2021-09-10 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

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

Connectathon Kick Off (add recording)

Raised by Lloyd - see tracker: 

https://jira.hl7.org/browse/FHIR-33263?filter=12656 

Re-validated that #1 - edge case with Medicaid and counties -  but still wouldn't have multiple coverages.  MK has seen it happen but is still comfortable tightening down to cardinality to 1..1 You could very easily split it.

Proceeding with tightening the cardinality to ..1. If needed, you can have two coverage resources with identical elements for edge case.  No objections from group. 27ppl on call. 

On #2-6 from the tracker - Long Discussion on Beneficiaries and what info is on the card. exploring value of a second patient resource. 

Knowledge of new plan, basic info from old plan card, and demographics - That's what was planned for the exchange.  

On PAS, Patient Subscriber and Patient Beneficiary - send both. Different problem.

This is trying to identify an individual based on the info on the Insurance Card.   

Coverage resource has a subscriber and beneficiary elements and both are reference back to the patient resource.  Coverage is the us core patient.  the member match process, says you take the coverage, details from the card and trying to link it to a patient demographics record that is relevant to the card.  

Trying to take the deterministic info from the card and allow the prior payer to use the demographics to align with their member/subscriber.  

Scenarios:

1) ID issued for each person

2) Subscriber number used for everyone on the plan.

Concern that the ID could be bogus - Mickey Mouse ID - it would need to be in the system. 

Proposal that Patient.identifier would no longer be mandatory or must support (drop expectation to use USCORE). If that's the case, then you can't derive the patient resource from US Core.  Then, we would need a PDex version which would be a slimmer version of USCore's Patient Resource that would be must support for:

• Name,
• Family Name,
• Gender,
• DOB,
• Address (same as elements in USCore) and that is what we'd require when referencing Coverage.

(Same as above for minors)

Implementers of USCORE would work fine (nothing would break) but systems would not have to have an Identifier or other data elements not needed for this use case.

The profile requirements are met right now by putting anything in the Identifier so that is not useful. We want to tighten down the profile. We want to say, it's still optional to have the Identifier, but if you have it, you must support it.

• Required for membermatch to work!

Must have an ID string or a coverage.value.id string and one of those two things must be present.  

y putting anything in the Identifier so that is not useful. We want to tighten down the profile. We want to say, it's still optional to have the Identifier, but if you have it, you must support it.

• Required for membermatch to work!

Multiple addresses needed? Kid vs. Mom vs. Dad Address.

Send everything you have?

Next Week

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