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Proposed Track Lead

Expected participants

  • Payer Organizations
    • Cambia Health Solutions (Payer)
  • Provider Organizations
    • Need Confirmation: Multicare ? (Provider)
    • Need Confirmation: Providence ? (Provider)
    • Need Confirmation: OCHIN ? (Provider)
  • EHR Vendors 
    • Need Confirmation: Epic ? 

...

  • System that will be responsible for consuming the Member Attribution List.
  • APIs that would be required
    • Ability to Search/Read on the Group resource
    • Invoke Bulk API for Group/$export
    • Consume the data that is received and at least analyze the data.
  • Effort Required: Few weeks if starting from scratch


Scenarios

Scenario 1: Discover the Group Resource. Consumer (Provider Organization) discovers the applicable Group Resource in Producers (Payer Organization) system

Ability for a Provider organization to discover the Group Resource representing the Member Attribution List that is applicable to their specific organization.

For example, Multicare would like to know which Group Resource in Cambi'a System is applicable for their organization using their NPI or TIN information.

Precondition:

  • Provider Organization knows its own NPI and TAX Identification number

API: 

GET <Server Base URL>/Group?identifier:oftype=http://terminology.hl7.org/CodeSystem/v2-0203|NPI|ExampleNPI&identifier:oftype=http://terminology.hl7.org/CodeSystem/v2-0203|TAX|ExampleTIN

Success Criteria:

  • Receive Group Resource from the API call.


Scenario 2: Consumer (Provider Organization) Requests the Member Attribution List from the Producer (Payer Organization)

Ability for a Provider organization to request the full Member Attribution List that is applicable to their specific organization. Note: The request has to be accepted by the Payer and eventually a Member Attribution List would be made available. This is an asynchronous request following Bulk Data IG specifications.

For example, Multicare would like to request the Member Attribution List from Cambia for a specific contract. 

Precondition

  • Provider Organization knows the specific Group Resource for the specific contract that represents the Member Attribution List.
  • The Group Id of the specific Group Resource that is applicable and was retrieved as part of Scenario 1

API

GET or POST <Server Base URL>/Group/[Group id]/$export?_type=Patient,Practitioner,PractitionerRole,Organization,Location,Coverage,RelatedPerson

Success Criteria:

  • Request is accepted by the Payer and a Content Location is received as part of the Response. 


Scenario 3:

  • Providers know their NPI and TAX Identification number

Success Criteria:

...

Consumer polls the Content Location for Request Completion and Member Attribution List data location. 

Ability for a Provider organization to poll the Content Location received as part of Scenario 2 to determine completion status of the Member Attribution List Request issued in Scenario 2 and once completed identify the location of the files that represent the Member Attribution List.

For example, Multicare would poll the content location received as part of the response in Scenario 2. 

Pre condition

  • Provider Organization has requested the Member Attribution List which was accepted by the Payer.
  • Provider Organization has the URL for the Content Location where the request status can be polled.

API

GET <Content Location from Scenario 2 response>

Success Criteria:

  • Completion Status indicated by 200 HTTP code and the Response Body containing the URLs for the files representing the Member Attribution List.
  • There needs to be at least one URL for each of the resource types specified using the _type parameter in the Scenario 2. (

    Patient,Practitioner,PractitionerRole,Organization,Location,Coverage,RelatedPerson)


Scenario 4: Consumer retrieves the files representing the Member Attribution List

Ability for a Provider organization to retrieve each of the files that represent the Member Attribution List.

For example, Multicare retrieves each of the NDJSON files representing the Member Attribution List.

Pre condition:

  • Provider Organization has the URLs to retrieve the files representing the Member Attribution List from the response indicating that the export request was completed.

API

GET <File URL for each Resource identified in Scenario 3 completion response>

Success Criteria:

  • Retrieve the NDJSON files for each of the following resources.
  • Patient,Practitioner,PractitionerRole,Organization,Location,Coverage,RelatedPerson


TestScript(s)

Indicate any test scripts that will be used to help verify system behavior

Security and Privacy Considerations

  • SMART on FHIR Backend Services Authorization is specified by the IG. However it is not required.