Page tree
Skip to end of metadata
Go to start of metadata

Warning:

Do not launch ANY of the links while your are in create or edit mode. There is a good chance all of your work will be gone.


Template Usage Information:

  1. Project Name and ID



Enter the name of the project here: Uniform Structure and Coding Elements for Prior Authorization

Project ID: 1656

Complete this section for all “Direct to Normative” ballot projects and when a project proceeds from “Informative to Normative” or “STU to Normative”.

Forward PSS to the TSC (via tscpm@HL7.org); this triggers American National Standards Institute (ANSI) Project Initiation Notification (PINS) submission.

 

TSC Notification:  Informative/STU to Normative 

Date:  Submission date

 

- or -                     Direct to Normative (no STU) (includes reaffirmations)       

 

Identify ISO, IEC or ISO/IEC standard to be adopted in text box below

Enter info here if an ISO, IEC, or ISO/IEC Standard is to be adopted as an American National Standard; Enter the designation of the standard(s) to be adopted:

Includes text from ISO, IEC or ISO/IEC standard: Check here if this standard includes excerpted text from one or more ISO, IEC or ISO/IEC standards, but is not an identical or modified adoption.

Yes

 

No - X

Select the unit of measure used in the standard; if no measurements are in the standard, select N/A

 X

N/A

 

U.S.

Metric

 

Both

 

Investigative Project (aka PSS-Lite)

Date : 

Check this box when the project is investigative or exploratory in nature, which allows limited project scope definition. Sections 1-Project Name, 2-Sponsoring Group(s)/Project Team, 3a-Project Scope, 3b-Project Need, 3e-Project Objectives/Deliverables/Target Dates, 3i-Project Document Repository, 6b-[Realm, if known], and 6d-[applicable Approval Dates] are required for Investigative Project. Investigative Project specific instructions are highlighted in yellow. An investigative project must advance in two WGM cycles, requiring a full scope statement. Otherwise the project will be closed.

2. Sponsoring Group(s) / Project Team

2.a. Primary Sponsor/Work Group

Primary Sponsor/Work Group
(1 (And Only 1) Allowed)

HL7 Financial Management

2.b. Co-sponsor Work Group(s)

Co-sponsor Work Group(s):

(Enter co-sponsor approval dates in Section 6.d Project Approval Dates)

PIE

Indicate the level of involvement that the co-sponsor will have for this project:
 Request formal content review prior to ballot
 Request periodic project updates. Specify period
 Other Involvement. Specify details here: 

2.c. Project Team

All names should have confirmed their role in the project prior to submission to the TSC.

Project facilitator (1Mandatory)

Melanie Combs-Dyer

Other interested parties and their roles


Multi-disciplinary project team (recommended)


     Modeling facilitator


     Publishing facilitator

     Vocabulary facilitator

Enter a name here (or ask Vocab for a name):

     Domain expert rep

Robert Dieterle

     Business requirement analyst

Jay Johnstone

     Conformance facilitator (for IG projects)


     Other facilitators (SOA, etc)




Implementers (2 Mandatory for STU projects)

FHIR Project Note: The implementer requirement will be handled by the “balloting” project.  Therefore work groups do not fill out the above section.  However, feel free to list implementers specific to your work group’s resources if you know of any.

1) Cigna

2) 

3. Project Definition

3.a. Project Scope


Describe the project; include what is expected to be accomplished/delivered along with specified features and functions. Include whether the deliverable(s) are universal, realm specific or applicable to various realms. Be sure to spell out all acronyms as these are carried forward to the NIB (Notice of Intent to Ballot) for ballot announcements..

