Chair: Mark Scrimshire
Scribe: Vanessa Candelora
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."
Minutes Approved as Presented
Meeting Minutes from Discussion
|Decision Link(if not child)|
|Management||Review ANSI Anti-Trust Policy|
Da Vinci April Education Session
Register Here - Early Bird Registration by 4/5/21
|HL7 May Connectathon - Save the date May 17 - 19|
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!
|Implementer Support Questions (PDex, Formulary, Plan Net)|
Call to All Implementers: We learn as a community and iterate on the IGs through real world experience, so your contributions are welcome! Please come with your questions. Options:
1) Send them to us on Zulip:
2) Ask questions live on the call
3) Edit and add your question to this page (in this box under "Question")
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)
Summary: Agree don't make UM clinical data based on encounter.
|Formulary Open Items / Discussion|
1) HIOS Discussion cont.: Is there a need for a national unique ID?
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.
2) FHIR-31572 Update from discussions.
Agreement to: Postpone the change to add multiple identifiers to the next major release.
|Reviewed FAQ Proposed Responses|
Based on Zulip chats
|Consent Discussion Cont. (if updates from Architecture Group)|
PDex IG Links and Updates
PDex Supplemental Guides
Updated to 0.1.29 on build.fhir.org: http://build.fhir.org/ig/HL7/davinci-epdx/index.html.
Source code is here: https://github.com/HL7/davinci-epdx
Presented to FM on 10/20
Start with: Exploring options to incorporate PA into PDex - Bob - PDex updates for PA.docx
Goal: trying to get something that is implementable and not too disruptive to PDex that will meet the need of the CMS Rule (final rule from January is currently pended) - Reference: Proposed Rule Fact Sheet
FAQ Review Cont. and Implementer Support
Adjourned at 12:57pm EST.
|PDex Companion Guides||PDex IG Companion Guide List|
|CARIN CPCDS to US Core Mapping|
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
|PDex - US Core |
Source PowerPoint: PDEXandUSCoreRelationship.pptx
|Da Vinci is seeking answers to open questions and clarifications needed on the implementation and operational needs of the upcoming CMS Patient Directed API Rules.|
Find initial questions and corresponding answers shared from our colleagues at CMS here
Attendees - 36
Intepro Solutions Rakesh Mathew Daniel Lilavois Patricia R Harbin Shalabh Gautam Kamaraj Kaliaperumal, Carefirst Bhanu Vemuri Narasimha Murthy Accenture Google Cloud Healthcare Maggie Mellon Courtney Bland
Present Name Affiliation CMS BCBST Deepthi Reddy Mettle Solutions Allscripts Eric Sullivan Inovalon MITRE India Duncan Optum Availity Susan Lestina AHA Bob Bowman CAQH Thomas Kessler CMS Patrick Edwards Briana Barnes Scope Info Tech Kishore Metla Mettle Solutions John Donnelly Lorraine Doo CMS Melanie Jones CMS Rim Cothren Yolanda Villanova CMS Manoj Kumar BCBSFL MITRE Srinivas Konchada Centene Corporation Sheryl Turney Anthem Helina Gebremariam Mike Novales BCBSIL Ric Light Humana Ann Gallagher Optum Chris Klesges Mitre Adam Gronsky Health Fidelity CaseNet Anthem CMS eClinicalWorks Healow Interfaceware Mark Rucci Spectramedix Anthem Cindy Monarch BCBSM Michael Kim Cognosante Jim Catan Accenture BCBSA Jia Chen Robert Dieterle Jeff Eastman Ernestine Cooper Jason Teeple CIGNA Lloyd McKenzie Mary Winter Rachel E. Foerster Tom Grannan Azuba Tony Benson BCBS AL Independence BC Henry Archibong Inovalon HL7 Consultant Abdul Sattar Anirudh Choudhary Todd Biske ESI Darrell Woelk Doug Stoss Rick Lisseveld Aegis LakshminarayananSaravanan Laurie Burckhardt WPS Health Plan Kevin Lynch Inovalon Joseph Minieri MITRE Durwin Day BCBS IL Pamela West Ravi Thakkar Aetna UO Aetna Swati Nanda Aetna CVS Health Cyrus Kevin MITRE Fred Harmon Ready Computing Blue Cross NC Michael Ryan NCQA HealthSparq CVS/Aetna Dorothy Lee NCQA Khoa Nguyen Suma Addagadde BCBSNC Caitlyn Campi FL Blue Diane Bengtson Sean Mahoney MITRE Balaji Richard Lisseveld Shanna Hartman CMS Kevin Day Edifecs
Patricia R Harbin
Google Cloud Healthcare
Chris Johnson Scott M. Robertson David Clowers Anthony Omosule Accenture
Present Name Affiliation Nancy Spector AMA Bruce Wilkinson Benmedica Avality BCBSAL MCG ONC Surescripts NCPDP Anupam Thakur BCBSFL Jonathan Hutchins BCBST Anthem Sunitha Godavarthi Christopher Gracon x12 Labcorp James Derrickson Intersystems Cognizant Neetha Joseph Cognizant Kaiser Permanente MITRE Rutika Express Scripts Brody Brodock Allscripts Michael Brody CME Online Theressa Baumann BCBS AL Mona Chandrapal eClinicalWorks Optum Aakash Deliwala eClinicalWorks Mayo Epic Shaheer Stanley Nachimson Anthony Smith UNC Health Howard Cohen Minaei Behnaz FDA BCBSA Shilesh Nair gdit NewWave MaxMD BC Idaho Edward Castagna Altarum Andrea Kent CoverMyMeds Carrie Denny Kim Pham Celine Lefebvre AMA Edifecs Josh Lamb UPMC Keya Shah Casenet Gevity MITRE Mrugen Mehta eClinicalWorks Revathi Jayakumuar Supriya Bapi Bhera Matt Dyer Vyne Sree Vijetha Vegi C-HIT BCBSA Rich Bloch Lumedic Cigna Paul Knapp Ron Urwongse CAQH Anand Raghavan HealthLX Ezequiel Morles Frank McKinney Hanna ? Brett Rauschke Carolyn McKinney Clarissa Winchester BCBS AL JC HealthShare Exchange (HSX) River Wong Rob McClure MD Partners Ronald Wampler Derrick Woolridge Beata Ferraiz Ed Donaldson Consultant with Humana Julie Burgoon Mark Neumuth Aetna Raj Sankuratri Aetna Dr. Cheryl D. Lohman Germantown, MD | Family Physician Barbara Valeno Eshaa Dhall eclinicalworks Angie Brandon Bryan Briegal ACP Beatrice Thompson Hema Srinivasa Kristin Ashby Aetna Nag Sanivarapu Abhishek Pandey Shailesh Prabhu Travis Hendrix Dr. First Zakir Guler Jason VanderJagt edifecs Erika Wagner Shamil Nizamov Michael Robinson Christopher Marchand Chris Busch
Scott M. Robertson