agreed last week that we should continue meeting to create "pictures and examples"
  • Homework from last week: Participants were asked to bring a list of things we should focus on (e.g., need more examples for X, need a diagram to help us better understand Y..., etc.)
    • Exercise all the different options we have in PAS - want to see the process end to end, how it works - real use case examples that we can bring back and say that the IG meets that use case, and here's what it looks like
      • Send a prior Auth, Get a partial approval, Need additional info, Send additional info, 2 additional lines get approved
      • Is this a professional vs. institutional request
      • How to handle header vs. line items
      • Several plans are doing this in real-time - are we looking for them to provide examples of how they're doing it?  Or this group to create examples of how it could/should be done?  Both
      • Do we need to start with happy path, or exception processing?
        • Making assumption that happy path is working, because we have those examples
      • Having a library of PAS requests would be helpful
        • Folks could use it to build a test harness at a minimum
        • Would be helpful to have real world data anonymized
      • Round-trip production testing or examples?
        • Grab real-world example 278s - de-identified
    • Sequence diagram of Prior Authorization that shows every step that happens for non-technical people
      • EHR gathers info, create FHIR resources, FHIR resources get fed to next step
      • Would also be helpful to layer on the technical piece (this API gets called to make this happen, etc.)
    • Sreekanth - there are gaps to take this into production
      • We have specification, but to take it to production - the kind of FHIR support for R4 in today's EHRs - most resources they support are more clinical in nature, or are needed for meaningful use criteria
        • Difficult to look into the kind of resources to see if EHRs have them
      • Security - single app is dealing with multiple payers, do we have a specific way to authenticate for all payers by using single sign on or something similar
      • PHI data and intermediaries - provider is at one endpoint, and payer is at another endpoint - intermediaries should be doing the translation and not storing the data ideally - how to handle things to make things easier for intermediaries
    • Janice Karin feedback
      • Bridging gap from conceptual view of world to actual Reference Implementations - no talk of APIs and data structures
        • Step through Reference Implementation and the de-bugger - difficult because there are different pieces of the process that need to be pieced together for CRD/DTR/PAS overall
        • Download all the RI pieces for CRD/DTR/PAS and walk through code path and de-bugger to get a sense of where the data is being constructed and how it's going from place to place
        • Can get a better sense of the data flow
    • Gary suggestion to take some of these ideas to the Connectathon - there might be some people there who could help us generate some of those examples
    • Sequencing diagram would be a helpful place to start
      • Happy path and non-happy path
      • Gary P. Gryan will reach out to Larry Decelles to determine what material we already have that could be used to start building this out


Next agendaNo call next week due to Connectathon (5/15)
 Adjournment

Adjourned at 3:51pm ET

Outline Reference

Supporting Document

Minute Approval
Connectathon Kick-Off Recording


Tasks

  •