2021-03-05 PDex Meeting

Da Vinci April Education Session

Da Vinci Education & FHIR Implementation Event by HL7 - April 26 - 30

Register Here

Any questions?  

For today:

1) Formulary: Behavior of authenticated members - follow up on question about drug plan  shopping and group (closed plans) David Hill

This will be added to the IG as a clarification.  

Question on Shopping Behavior: would there be a required shopping experience behind patient access API?  The requirement now is to show the formulary not shopping.

The choices on the formularies that are available to a member, this falls on the payer's business logic to make the data available. 

How would the member/requester/client know if shopping experience was available?

• It would be through a query and be able to get multiple plans back.
• Nothing that says you can ask - is shopping supported?   yes/not. You would just get back more plans as options. 
• Do the third party developers understand what the options are? The client being developed that is working with multiple payers to create a 

If you are enrolled in a plan, there should be a  

Check for coverage record for pharmacy plan, if you find one, you get one. if you don't find one, then ask for formulary.  If you don't get any, then there is aren't any (restricted).  if you get one or more, then they are all eligible.  then they pick one and the others are no longer available.  

For more info on the Shopping for health plans - see CMS Answer 6017 on this page: CMS Final Rule Questions and Answers log

Action Item: Do we need a separate shopping access for those members that are enrolled with group plans already that still may have options and want to shop.  May use the coverage record to tell you which one you are actually on.  David Hill Robert Dieterle

FHIR -30412

JIRA Dashboard of all Formulary tickets:  https://jira.hl7.org/secure/Dashboard.jspa?selectPageId=11904 

These would be slated for STU2 - January 2022 timeline. Want to avoid any breaking changes

. 

• TBD: FHIR 30924 May be able to squeeze in depending on the solution so let us know if you feel strongly. 
• FHIR-29965 Marketing URL - recommend creating a landing page to select language and correct brochure. 

The following are tickets we'd put into an STU Update (not ballot - shorter process 14 day comment period and then Pharmacy WG approval process)

Please see past meeting minutes for the ongoing discussion on this.

Many questions about the rules answered here:  https://confluence.hl7.org/display/DVP/CMS+Final+Rule+Questions+and+Answers+log 

Member comes back 30 days after new plan to request their data.  There may still be open claims, uncompleted information, should you wait to send data for 30 days, 60 days, ?

• Timeline for turnaround of the data upon request in the rule?
  • 1 business day to share the data? That is the proposed Burden Reduction Rule is the 1 business day. 
  • The interoperability Rule does not have a timeframe for when the request needs to be responded to.  There is a 5 year timeframe for the data. 
  • One and done exchange vs. a continuous process to share updates?

Added post call: CMS Final Rule Questions and Answers log The 1 business day in Patient Access API is clarified a few times... "payers make available through the Patient Access API, no later than one (1) business day after the information is received: (1) adjudicated claims, including claims data for payment decisions that may be appealed, were appealed, or are in the process of appeal, and (2) encounter data. We reiterate that this is one (1) business day after the claim is adjudicated or encounter data are received.

If the intent is to give the info to the new payer for patient clinical data visibility, then waiting 30,60days is not very helpful. 

• Member Mediated vs. Member Directed
  • Member Mediated - prior payer ask to send data to new payer. 
  • Member Directed - how do we make sure the run off data is included?  Counter productive to wait, but want to capture the run off data as well. 

May want to include in the patient consent/authorization the flexibility to share data over time until data is no longer changing.  ie. data no longer changing.  

• Token has an expiration date.

• OATH exchange can have a refresh token to last for a particular period. the refresh token lasts longer and can get you an updated oath token.

• New member with new health plan - should send updates for the next 4-5months.  Most recent claims not submitted.  

Grounding comments about obligations of the rule vs. what the intent is and spirit is as a challenge for implementers right now.  Industry wide - Making hard decisions.

• Want to avoid re-work with the rule that may be published soon.    

There is a need for re-occurring request between payers as patient data may continue to change (claims get adjudicated after the patient may leave the old plan)

• USCDI data includes the clinical portion of claims. This can change after the member is no longer enrolled. 
  • Sure, likely labs, etc. other clinical data wouldn't be captured after the member is no longer enrolled.
  • Answering a Question: If you get a claim and do nothing but pay it, doesn't go into patient records in any way (at all) then you don't have to share.  It's about Maintaining the data.   

• Note: the proposed Burden Reduction Rule includes EOBs, you will need to share then. 
• As soon as the regulation publishes. Da Vinci members will convene a group to clarify questions with CMS to interpret the rule. 

From chat: 

12:45 PM
Joe Quinn (HSX) to Everyone

Does anyone if there is an HL7 Working Group which deals with "Consent"?  I thought that it was Community-Based Care and Privacy but the link to that WG on the HL7 website is broken.

12:45 PM
Mark Scrimshire (@ekivemark) to Everyone

Security WG also deals with Consent

12:46 PM
Joe Quinn (HSX) to Everyone

Link to Security WG on HL7 website is also broken.

12:47 PM
Joe Quinn (HSX) to Everyone

Are CBCP and Security WGs still active?  Does anyone know?  Thanks.

12:50 PM
Joe Quinn (HSX) to Everyone

Looks like CBCP has WG call at noon on March 9 and Security WG has call at 3pm on March 9.  Would be interesting to hear what either/both of these WGs think about the consent options that were posed earlier.

12:54 PM

Michael Gould to Everyone

Discussion on Consent resource at HL7 WGM Jan 2021 - see https://confluence.hl7.org/display/CBCP/2021-01-28+CBCP+WGM+Minutes+DRAFT

12:56 PM

Alex Kontur to Everyone

CBCP is definitely active - https://confluence.hl7.org/display/CBCP

12:57 PM
Alex Kontur to Everyone

CBCP is tuesdays at noon ET, security is tuesdays at 3 pm ET. CBCP zoom is https://us02web.zoom.us/j/89234543086?pwd=anE3djgyQXFYbkFYTEZCNVBPYkVzZz09

12:59 PM
Michael Gould to Everyone

Key thing about Consent resource is that it is a resource about the event of consenting - who (person/member giving consent to another (person/org (provider/payer) for something), when  - what parties consent to is a reference to a URL for the details of the consent terms

PDex IG Links and Updates

PDex Supplemental Guides

PDex IG Companion Guide - Laboratory Reporting Resources

FAQ Review Cont. and Implementer Support

Consent Discussion Cont. (if updates from Architecture Group)

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

• Links to Published IGs

• PDex STU 1.0.0
• Plan Net STU 1.0.0
• Formulary - STU 1.0.1