As a supplement to the Da Vinci Coverage Requirements Discovery (CRD), Documentation Templates and Rules (DTR), and Prior Authorization Support (PAS) FHIR implementation guides, this group will:

  1. Choose a topic item, services or domain(e.g. Imaging)].
  2. List industry requirements for documentation for the specific item/service/domain.
  3. Determine if there is existing support in FHIR for specific elements and code systems/value sets to describe the required documentation for the topic.
  4. Define required changes/enhancements to existing FHIR resources or code systems/value sets.
  5. Determine if the current version of USCDI supports the necessary concepts.
  6. Where necessary, submit request to ONC for inclusion of required concepts in the next version of USCDI.
  7. Where external code systems have gaps, work with the responsible organization to enhance LOINC, SNOMED, ICD-10, or HCPCS where appropriate.
  8. Create or expand existing value sets to include required codes from the appropriate code systems.
  9. Work with HL7 Cross-Group Projects Workgroup to enhance next version of US CORE profiles to support required data elements, code systems, and value sets.


3.b. Project Need


This information is required by ANSI for all ballots. Briefly explain the reason behind the need for this project. This may be related to legislative requirements, industry need, or similar justifications.
.

The United States has one of the world’s most complex healthcare systems, with different organizations providing different types of care across geographic and clinical lines as well as with hundreds of separate payer organizations often with differing documentation requirements to justify coverage/payment.  Providers can often feel overwhelmed by the differing and hard to access documentation requirements of the various health plans.

There are a number of benefits that could be recognized if required documentation elements were more clearly defined across payers.  If required data elements are more clearly defined, there may be reduced provider burden by:

  • Encouraging both provider and payer support for the defined elements
  • More quickly developing support for payer specific requirements
  • Validating/capturing required data elements for specific purposes (e.g. prior authorization)


3.c. Security Risks


Will this project produce executable(s), for example, schemas, transforms, style sheets, executable program, etc.  If so the project must review and document security risks. Refer to the Cookbook for Security Considerations for additional guidance, including sample spreadsheets that may be used to conduct the security risk assessment. 

Yes

X

No

Unknown


3.d. External Drivers


Describe any external schedules or calendars which may not be known outside of the project team that are driving target dates for this project..


3.e. Project Objectives / Deliverables / Target Dates

Within each row, enter the explicit work product(s) / objective(s).  Indicate their target date at the right in WGM/Ballot Cycle format.  Include the project end date as the last objective (for standards projects, the end date will be the projected ANSI approval date). 

Target Date(in WGM or ballot cycle format, e.g.

‘2017 Sept WGM’ or

‘2017 Jan Ballot’)

Enter objective/deliverable here.

All planned ballots and their target dates should be included

Enter Target Date

2024 June

Submit for first Informative Ballot

2022 Jan Ballot

Complete Reconciliation

2022 May WGM

Submit for 2nd Informative Ballot

2022 September Ballot

Complete Reconciliation

2023 January WGM

Informative Period

2024 January WGM

Submit for Normative Ballot

2024 May WGM

Receive ANSI Approval

2024 June

Project End Date (all objectives have been met)

2024 July


3.f.   Common Names / Keywords / Aliases


What common name does your group use to refer to the product(s) produced?  What alternative names, aliases and keywords does your group use to refer to the product(s) that will be produced?  Some examples: C-CDA, LRI, eDOS.  

Uniform Structure and Coding Elements for Prior Authorization, Payer Uniformity, Superset of Payer Documentation Requirements, Common Elements


3.g. Lineage


If your project creates a Post-Release 1 version; indicate the name of the prior product and if it is supplanting, replacing or coexisting with a previous release:

N/A

3.h. Project Dependencies


Enter any dependencies or the name & Project Insight ID of project(s) that this project is dependent upon to achieve its objectives:

1493 – Documentation Templates and Rules (Da Vinci)

1490 – Prior Authorization Support (Da Vinci)

1428 – FHIR Implementation Guide for Coverage Requirements Discovery (Da Vinci)

 

Projects and their Project Insight IDs can be found via http://www.hl7.org/special/Committees/projman/searchableProjectIndex.cfm?ref=common


3.i.   HL7-Managed Project Document Repository Location


Projects must adhere to the TSC's guidelines (which were approved on 2016-04-04 and summarized in Appendix A).

