2021-01-22 PDex Meeting

HL7 January Connectathon 26

January 13-15, 2021

Link to Hrex IG with Member match:  http://build.fhir.org/ig/HL7/davinci-ehrx/OperationDefinition-member-match.html 

Summary: Da Vinci Use case team to explore providing further guidance on:

• How to handle the variability among payers to identify members with membermatch vs. member credentialing. i.e.  How does a plan ask a new member for information, if they have a digital ID for a member?
• How does one plan find another plan to exchange the information?

Where should this guidance documentation live?  Suggestion to start with a Supplemental Guide and queue this up for Q&A, then we can see if it makes sense to have this guidance in an IG as it continues to evolve.  

• With attempting to get all the data from CARIN EOBs, Clinical Data, Provider Directory, and Formulary into a single server, feedback heard was that it is an unrealistic scenario since the data is not all in one place today at the payer.  
• The client would need to authenticate to each.
• Learned: Challenge to have an RI that covers all that data. 
• Explore linkage from claims and clinical data to the provider directory- which in the rule is public, outside the Patient Access auth.
• For Formulary Data:
  • Only want to show Plan within the formulary that is relevant for the patient.  Maintaining that context to provide only the relevant information. 
• How do you integrate the multiple sources? 
• How hard is it to link to the patient access api with the outside api?  
• For a client trying to provide an integrated view for a patient with Claims and clinical data into the same Provider (Org or Practitioner) there is not an easy way to do that.  NPIs and Tax IDs should usually match to a provider, assuming it's in the current directory. 
• Location looking a claim to see Dr. Jones, to get to a link to the directory to see dr. jones and the reference in the EOB, it would involve a search within the application.
• Formulary - plan id, NDC codes to get to the relevant patient info. 
  • Filtering at the app, payer would need to provide it all
  •  
• In the shopping of plans experience, Geography is needed to share - drifted into Implementer support question #2 below.
  • Do we include the location under Coverageplan?
  • geography based on plan info - likely not in the same place.

Summary: Da Vinci Use case team to huddle and explore next steps regarding:

• How to navigate the combination of the data across clinical, claims, encounters, formulary, and directory data
• Take lens of Smart-on-Fhir apps (payers too) to get relevant formulary data to the patient  
• Vanessa Candelora set this up. 

CMS Rule announced on 1/15/2021 builds on CMS Interoperability and Patient Access final rule -  CMS Final Rule

Press Release announcing Final Rule Dropped on Jan 15, 2021

CMS Fact Sheet

Final Rule 

Previous from Proposed Rule:

NPRM Summary Deck - Reducing Provider and Patient Burden V2.1.pdf

Da Vinci Response to CMS Reducing Burden NPRM 

Discussion about Rule not being officially put into Federal Registry and hold from Biden Administration as of Wed.  The Rule is still very likely to proceed and is aligned with guidance from CMS regardless.  The existing 3 Pdex IGs are all still aligned with the Patient Access API Rule and this rule would build upon what is there with new profiles, etc.  This work is being planned in the next month or so.

Implementers can take advantage of tools: See the Reference links on the Payer Data Exchange (PDex) page to access links for Reference Implementations, sandboxes, test scripts, and more!

Helpful Links for question: 

CMS Responses that helps to address this here and see # 6017

Formulary Continuous build IG section on Privacy for the Patient Access API authenticated members’ scenario:  which you’ll see points to the HRex parent IG security section referencing SMART-On-FHIR and OAuth

Questions submitted for discussion:

Regarding the Formulary IG: David Hill please look to Zulip for updated questions on #1 and #3 below that we'd like to provide answers to prior to next meeting (2 weeks out):
1) The available selections for CopayOption and CoinsuranceOption are not accurate if the Medicaid Plan has a deductible of $0. We can use "After-deductible" for now but recommend adding another selection that is specific to this scenario.
2) Allow location-based searches for CoveragePlans - discussed above, project team will huddle and come back to the group. 
3) Change the constraint on usdf-PlanID-extension attribute in MedicationKnowledge non-mandatory

PDex IG Links and Updates

PDex Supplemental Guides

PDex IG Companion Guide - Laboratory Reporting Resources

No call, resume on 2/5.

Change of 

Latest draft CARIN CPCDS Mapping document: CARIN Mapping to FHIR interim 2020 0513.xlsx

DRAFT - PDEX US Core Mapping from CPCDS source: ResourceMappingUSCoreCPCDS-2020-05-29-v26.xlsx

Find initial questions and corresponding answers shared from our colleagues at CMS here