2021-08-27 Payer Data Exchange (PDex/Formulary/PlanNet) Implementer Support Meeting

See Supporting section below!

STU Update (1.1.0) approved by Pharmacy so moving forward with peer-to-peer review period.  (Dave Hill)

See Recording of Formulary Tickets for STU 1.1.0 Overview

Stage for people to review:  https://build.fhir.org/ig/HL7/davinci-pdex-formulary/branches/stu-update-1.1/ 

Pharmacy WG approved. Period review will take about 2 weeks. If no comments, can proceed to publication. 

Many of the items came up on this call, thank you for the feedback and input!

Need to submit publication request. 

Sean - share updated proposal for Plan Type additions/changes based on discussion on 8/20.

Is the need for Catastrophic time-sensitive? We discovered, this, curious how Payers are doing this today as we plan our timelines for updates to the IG?

• Note: this is extensible. 

Discuss options to have a catastrophic (as defined for QHP plans). Question on need to provide other options for different deductible- as many payer has already implemented this IG, it was discussed to not change definitions on the terms we have now. Current proposal is to keep everything the same display and definition and adding Catastrophic plan. 

Important to know that this is an extension. 

For payer data exchange, once the new plan gets a Patient's data from old plan.. how do you recommend to keep that data separate from the data already present in new plan? (avoiding data pollution).

• push from CMS, creating a longitidunal record and having it accessible to the payer API
• requirement from CMS is that when the information is exchange, it must be part  of the patient record now
• provenance may be important, intent to have payer indicate who transmitted the data to them

• Robert Dieterle (EnableCare) to Everyone

  (f) Coordination among payers. (1) An MA organization must maintain a process for the electronic exchange of, at a minimum, the data classes and elements included in the content standard adopted at 45 CFR 170.213. Such information received by an MA organization must be incorporated into the MA organization’s records about the current enrollee. With the approval and at the direction of a current or former enrollee or the enrollee’s personal representative, the MA organization must:
  (i) Receive all such data for a current enrollee from any other payer that has provided coverage to the enrollee within the preceding 5 years;
  (ii) At any time an enrollee is currently enrolled in the MA plan and up to 5 years after disenrollment, send all such data to any other payer that currently covers the enrollee or a payer the enrollee or the enrollee’s personal representative specifically requests receive the data; and
  (iii) Send data received from another payer under this paragraph (f) in the electronic form and format it was received.

Share updates to the PDex Guide for an STU Update: http://build.fhir.org/ig/HL7/davinci-epdx/ChangeHistory.html

• Changes to how the $MemberMatch and Consent is written. 
• $MemberAccess Operation

This will become a 1.1.0 update. If you look at the table to see what has changed, we have added the JIRA tickets and links to where the changes have been applied. 

Covering changes to

• PDEx provenance, reverting the recording of element to US Core.,
• use of $everything in Payer to Payer exchange. because the $everything is an operation rather than a search you could not specific parameters. Instead you use the underscore to define which paramenter/resource you would like to return.
• guidance of consent resource- looking at member match and member access as part of the payer to payer exchange
  • separate the member match and the token to grant access, make it into two separate operations
  • may try to do initial testing at the connectathon
  • using a point to point connection NTLS- certified connection between payers. Member match would be open access request to those who have NTLS
  • $everything option to retrieve data on the member would have restrictions. Could also use the metadata in directory to identify what Trust framework each payers would use for the exchange 
  • ability to authenticate each end
• OAuth and UDAP security/FAST- Eric H, can provide reference on what is being worked on right now. He is seeing fragmented efforts on solving the same problem.

Implementer Support

Review FAQ Proposed Responses 

Adjourned at pm EST.

Source PowerPoint: PDEXandUSCoreRelationship.pptx

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

• Other Spreadsheets used to support tables in PDEX IG:

• PDEX-USCore3-1-1-2020-10-20-v5.xlsx
• PDEX-Plannet-formulary-2020-10-20-v3.xlsx
• Observation-FHIR_R4 v1.4.xlsx

HL7 FM PDEX What to Review 2020-10-20-v1.pptx