A template to create a Project Page on the HL7 Wiki is available at: http://wiki.hl7.org/index.php?title=Template:Project_Page.

Enter the SPECIFIC URL of the HL7-MANAGED SITE where supporting project documents, deliverables, ballot reconciliation work and other project information will be kept
HTTP://


3.j.   Backwards Compatibility


Are the items being produced by this project backward compatible?


Yes

No

Unknown

X

N/A

If you check 'Yes' please indicate the earliest prior release and/or version to which the compatibility applies:


For V3, are you using the current data types? 

(Refer to TSC position statement on new projects using R2B for more information on the current V3 data types)

Yes

No

Unknown

X

N/A



If you check no, please explain the reason:

If desired, enter additional information regarding Backwards Compatibility.


3.k. External Vocabularies


Will this project include/reference external vocabularies?

X

Yes

No


Unknown

N/A

If Yes, please enter the vocabularies: LOINC, SNOMED CT, HCPCS/CPT, RxNORM, ICD-10-CM


4. Products (check all that apply)



Arden Syntax


V2 Messages – Administrative


Clinical Information Modeling Initiative (CIMI)


V2 Messages - Clinical


Clinical Context Object Workgroup (CCOW)


V2 Messages - Departmental


Domain Analysis Model (DAM)


V2 Messages – Infrastructure


Electronic Health Record (EHR) Functional Profile


V3 Domain Information Model (DIM / DMIM)

X

FHIR Extensions (recommendations)


V3 Documents – Administrative (e.g. SPL)


FHIR Implementation Guide (enter FHIR product version below)


V3 Documents – Clinical (e.g. CDA)

X

FHIR Profiles (enter FHIR product version below)(recommendations)


V3 Documents - Knowledge


FHIR Resources


V3 Foundation – RIM

X

Guidance (e.g. Companion Guide, Cookbook, etc)


V3 Foundation – Vocab Domains & Value Sets


Logical Model


V3 Messages - Administrative


New/Modified/HL7 Policy/Procedure/Process


V3 Messages - Clinical


New Product Definition (please define below)


V3 Messages - Departmental


New Product Family (please define below)


V3 Messages - Infrastructure


Non Product Project - (Educ. Marketing, Elec. Services, etc.)


V3 Rules - GELLO


White Paper


V3 Services – Java Services (ITS Work Group)


Creating/Using a tool not listed in the HL7 Tool Inventory


V3 Services – Web Services (SOA)

If you checked New Product Definition or New Product Family, please define below:


For FHIR IGs and FHIR Profiles, what product version(s) will the profiles apply to?

FHIR R4/R5


5. Project Intent (check all that apply)



Create new standard



Supplement to a current standard

Revise current standard (see text box below)


Implementation Guide (IG) will be created/modified

Reaffirmation of a standard


Project is adopting/endorsing an externally developed IG:

New/Modified HL7 Policy/Procedure/Process


Specify external organization in Sec. 6 below;





Externally developed IG is to be (select one):


White Paper (select one):


Adopted  - OR -

?

Endorsed


X

Balloted Informative OR

Non-balloted WG White Paper


N/A  (Project not directly related to an HL7 Standard)











If revising a current standard, indicate the following:


-    Name of the standard being revised:
-    Date it was published (or request for publication, or ANSI designation date)
-    Rationale for revision
-    The relationship between the new standard and the current standard (is it designed to replace the current standard, a supplement to the current standard, etc.)


5.a. Ballot Type (check all that apply)


Comment (aka Comment-Only)


Joint Ballot (with other SDOs)

X

Informative


N/A  (project won’t go through ballot)

STU to Normative     - OR -

Normative (no STU)











If necessary, add any additional ballot information here.  If artifacts will be jointly balloted with other SDOs, list the other groups.

The intent is to create an informative guide to recommend enhancements to current FHIR artifacts (including code systems and value sets) to support concise definition of payer documentation requirements.


