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NOTE: Previously called $payer-match.


Find Member using Patient and Coverage Resources

OPERATION: Find member using search driven by member patient and coverage information

When a member switches from one plan to another the member has the option to request their data be passed to their new health plan.

The new Health Plan SHALL enable an enrolling member to provide the coverage details for their prior health plan. The new Health Plan SHALL create the following resources that will be compiled into a Parameter Resource and submitted to the $member-match operation on the Patient FHIR endpoint for the old health plan:

  • US Core Patient (Containing Member demographics)
  • Coverage (details of prior health plan coverage provided by the member, typically from their Health Plan coverage card)
  • Coverage (details of new or prospective health plan coverage, provided by the health plan based upon the member's enrollment)

The New Health Plan Coverage record provides information for the prior Health Plan to determine the identity of their member in the new health plan, enabling them to identify the member in the new Health Plan for any future communications.

The Health Plan should enter the unique member identifier

The Old Health Plan should return the following data:

  • The unique member identifier added to the Patient.identifier in the Patient resource submitted by the new health plan.
  • The new health plan coverage resource.
  • Only one Patient and one Coverage record are returned.

Reference Implementation Information: Member-Match Reference Implementation

Providing a directory of FHIR Endpoints that support the $member-match operation for each health plan is outside the scope of this operation.

A suggestion is that the FHIR endpoint is discoverable via a file in the .well-known folder of the URL for the health plan that is typically found on a member's health plan insurance card.


Operation:

URL: POST [base]/Patient/$member-match


Patient.identifier

When the New Health Plan creates an OldCoverage parameter where the Coverage resource has a Coverage.identifier where the identifier.type is "MB". The "MB" value is taken from the http://terminology.hl7.org/CodeSystem/v2-0203 value set.

When the Old Health Plan returns the Patient Record they SHALL ADD a Patient.identifier with the Patient.identifier.type = "UMB" (Unique Member Identifier). This is a new type value.

A code system will be created with a value set with a single entry "UMB" and will be referenced by the value set for identifier.

Note: the UMB value is a placeholder for Connectathon-24. Other potential Patient.identifier.type values that could replace UMB include PI or PT. (Feedback is welcomed on this choice).

Unique Member Identifier

The Health Plan SHALL return a unique member identifier and a corresponding system value that identifies the plan. 

The member identifier SHALL be either the internal unique identifier, or an identifier that is mapped one-to-one to the Health Plan's unique member identifier.

Parameters

Use


NameCardinalityTypeBindingDocumentation
INresource1..1Parameter
Use this to provide a set of coverage and beneficiary details for the match operation to search for a unique member record (e.g. POST a parameter with Patient, Old Coverage and New Coverage to Patient/$member-match).
OUTreturn1..1Parameter
The returned Parameter resource will contain the New Plan's Coverage record and their Member Patient record with the ADDITION of an identifier of type "UMB" that represents the Unique identifier to identify the member records at the old health plan. If the operation failed to find a unique match then a BadRequest status code is returned. (e.g. 422 - Unprocessable Entity).


The response from a successful $member-match is a parameter containing the updated Patient resource submitted, but with the UMB identifier, and the new health plan coverage record as submitted in the original Parameter request.

The response from a failed $member-match is a 422 Unprocessable Entity Status Code.

After a successful $member-match the new health plan will then use the unique member identifier provided by the Old Health Plan in the Patient.identifer field to query for any subsequent transactions related to payer-to-payer exchange.

For example, in PDex the new health plan will subsequently use the UMB identifier to request the member’s health records. This can be done by querying the US Core FHIR profile endpoints which will be constrained to the identified member. Alternatively the new health plan can perform a $everything operation to the Patient/{ID}/$everything operation endpoint to receive a bundle of the member’s health records.

For PCDE, the new health plan will subsequently use the UMB identifier to send a Task message and request the PCDE coverage transition bundle.


Member matching Logic

This specification is not attempting to define the member matching logic that is used by a Payer that processes a $member-match operation.

The specification is:

  • defining that only a SINGLE unique match is returned.
  • No match returns a 422 status code.
  • Multiple matches returns a 422 status code. 
  • Defining the content passed into the $member-match operation.
  • Defining the data returned from the $member-match operation.

An important objective of this specification is to ensure that a payer operating a $member-match operation has sufficient data provided to enable a match operation to be performed. 

For the requesting payer the specification assumes that a new member is able to provide their demographic information (name, date of birth, gender) and the identification details that would be present on their health plan insurance card.

$member-match Parameter Example

Example request: $member-match Parameter resource submitted by the new health plan. Note the Patient identifier type set to "MB".

$member-match accepts a POST with the Parameters json bundle in the body.

