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Owning Workgroup:

Financial Management

Committee Approval Date:

Requesting November, 2019


Publishing Lead:

Amol Vyas (amol.vyas@cambiahealth.com)


Contributing or Reviewing Work Groups:

Community Based Care and Privacy

Security

Payer/Provider Information Exchange

FHIR Development Project Insight ID:

1538


Scope of coverage:

This guide will define the exchange methods and interoperability "standards" and specific use of FHIR resources to support Health Plan member-authorized exchange of adjudicated claims (i.e. EOBs) information from the Health Plan to members and third-party applications.


Content location:

https://build.fhir.org/ig/HL7/carin-bb/index.html


Proposed IG realm and code:

US/carin-bb


Maintenance Plan:

The CARIN Alliance intends to provide ongoing support of this implementation guide.


Short Description:

Develop a FHIR R4 based implementation guide for an API similar to the CMS Medicare Blue Button 2.0 API, FHIR R3 based, that will allow consumer-directed exchange of commercial Health Plan/Payer adjudicated claims data to meet the requirements of the CMS Interoperability and Patient Access proposed rule.


Long Description:

Medicare Advantage (MA), Children's Health Insurance Plans (CHIP), Medicaid Managed Care & Qualified Health Plans (QHPs) will have to adopt a standards-based API in the CMS Interoperability and Patient Access proposed rule so beneficiaries can connect an app of their choice to their claims. The rule has a current proposed implementation date of 1/1/2020. Health plans are required to use standards-based API options, including CMS Medicare Blue Button 2.0 and this implementation guide will provide a FHIR R4 means to meet those requirements. This implementation guide will help those plans meet the proposed regulatory requirements.

History of Blue Button

  • VA Blue Button on “My HealtheVet” patient portal (2010)
    • Format: Custom downloadable text files
    • Content: Patient demographic and clinical data
  • ONC Blue Button Pledge Program (2011)
  • ONC Blue Button+ API (2013)
    • Format: HL7 C-CDA standard
    • Content: Patient demographic and clinical data
  • CMS Blue Button 2.0 API (2018) [https://bluebutton.cms.gov/]
    • Internal name: “Blue Button on FHIR”
    • Format: HL7 FHIR STU3 (i.e. version 3) standard
    • Content: Medicare beneficiary’s adjudicated claims (Explanation of Benefits/EOBs) data
  • CARIN Blue Button API (2019-20) [https://build.fhir.org/ig/HL7/carin-bb]
    • Common data model: Common Payer Consumer Data Set (CPCDS) v1
    • Format: HL7 FHIR R4 (i.e. version 4) standard
    • Content: Health Plan member’s adjudicated claims (Explanation of Benefits/EOBs) data

Involved parties:

This implementation guide has been developed by payer and consumer app organizations as part of the CARIN Alliance.


Expected implementations:

Cambia Health, BCBSA, United Health Care, Kaiser Permanente, BCBS of NC, Humana, Security Health Plan


Content sources:

Requirements are drawn from the CMS Medicare Blue Button 2.0 API, the CMS Proposed Rule as well as payer and consumer app organizations as part of the CARIN Alliance.


Example Scenarios:

An Authenticated Member at a Health Plan will be able to use an OAuth2.0 authorization to permit a Third-Party Application to access the Health Plan's FHIR API to read their adjudicated claims (i.e. EOBs).


IG Relationships:

This guide will reference, where possible, the "standards" defined by Argonaut and US Core efforts for FHIR R4.


Timelines:

STU Ballot in Jan 2020


FMG Notes

1 Comment

  1. FMG approved this proposal on 11/6/2019