Facilitator:  Chris Johnson Peter Gunter 

Scribe: Robin Isgett  


Agenda Topics

Agenda Outline

Agenda Item

Meeting Minutes from Discussion

Decision Link


HL7 ANSI Anti-Trust Policy

HL7 adheres to the ANSI Anti-Trust policy.  We should avoid sharing any information on this call that could be interpreted as anti-competitive.  If there are topics that you don’t normally speak about in other public settings, such as conferences or trade shows, then it’s probably best to save those topics for another time as this is a public call. If you have any questions you can refer to the GOM section 05.01 or consult your companies legal division.

Chris Johnson reviewed the Antitrust statement.

 Minutes Approval  - Jan 10, 2023

Minutes approved by consensus.

New Proposals and PSS for review - PIE comments or interest

Project proposal to enhance the FHIR standard for situations where the individual and their important social relationships are best, and sometimes required, to be expressed using Person-Centric view for FHIR. 

After discussion, the PIE WG decided that the project requires better definition, and will ask the submitter for a a clearer definition of what this project is all about before deciding on its role going forward.  WG members believed they may be a significant overlap with the Gravity Project with respect to  SDOH.

Pat Taylor

Sam Undine


There is an issue around how to submit the subscriber’s name when the patient is not the subscriber.  The current version of the IG proposes sending it in the Patient Resource; i.e., there would be two Patient Resources – one for the patient and one for the subscriber.  We wish to propose an alternate approach.

Pat Taylor who provided a summary of the PCT workflow and the bundle concept.  Within a bundle there is the Patient Care Transparency (PCT) concept.  Ms. Taylor reviewed how the IG covers the use case of when the patient is not the subscriber.  Under X12, one would need the subscriber ID and the subscriber name, but not the DOB nor the gender.  The IG currently calls for submission of the subscriber information in the patient resource.  Therefore, one patient resource would describe the child and the other the subscriber.  Mistakes are being made and the proposal is to provide the name of the subscriber in the display.  This would allow alignment with claims submission standards in payer adjudication systems.  Would change instruction to require subscriber if the patient is not the subscriber.  Robert Dieterle suggested that it should require both the subscribe name and ID. In x12 there are two loops, the subscriber and patient.  If the subscriber is not the patient then both loops are necessary.
Ms. Taylor suggested that they will try to streamline instructions to minimize errors and will make recommendation based on the discussions and she appreciated the feedback of the PIE WG. 


Advancing Interoperability and Improving Prior Authorization NPRM 

Discussion Guide review

Robert Dieterle provided a summary of the proposed CMS rules related to Prior Authorization and Attachments which were a major focus of the HL7 WG meetings.  Mr. Dieterle first provided a summary of the Interoperability and Improving Prior Authorization Processes CMS-0057-P regulation including a review of the Covered Plans, Provider Programs, Scope of APIs [Patient Access, Provider Access, Provider Directory, PARDD (Prior Authorization Requirements, Documentation, and Decision) and Payer-to-Payer].  Mr. Dieterle stated that it stipulates the plans that CMS can regulate:  Medicare Advantage, Medicaid and CHIP Fee For Service Programs, Medicaid and CHIP Managed Care, and the Qualified Health Plans (QHP) issuers on the Federally-facilitated Exchanges (FFEs).  CMS also provides incentives for providers to adopt the regulation.
•   The regulation’s effective date which is January 1, 2026 (ability for States to delay for 1 year with justification and authorization).  
• Mr. Dieterle also reviewed a summary of the required standards and proposed implementation guide and described the reasons CMS may have taken that approach.
• Originally, CMS tried to phase in prior authorizations which was problematic.  The new rule date is 1/1/26 and all services requiring PA must be supported
* Taken two approaches to naming standards.  One approach is to name the underlying FHIR standard as required.  The other approach is the name the recommended IGs. CMS is required to name a specific standard if they designate a standard as required.  If the requirement is recommended, then covered organizations could implement newer versions as they become available.  The use of recommendations nudge the industry towards implement the requirement because there is the clear intent that it will become recommendation may be designated as a required in the future.
* Current belief is that CMS will not adopt FHIR R5.  Will probably adopt FHIR R6 in 3 years.  US is on even versions and Europe is on odd versions.
* Mr. Dieterle then discussed the Attachments Rule (Administrative Simplification: Adoption of Standards for Health Care Attachments Transactions and Electronic Signatures, and Modification to Referral Certification and Authorization Transaction Standard) which has received a fair amount of negative feedback, unlike the Prior Authorization which seems to be favorably receives.  He pointed out that the attachment rules applies to all covered entities under HIPAA (health plans, providers, and clearinghouses).
* Regarding the Attachments Rule, it seems CMS used a lot of HL7 feedback made to NCVHS in 2016 which was prior to FHIR and many other enhancement alternatives developed by HL7.  However, this resulted in an incompatibility between the Prior Authorization and Attachment rules.  
o Effective 24 months after published
o Scope defines
* Attachment information
* Code sets (anointed LOINC as standard for requesting attachments)
* Expanded definition of Health Claims Attachments
* Electronic signature
* Standards required to request and exchange attachments for claims, referrals, and authorizations
o The rule reflects a new definition for attachments information as:
* documentation that enables the health plan to make a decision about health care that is not included in either of the following:
* A health care claims or equivalent encounter information transaction, as described in § 162.1101.
* A referral certification and authorization transaction, as described in § 162.1301(a) and the portion of § 162.1301(c) that pertains to authorization.
* “Electronic signatures” is defined in such a way that it is really digital signatures in what seems to be an error.
* Standards being proposed are:
* Exchange Standards –  Incorporated by reference (X12 TR3s): 
* X12N 275—  Additional Information to Support a Health Care Claim or Encounter (006020X314); 
* X12N 275—Additional Information to Support a Health Care Services Review (006020X316);
* X12N 277—HealthCare Claim Request for Additional Information (006020X313); and 
* X12N 278—Health Care Services Request for Review and Response Version (006020X315) 
* Content Standards –  Incorporated by reference (HL7 IGs):
* HL7 CDA R2 Attachment Implementation Guide: Exchange of C–CDA Based Documents, Release 1, March 2017; 
* HL7 Implementation Guide for CDA Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) Draft Standard for Trial Use Release 2.1, Volume 1—Introductory Material, June 2019 with Errata;
* HL7 Implementation Guide for CDA Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) Draft Standard for Trial Use Release 2.1, Volume 2—Templates and Supporting Material, June 2019 with Errata.
* Electronic Signature Standards –  cited in the preamble (HL7 IG)
* (1) HL7 Implementation Guide for CDA Release 2: Digital Signatures and Delegation of Rights, Release 1
Mr. Dieterle then went over a list of issues which included:
1) Cannot support reporting burden reduction attachments as FHIR bundle (application/JSON)
2) Requires overhead of X12N 275 and HL7 CDA 2.1 to report any FHIR resource 
3) Unable to request Questionnaire for required additional information after a PAS submission
4) Does not allow for the use of CDex to request and exchange Attachments 

Mr. Dieterle’s slides are available on PIE website under Documents and Presentations

Mary Kay CDex  12X tables for RFAI and Submit AttachmentsRollover to next call.
Management Next agendaContinue NPRM discussion.
 Adjourned at 3:30 PM EST

Supporting Documents

Outline Reference

Supporting Document

Minute Approval

Action items