Example Parameter
{
    "resourceType": "Parameters",
    "parameter": [
        {
            "name": "MemberPatient",
            "resource": {
                "resourceType": "Patient",
                "id": "1",
                "identifier": [
                    {
                        "type": {
                            "coding": [
                                {
                                    "system": "http://hl7.davinci.org",
                                    "code": "MB"
                                }
                            ]
                        },
                        "system": "http://oldhealthplan.example.com",
                        "value": "55678",
                        "assigner": {
                            "reference": "Organization/2",
                            "_reference": {
                                "fhir_comments": [
                                    "MB is passed from coverage card by new health plan."
                                ]
                            }
                        }
                    }
                ],
                "name": [
                    {
                        "use": "official",
                        "family": "Person",
                        "given": [
                            "Patricia",
                            "Ann"
                        ]
                    }
                ],
                "gender": "female",
                "birthDate": "1974-12-25"
            }
        },
        {
            "name": "OldCoverage",
            "resource": {
                "resourceType": "Coverage",
                "id": "9876B1",
                "text": {
                    "status": "generated",
                    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the coverage</div>"
                },
                "contained": [
                    {
                        "resourceType": "Organization",
                        "id": "Organization/2",
                        "name": "Old Health Plan",
                        "endpoint": [
                            {
                                "reference": "http://www.oldhealthplan.com"
                            }
                        ]
                    }
                ],
                "identifier": [
                    {
                        "system": "http://oldhealthplan.example.com",
                        "value": "DH10001235"
                    }
                ],
                "status": "draft",
                "beneficiary": {
                    "reference": "Patient/4"
                },
                "period": {
                    "start": "2011-05-23",
                    "end": "2012-05-23"
                },
                "payor": [
                    {
                        "reference": "#Organization/2"
                    }
                ],
                "class": [
                    {
                        "type": {
                            "coding": [
                                {
                                    "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                                    "code": "group"
                                }
                            ]
                        },
                        "value": "CB135"
                    },
                    {
                        "type": {
                            "coding": [
                                {
                                    "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                                    "code": "plan"
                                }
                            ]
                        },
                        "value": "B37FC"
                    },
                    {
                        "type": {
                            "coding": [
                                {
                                    "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                                    "code": "subplan"
                                }
                            ]
                        },
                        "value": "P7"
                    },
                    {
                        "type": {
                            "coding": [
                                {
                                    "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                                    "code": "class"
                                }
                            ]
                        },
                        "value": "SILVER"
                    }
                ]
            }
        },
			{
        "name": "NewCoverage",
        "resource": {
          "resourceType": "Coverage",
          "id": "AA87654",
          "contained": [
              {
                "resourceType" : "Organization",
                "id" : "Organization/3",
                "name" : "New Health Plan",
                "endpoint" : [
                  {
                    "reference" : "http://www.newhealthplan.com"
                  }
                ] 
              }
            ],
            "identifier": [
            {
              "system": "http://newealthplan.example.com",
              "value": "234567"
            }
          ],
          "status": "active",
          "beneficiary": {
            "reference": "Patient/1"
          },
          "period": {
            "start": "2020-04-01",
            "end": "2021-03-31"
          },
          "payor": [
            {
              "reference": "#Organization/3"
            }
          ],
          "class": [
            {
              "type": {
                "coding": [
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                    "code": "group"
                  }
                ]
              },
              "value": "A55521",
              "name": "New Health Plan Group"
            },
            {
              "type": {
                "coding": [
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                    "code": "subgroup"
                  }
                ]
              },
              "value": "456"
            },
            {
              "type": {
                "coding": [
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                    "code": "plan"
                  }
                ]
              },
              "value": "99012"
            },
            {
              "type": {
                "coding": [
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                    "code": "subplan"
                  }
                ]
              },
              "value": "A4"
            },
            {
              "type": {
                "coding": [
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                    "code": "class"
                  }
                ]
              },
              "value": "GOLD"
            }
          ]
        }
      }
    ]
}


