2023-03-10 Payer Data Exchange (PDex/Formulary/PlanNet) Implementer Support Meeting

Review ANSI Anti-Trust Policy

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• Mark updated numbering of all the section. 
• Mark and Bob have been working to align with National Directory Endpoint profiles that publish the payer to payer exchange APIs. Need value sets and code systems to be finalized so we can incorporate into the PDex guide. No way in our examples to say that the endpoint relates to PDex IG and payer to payer use case. Hopefully, there will be code systems and value sets in endpoint resource to support this functionality so that records are searchable. Will take another week or two to get this finalized under National Directory so we can pick it up and use it in the PDex guide.
• Have also been working on adding detail into payer to payer exchange page on operation of certificates for trust framework. Some relates to definition of endpoint examples as well. Two sides of the process to obtain mTLS certificate for dynamic registration, and having a certificate that identifies the party is part of a trust framework for payer to payer exchange. After this is resolved, will help us address the remaining open tickets for PDex. 
• Also discussing potential adoption of UDAP. Mark is working to connect with Luis Maas to see how that could potentially be used in the IG. This conversation will be coordinated after we get the IG published. Then we can move toward an STU update that would potentially incorporate UDAP. 
• Shanna shared that CMS will hold a virtual connectathon July 18 - 20, 2023. 
• RW: Connectathon third party app testing was limited. Do you envision where we should focus testing next? Versioning, or something else. 
• MS: From PDex perspective, looking for folks who are willing to test the prior authorization profile. Does it have the necessary information in it. We built the profile based on work done in PAS. The history of EOB, was it was built from claim and claim response. We haven't had anyone step forward to put sample prior auths together to confirm that it will meet the requirement to communicate something useful to patients. We would really like to see some support in this area from app vendors. 
• RW: Testing of PAS, that's in preparation for the future or is that something live for now? Are we trying to test something to baseline early tests of the future? 
• MS: That would be a question for the burden reduction use case team. Believe there are organizations who have implemented the suite of guides. Also recommend that you review Da Vinci's response to the prior auth rule. Recommending clinical data exchange be included in the set of guides recommended by CMS. CDex and PAS reference each other so makes sense for that guide to be added. 

• Rick shared the dashboard for PlanNet. Many of these tickets had been marked consider for future use. Rick triaged the tickets and reviewed all of them. There are 16 issues and Rick has identified four for discussion today. 

FHIR-31691 - Getting issue details... STATUS

• Rick provided an overview of the ticket. 
• The ticket is proposed to be not persuasive since core FHIR spec constrains this to organization. Could potentially create an extension in the future if needed.
• MS: There is actually a linkage from practitioner role.
• BD: Would have practitioner role point to a healthcare service that would point to a service that you deliver. No need to point to an organization. No reason to change what we have. 
• MS: If you go to home page of PlanNet IG, look at resource relationships. 
• BD: We already cover this now. Whoever was looking at it was looking at healthcare service and though we needed something more but we already have that. 
• Ticket marked ready for vote. 

FHIR-31674 - Getting issue details... STATUS

• Rank is flagged as MustSupport. It's rank on telecom. So says if you are going to contact someone, this is how you should do it. 
• BD: For things like network, you probably only have a single contact. It isn't likely that you would have more than one. Which resource profiles have MustSupport.
• RG: PlanNet organization and practitioner role.
• BD: Those are resources where you would expect that to happen. We made must support because there was an expectation that you would have more than one of them. 
• LM: Most systems differentiate priority. 
• DV: To your example, there may be phone number for weekday and one for weekend. 
• BD: There is more than one way to contact someone - telephone, fax, etc. 
• RG: There are other fields that aren't flagged. Is this important enough that everyone needs to support it. 
• BD: We went through this with the payers and they wanted this. It's out there an has been adopted. Not sure there is value in removing must support.
• MS: You have telecom and healthcare service and location but they haven't made rank a requirement there. 
• BD: If I contact a location for healthcare service, what is the number I call and what are the office hours so those are in healthcare service and location. 
• Ticket deemed not persuasive and marked ready for vote. 

FHIR-38750 - Getting issue details... STATUS

• Noted that expected to see Node in the snapshot table but it is not present. 
• It was struck out in the differential so it strikes it out and removes it from the snapshot. 
• If this Called it not persuasive.  
• Is it correct to make it 0..0? 
• DV: Why would you prohibit someone from collecting this data point even if you don't care about it? 
• LM: We could set it to a fixed value if we say it must always be one or the other. You should only prohibit tings if there are errors to be present. You can prohibit patient.deceased if it is an error. Otherwise, prohibiting things is not recommended. 
• DV: Are we saying that plannet organizations cannot be instances? 
• LM: Saying they must be instances so should be a fixed value. 
• BD: This is in production. Is there value in making this change?
• DV: Are you saying that for some other non-PlanNet use case, my location resources should have the mode...what does patient access API say about mode? 
• BD: It was restricted. Any change to production statement has to have a really good reason to make a change. 
• MS: What does US Core say?
• RG: US Core doesn't constrain it all. Recommend we find it not persuasive. But if she thinks that cardinality be changed, she should file another ticket. 
• Ticket marked ready for vote. 

FHIR-31752 - Getting issue details... STATUS

• The way we do it, is insurance plan points to network that is relevant. Networks don't point to insurance plans. Any insurance plan can point to any network. No network points to an insurance plan.
• DV: So, what insurance plans are supported by this network? 
• BD: You do a reverse include on the insurance plan like we do with a number of things. 
• DV: To answer the question it is insurance plan = 
• MS: You wouldn't want to put a pointer in to insurance plan because it provides a bidirectional problem. 
• RG: Lisa is asking for a search parameter to allow that. So there is no search parameter on a network. 
• BD: That's something we probably should add.
• DV: Should this be added to R4? 
• RG: Can't add to R4. Will have to be added to R5. 
• RG: Ticket found to be persuasive with mod. For now, we will add a search parameter to a future version of the IG. Will also ask that the submitter file a change request for enhancement to a future version of core FHIR. 
• Ticket marked ready for vote. 

Adjourned at 2:03 pm ET

Source code is here: https://github.com/HL7/davinci-epdx

Payer-Payer Trust outline: Payer-Payer Trust V3.docx

Mark Scrimshire

Corey Spears

Charlie Provenzano

David Hill (Dave)

Lloyd McKenzie

Robert Dieterle

Susan Langford

Daniel Venton 

Jeff Brown 

Christopher Gracon

Alex Kontur

Chris Johnson 

Ezequiel Morales 

Mark Neumuth 

Damian Smith

Shanna Hartman