2021-08-20 Payer Data Exchange (PDex/Formulary/PlanNet) Implementer Support Meeting

Call Structure & Name Changes

• Friday 12noon ET - Payer Data Exchange (PDex/Formulary/PlanNet) Implementer Support Meetings
• Friday 2pm ET - Payer Data Exchange (PDex/Formulary/PlanNet) Version 2 Meetings (formerly the PCDE call)

When: 9/13-9/15

Registration is now available here

Last day to register is August 30th. 

Visit the Da Vinci HL7 Connectathon page for quick highlights on each tracks. 

Discussion continued. 

This table is what the final result would look like:

RM:  agree the right approach.  Questioning the "Catastrophic Deductible" - low, medium, high, superhigh.... 

• Catastrophic is a term used by payers beyond QHP plans.  It is a well known thing that is a high level policy that is there in the event of a catastrophic issue - building, construction, healthcare, etc.  It is not otherwise restricted.
• What are we defining as a low vs. high deductible - the amount is defined by each payer based on their plans.  
• Then, can we also define catastrophic.  
• Daniel Venton Proposed definitions (tweaked):
  • low deductible - Lowest 1/3rd of plans offered by the payer
  • Medium deducible  - Middle 1/3rd of plans offered by the payer
  • High Deductible - Top 1/3rd of plans offered by the payer but not catastrophic.
• Catastrophic - definition proposed works, change the name to catastrophic plan
• Again, is that true across all payers? 
• Option for Text - concerned because there is stratification. 

Payer with plan has three levels of a Medicare HMO, none of which has a deductible.. so how does this work?

Discussion about renaming away from "deductible" to "cost share"  or just "share" to really represent the need of the patients when looking at the different plan types. 

Catastrophic - ..... with significant illness. 

HMO plans have no co-pay related map to low deductible. 

• Payer to Payer focused - Consent, membermatch workflow, bi-directional extension
• Tickets for V2 - will be reviewed at 2pm ET meeting.  

Need to set the scope of the consent and the requirement for the ability to communicate whether the member is asking to have all data or just the non-sensitive data (42 CRD part 2 or by state requirements) 

• It's our intend to add the requirement: 
  • The consent resource needs to be exchanged
  • Include the determination of patient consent for either:
    • all data
    • only non-protected data. (in line with Federal and State regulations of definitions of this data)
• Payer could reject and say "sorry we won't share protected data" 

Further segmentation of the non-protected data gets complicated fast, so we'd keep it at the level mentioned above.  2 options. 

Discussion:

q) let's say I'm in a state that allows mental health info to be shared, but my previous employer state does not allow it.  

a) It's always the state of where the data is held (based on the state of the Insurer)

q) Differences for ASO/Self-funded accounts/employers.  

a) this does not apply to them, it's only Medicare, Medicaid, QHP, Federal exchange plans, 

Team still has concerns about the token and tying this to membermatch.  

Agreed!  Focus for Sept. Connectathon! 

Let's come up with some user stories that exercise the edge cases. 

PDex: $everything on Patient and Bulk

We've heard some confusion around using $everything on patient and using bulk and how the provenance needs come into this. 

We want to clarify what the $everything on Patient means.  

FHIR-33173 created to track this change.

This may be going into STU2 update, wanted to share that this now has a JIRA ticket.

PDex IG Companion Guide List

PDex IG Companion Guide - Laboratory Reporting Resources

Latest draft CARIN CPCDS Mapping document: CARIN Mapping to FHIR interim 2020 0818 v2.xlsx

DRAFT - PDEX US Core Mapping from CPCDS source: ResourceMappingUSCoreCPCDS-2020-05-29-v26.xlsx

Find initial questions and corresponding answers shared from our colleagues at CMS here

• Links to Published IGs

• PDex STU 1.0.0
• Plan Net STU 1.0.0
• Formulary - STU 1.0.1

Implementer Resources

Da Vinci Implementer Support Page 

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!

Da Vinci PDex for Patient Access API Frequently Asked Questions (FAQs)

CMS Final Rule Questions and Answers log

ONC FAST National Healthcare Directory (including end points) solution page that includes links to everything (solution doc, Connectathon, HL7 workgroup, etc.): https://oncprojectracking.healthit.gov/wiki/display/TechLabSC/National+Healthcare+Directory

For questions, reach out to us on Zulip:

• PDex: https://chat.fhir.org/#narrow/stream/235286-Da-Vinci.20PDex/topic/Implementers
• Plan Net: https://chat.fhir.org/#narrow/stream/229922-Da.2BVinci.2BPDex.2BPlan-Net
• Formulary: https://chat.fhir.org/#narrow/stream/197730-Da-Vinci.20PDex.20Drug.20Formulary

Formulary - Searching by DrugName.docx

Recording of Formulary Tickets for STU 1.1.0 Overview