5.b. Joint Copyright

Check this box if you will be pursuing a joint copyright.  Note that when this box is checked, a Joint Copyright Letter of Agreement must be submitted to the TSC in order for the PSS to receive TSC approval.

Joint Copyrighted Material will be produced?


Yes

X

No


6. Project Logistics

6.a. External Project Collaboration


Include SDOs or other external entities you are collaborating with, including government agencies as well as any industry outreach.  Indicate the nature and status of the Memorandum of Understanding (MOU) if applicable.

For projects that have some of their content already developed:

How much content for this project is already developed?

0 %

Was the content externally developed ? :

N

Is this a hosted (externally funded) project?  (not asking for amount just if funded)

Yes

No


6.b. Realm


Universal 

- OR -

 X

Realm Specific



 

Check here if this standard balloted or was previously approved as realm specific standard

U.S.

Enter “U.S.” or name of HL7 affiliate(s) here.  Provide explanation/justification of realm selection. For projects producing deliverables applicable to multiple realms, document those details here. 

For Investigative projects, indicate if the project is planned to be Realm Specific or Universal, if known. Work Groups are encouraged designating project a Universal project initially, and discover which Realms can contribute to the work effort during the discovery phase of the project. Note: This status is subject to change during the investigative process.



6.c. Stakeholders / Vendors / Providers

This section must be completed for projects containing items expected to be ANSI approved, as it is an ANSI requirement for all ballots

 

Stakeholders

 

Vendors

 

Providers

Clinical and Public Health Laboratories

Pharmaceutical

  

Clinical and Public Health Laboratories

  

Immunization Registries

X  

EHR, PHR

  

Emergency Services

  

Quality Reporting Agencies

X  

Equipment

  

Local and State Departments of Health

X  

Regulatory Agency

Health Care IT

 X 

Medical Imaging Service

X  

Standards Development Organizations (SDOs)

Clinical Decision Support Systems

 X 

Healthcare Institutions (hospitals, long term care, home care, mental health)

X  

Payors

X  

Lab

  

Other (specify in text box below)

  

Other (specify in text box below)

  

HIS

  

N/A

  

N/A

  

Other (specify below)


 

 


  

N/A

 

 


Other:  Indicate other stakeholders, vendors or providers not listed above.










6.d. Project Approval Dates

Click here to go to HL7 Project Scope Statement Instructions#Appendix A for more information regarding this section.
Approvals are by simple majority vote of the approving body

Sponsoring Work Group Approval Date:

WG Approval Date

Approved name change

2020-09-24  30-0-0

2020-10-06  17-0-0

Administrative review – in parallel with Work Group Approval

Co-Sponsor Group Approval Date


PIE

2020-09-29 17-0-2

Family Management Group Approval Date(s)

CIMI Projects: CIMI Management Group

CIMI MG Approval Date

CDA Projects: CDA Management Group

CDA MG Approval Date

FHIR Projects: FHIR Management Group

FMG Approval Date

V2/Publishing Projects: V2 Management Group

V2 MG Approval Date

US Realm Projects: US Realm Steering Committee Approval
(Email WG approved PSS to: tscpm@HL7.org)

USRSC Approval Date

Affiliate Specific Projects: Affiliate Approval Date

Affiliate Approval Date

Submit PSS to Steering Division after all of the above approvals are received

Steering Division (of Primary Sponsor WG) Approval Date:

SD Approval Date CCYY-MM-DD

Last PBS Metrics Score:

 Green

 Yellow

 Red

PBS Metrics Reviewed? (required for SD Approval if not green)

 Yes

 No

ARB and Steering Division approval may be in parallel

Architectural Review Board Approval Date:

(required for externally developed content)

ARB Approval Date

TSC Approval

If applicable, TSC has received a Joint Copyright/Distribution Agreement (containing the verbiage outlined within the SOU),
signed by both parties.

Yes

No

 N/A


Technical Steering Committee Approval Date:
(Email SD WG approved PSS to: tscpm@HL7.org)

TSC Approval Date