2021-03-26 PDex Meeting

Da Vinci April Education Session

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

Register Here - Early Bird Registration by 4/5/21

2021 - 05 Connectathon 27

2021-05 Da Vinci

Any questions?  

What is the right FHIR resource for maintaining Authorization & appeals as part of utilization management?  we are planning to leverage "Encounter" resource for this.  is this the right approach?

Authorizations and Appeals are not named in USCDI, but the procedures, services, vital signs, etc. are all named.  

Authorization = Prior Authorization (PA)

Appeals = Denied Authorization or a 

PDex is based on USCORE. If you look at all clinical data is basically related to encounter (provider view)

Prior. Auths, Appeals, business management - reaching out to the patient.  Underlying data 

How to include PA into PDex is an ongoing conversation right now. 

Bob: does NOT believe encounter is the basis.  Service or device is the base for PA, not encounter.  

Can you hold off?  We are in the process for evaluating options to include PA into PDex.   likely may possibly be to use the claim response and the profile on it. 

RM: Agrees, don't make it encounter, it's a claim thing.  

If you capture the data as part of UM, DM, CM, are you required to share it? All managed data, yes.

The authorization itself  is not required under the current rule, but will be under the pended Burden Reduction rule.

There is no context of the care plan.  The plan is not the actual event. 

Payers don't have all the clinical information, they only have what they have - the must support with a 1..1 cardinality "if you have it, share it, or null.... if it's a codable concept, you have to do a data absent reason.  You can do the extension on any elements.  If you have a required binding, you can't.  

Trying to solve a really complex problem, please pause and come to this call next week to talk about options (PA in PDex) 

Care Team;

Prior Auth, 

Summary: Agree don't make UM clinical data based on encounter.

Across all health plans.

Only the QHPs have HIOS ids. 

JT: Do we have any PBMs on the line?  Would it cause a problem for them with multiple payer clients and sub clients and variation base don plan design. 

Dave, Jason, Mike Gould, - check with the PBMs

If we need a payer ID, then we'd need a combination of data to create a unique 

Payer IDs - in Pharmacy space, Bin numbers are used to identify the entity that is doing the processing.  Sometimes they accept the id from others and sometimes they generate their own. 

US Card Standard - replace member number with Rx # and group numbers. 

Laurie, WPS - not using CMS number assigned that allows selling on the federal market exchange, not used to identify the payers.  they assign their own payer ID and let their trading partners know that. 

From Federal exchange, they all come under the same payer ID, then 

BB: HIOS plan ID - 14byte going to plan level. Breakdown the plan ID; if there isn't one today, this is how we'd model it. Who assigns and who manages that?

Clearinghouses assigning their own numbers to payers.

We are talking about Drug Plans, NCPDP Transactions, and this typically go to their Rx Bin number. 

• Next Step: Verify with NCPDC that the Rx Bin number will work.  

2) FHIR-31572 Update from discussions. 

Agreement to: Postpone the change to add multiple identifiers to the next major release.  

Based on Zulip chats

PDex IG Links and Updates

PDex Supplemental Guides

PDex IG Companion Guide - Laboratory Reporting Resources

Start with: Exploring options to incorporate PA into  PDex - Bob - PDex updates for PA.docx 

FAQ Review Cont. and Implementer Support

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