Parameter Response


Parameter Response
{
  "resourceType": "Parameters",
  "parameter": [
    {
      "name": "MemberPatient",
      "resource": {
        "resourceType": "Patient",
        "id": "1",
        "identifier": [
          {
            "type": {
              "coding": [
                {
                  "system": "http://hl7.davinci.org",
                  "code": "MB"
                }
              ]
            },
            "system": "http://oldhealthplan.example.com",
            "value": "55678",
            "assigner": {
              "reference": "Organization/2",
              "_reference": {
                "fhir_comments": [
                  "MB is passed from coverage card by new health plan."
                ]
              }
            }
          },
          {
            "use": "usual",
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
                  "code": "UMB",
                  "display": "Member Number",
                  "userSelected": false
                }
              ],
              "text": "Member Number"
            },
            "system": "https://old.payer.example.com/diamond-health-ppo/uniquemember",
            "value": "dhu-10102"
          }
        ],
        "name": [
          {
            "use": "official",
            "family": "Person",
            "given": [
              "Patricia",
              "Ann"
            ]
          }
        ],
        "gender": "female",
        "birthDate": "1974-12-25"
      }
    },
    {
      "name": "NewCoverage",
      "resource": {
        "resourceType": "Coverage",
        "id": "AA87654",
        "contained": [
          {
            "resourceType": "Organization",
            "id": "Organization/3",
            "name": "New Health Plan",
            "endpoint": [
              {
                "reference": "http://www.newhealthplan.com"
              }
            ]
          }
        ],
        "identifier": [
          {
            "system": "http://newealthplan.example.com",
            "value": "234567"
          }
        ],
        "status": "active",
        "beneficiary": {
          "reference": "Patient/1"
        },
        "period": {
          "start": "2020-04-01",
          "end": "2021-03-31"
        },
        "payor": [
          {
            "reference": "#Organization/3"
          }
        ],
        "class": [
          {
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                  "code": "group"
                }
              ]
            },
            "value": "A55521",
            "name": "New Health Plan Group"
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                  "code": "subgroup"
                }
              ]
            },
            "value": "456"
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                  "code": "plan"
                }
              ]
            },
            "value": "99012"
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                  "code": "subplan"
                }
              ]
            },
            "value": "A4"
          },
          {
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/coverage-class",
                  "code": "class"
                }
              ]
            },
            "value": "GOLD"
          }
        ]
      }
    }
  ]
}



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11 Comments

  1. I appreciate the details above.  What are we doing for the instances of when a beneficiary/patient might have secondary health insurance or supplemental insurance like Medigap?  Are we creating a use case to further define how beneficiary/patient information will be shared from the primary health plan/payer to secondary health plan/payer?  Please forgive me if this was covered already; I am unable to locate this specific use case.  I would appreciate any insight and feedback for the team.  Thanks

  2. Bundle type shouldn't be 'transaction'.  In fact, would recommend not using a Bundle at all.  Instead, use a Parameters resource, which is the general mechanism for invoking a FHIR operation with multiple arguments. 

    Are the "id" elements on Patient and Coverage expected to be persistent/resolvable on future calls?



  3. Thanks Lloyd McKenzie.  I took a first pass at migrating the above example from a transaction Bundle to a Parameter resource instance. This example also passed FHIR validation for structural integrity.

    Let me know if something like the attached JSON is what you had in mind.  pcde-payermatch-parameter-example.json

    cc: Mark Scrimshire

    Thanks! ~May

    1. I'd have probably kept the parameter names a bit shorter - "patient", "oldCoverage", "newCoverage".  (HealthPlan isn't really a term in FHIR, so better to stick with standard concept names if you can).  Other than that, looks good to me.

  4. Thanks Lloyd!  I'll make the suggested edits and re-post.  Mark Scrimshire - we can review the changes at the Wednesday morning PDEx working session.

  5. The 'Parameters' table does not match the examples - it should list the name of the various parameters.


    The sample request and response have an 'exact' parameter that is not explained anywhere.


    I don't think it is a good idea to have the operation return 404 if there is no match: that's the code you get if the URL you used points to nothing - that is not really the case here. I'd suggest using 422 instead.

  6. Instead of returning the identifier inside the patient resource using a special type to identify it etc. wouldn't be simpler / easier to return it as a separate parameter?

    1. It would certainly be easy to return the Unique Member Id as a separate Parameter.

      Michele Mottini  May Terry  What do you think about returning the Identifier dict from the old plan's patient record rather than just returning a value.

      eg. 

      {"name": "uniqueMemberId",

      {
      "use": "usual",
      "type": {
      "coding": [
      {
      "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
      "code": "UMB",
      "display": "Member Number",
      "userSelected": false
      }
      ],
      "text": "Member Number"
      },
      "system": "https://old.payer.example.com/diamond-health-ppo/uniquemember",
      "value": "dhu-10102"
      }

      }

      1. Yes, you'll need the entire identifier as the parameter value because it has both a value and a system - and you'd need both; but if the only purpose of identifier.type was to  distinguish that identifier from the other ones that's no longer needed, so:


        {

            "name": "uniqueMemberId",

            "valueIdentifier": {
                "system": "https://old.payer.example.com/diamond-health-ppo/uniquemember",
                "value": "dhu-10102"
            }

        }


  7. Michele Mottini - re: using 422 instead of 404.  This makes sense and seems more appropriate for a return error. 

    Perhaps we can discuss this at the Connectathon kick-off tomorrow, May 14, at 10a ET? Since we already have some implementations that are already writing to this current behavior, it makes sense to bring up and see if they can refactor during the connectathon. cc: Mark Scrimshire

  8. Why does the new health plan need an identifier for the patient in the old health plan? Wouldn't the (old plan) patient id be enough?